AAIM – ABIM PIM Project Teaching and Learning PBL&I and SBP

1. AAIM – ABIM PIM ProjectTeaching and Learning PBL&I and SBP

2. Objectives • Teach residents: • Definition of quality of care • Reflective practice • How to apply the IOM goals and rules • Important principles and tools in quality improvement • Learn to apply the PDSA model of improvement • Practice flowchart exercise for your residency clinic

3. Teaching and Learning PBL&I and SBP What goals do you have for these competencies in your residency?

4. Teaching and Learning PBL&I and SBP What is quality of care?

5. Quality of Care: What Is It? • Institute of Medicine, 1990: • Quality consists of the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (evidence)” Blumenthal, NEJM

6. IOM Definition “Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and with cultural sensitivity.” IOM, 2001

7. IOM Recommendations • Six major aims for health care: • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

8. IOM’s 10 Rules • Care should be based on continuous healing relationships • Customization based on patient needs and values • The patient as the source of control • Shared knowledge and free flow of information • Evidenced-based decision making

9. IOM’s 10 Rules • Safety as a system property • The need for transparency • Anticipation of needs • Continuous decrease in waste • Cooperation among clinicians

10. Reflective Practice • Definition Reflective practice simply refers to a systematic approach to review one’s clinical practice, including errors, seek answers to problems, and make changes in practice habits, styles, and approaches based on self-reflection and review. • Value • Accountability • Self-assessment

11. Quality of Care: Residency Clinic • A 48 year old unemployed Spanish speaking male with hypertension and moderate obesity is seen for follow-up in the residency clinic 6/04. He has been seen 3 times in the last year but has also missed 4 appointments. His BP was 148/93 at his last visit in 3/04.

12. Quality of Care: Residency Clinic • His most recent lab work, in 9/03, showed an LDL 162, HDL of 38, triglycerides 220, and a Cr 1.5. He has seen a different resident at each of his three clinic visits. His current meds are HCTZ 25 mg qday and Atenolol 50 mg qday. His meds were not adjusted at the most recent visit.

13. Quality of Care: Residency Clinic • How well does this patient’s care meet the 6 IOM criteria? • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

14. Quality of Care: Residency Clinic Does patient care provided by your residency clinic meet these IOM criteria? Why or why not?

15. Practiced-based Learning and Improvement Residents are expected to use scientific evidence and methods to investigate, evaluate, and improve patient care practices Internal Medicine Working Group

16. PBL and I • Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care • Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education

17. PBL and I • Identify areas for improvement and implement strategies to enhance knowledge, skills, and attitudes and processes of care • Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice

18. PBL and I • Two major themes: • Effective application of EBM to patient care • Diagnostics, therapeutics, etc • Includes clinical skills! • Quality improvement • Individual improvement: reflective practice • Systems improvement: active participant

19. Systems-based Practice Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care Internal Medicine Working Group

20. Systems-based Practice • Understand, access and utilize the resources, providers, and systems necessary to provide optimal care • Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient

21. Systems-based Practice • Apply evidenced-based, cost conscious strategies to prevention, diagnosis, and disease • Collaborate with other members of the health care team to assist patients to deal effectively with complex systems and improve systematic processes of care

22. IOM Competency Model IOM, 2003

23. Resident “Competency”: PBL&I • Customer knowledge: Able to identify needs within resident’s patient population • Measurement: Use balanced measures to show changes have improved patient care • Making change: Demonstrate how to use several cycles of change to improve care delivery • Developing local knowledge: Apply CQI to discrete population or different subpopulations Ogrinc Acad Med, 2003

24. Resident “Competency”: SBP • Health care as system: Understand and describe the reactions of a system perturbed by change initiated by the resident • Collaboration: Contribute to interdisciplinary effort • Social context/accountability: Demonstrate business case for QI and identify community resources Ogrinc Acad Med, 2003

25. Residents and QI skills • Understand key definitions and IOM rules • Defining aim and mission statement • How to measure quality • Understand micro-systems • Process tools: • PDSA • Flowcharts

26. Residents and QI skills • Role of physician leadership • What is a physician opinion leader/champion? • Working in inter-disciplinary teams • Move beyond the ward team concept

27. Mission Statements Key ingredients for the explicit expression of goals: • Measurables • Deliverables • Timeline Dembitzer, Stanford Contemporary Practice, 2004

28. Effective Mission Statements • Clear and concise and unambiguous • Define the “problem” to be fixed • Measurable and specific • Context, target population, duration • Outcome-based (explicit positive rate or failure rate target) Dembitzer, Stanford Contemporary Practice, 2004

29. Effective Mission Statements • Reasonable, worthwhile, relevant, important topic • Issue around which to rally • Reality-based goal for broad buy-in • Related to baseline status for comparison

30. Example: Mission Statement • Improve blood pressure control in hypertensive patients VERSUS • “Within the next 12 months, 80% of our hypertensive patients will have documented blood pressures less than 140/90”

31. Measuring Quality Donabedian Model • Structure: the way a health care system is set up and the conditions under which care is provided

32. Micro-system: Definition • Small group of people who work together on a regular basis to provide care to discrete subpopulations of patients • Shares: • Clinical and business aims • Linked processes • Information • Produces performance outcomes Nelson, 2003

34. MODEL FOR EFFECTIVE CHRONIC CARE: MACROSYSTEM Health System: Organization of care Community resources and policies Delivery System Design Decision Support Clinical Information Systems Informed Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

35. Measuring Quality Donabedian Model • Process: the activities that constitute health care • Diagnosis, treatment, prevention, education, etc.

36. Understanding a Process • Any human activity that produces an output is a process • Processes tend to be hierarchical • Step A before Step B before Step C… • Helps manage complexity without drowning in detail • Allows focus within context Rudd, Stanford Contemporary Practice, 2004

37. Understanding a Process • An explicit model • Allows shared understanding and approach • Allows criticism, comparison, and improvement • Indicates what and when to measure • Documenting the process • Flow charts: conceptual block diagrams or decision flows Rudd, Stanford Contemporary Practice, 2004

38. Flowcharting TIPS -Flowchart a process, not a system -Avoid too much detail -Process should reflect mission statement -Get all necessary information -Show process as it actually occurs, not in ideal state -Critical stage: take as much time as needed -Show the flowchart to other front line people for input -Look for areas of delay, rework loops, hassles, complaints Pt checks in Pt makes appt Pt brought to room Pt examined by MD Pt processed by checkout staff MD completes papers Rudd, Stanford Contemporary Practice, 2004

39. Measuring Quality Donabedian Model • Outcomes: the changes (desired or undesired) in individuals that can be attributed to healthcare • Change in health status • Change in knowledge among patients • Change in patient behavior • Patient satisfaction

40. Practice (System) Based Patient Needs Process of Care Outcomes of Care Practice Systems

41. Practice (System) Based Patient Needs Process of Care Outcomes of Care Demographics Co-morbidity Risk Factors Barriers to Self-Care Clinical Functional Satisfaction Safety Cost Practice Systems Access Evaluation DX RX P. Activation

42. Practice (System) Based Patient Needs Process of Care Outcomes of Care Practice Systems Leadership & Teamwork Improvement Process Service Coordination Information Management Patient Education Phone/e-mail/Visits Access Evaluation DX RX P. Activation

43. Model for Improvement Act Plan Study Do What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? IHI: Nolan

44. PDSA Cycle • Plan: • Identify the problems/process first • Describe current process around improvement opportunity • Describe all possible causes of the problem - agree on root causes • Develop effective and workable solution and action plan - select targets!

45. PDSA Cycle • Do • Implement the solution of process change • Study • Review and evaluate the result of the change • Will almost always require some form of data collection (medical record audit, patient satisfaction, etc)

46. PDSA Cycle • Act • Reflect and act on the what was learned “Reflective practice for the group” • Assess the results, recommend changes • Continue improvement process where needed, standardize when possible • Celebrate success!

47. Data and Improvement • Data essential in quality improvement Without quality data, you cannot effectively: • Complete an accurate needs assessment • Measure change • Develop individual action plans • Change systems to improve patient care and residency educational programs

48. Flowcharting: Group Exercise • Flowchart a 48 year old male patient’s first visit to your residency clinic with the following known positive risk factors for cardiovascular disease: • Hypertension • Family history of AMI (Father – age 52)

49. Flowcharting: Group Exercise • How would you put together a team to improve the care of patients at risk for cardiovascular disease in your clinic?

50. Working in Teams • Multi-disciplinary • Each discipline contributes its particular expertise independently to an individual patient’s care • Physician responsible for determining contribution of other disciplines and coordination of services • Parallel structure Hall and Weaver, 2001