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AAIM ABIM PIM Project Teaching and Learning PBL

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Title: AAIM ABIM PIM Project Teaching and Learning PBL


1
AAIM ABIM PIM ProjectTeaching and Learning
PBLI 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 PBLI and SBP
  • What goals do you have for these competencies in
    your residency?

4
Teaching and Learning PBLI 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
IOMs 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
IOMs 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 ones 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 patients 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 PBLI
  • Customer knowledge Able to identify needs within
    residents 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
33
(No Transcript)
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
MD completes papers
Pt processed by checkout staff
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
Outcomes of Care
Process 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
Outcomes of Care
Process 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
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 patients 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
    patients care
  • Physician responsible for determining
    contribution of other disciplines and
    coordination of services
  • Parallel structure

Hall and Weaver, 2001
51
Working in Teams
  • Inter-disciplinary
  • Team members work closely together and
    communicate frequently to optimize patient care
  • Team organized around solving common set of
    problems
  • Frequent consultation
  • Matrix structure

Hall and Weaver, 2001
52
Interdisciplinary Education
  • Important principles
  • Idea dominance
  • Clear and recognizable idea must serve as focus
    for teamwork
  • Patient center of that focus
  • Team must also be able to recognize success and
    achievements

Petrie, 1976
53
Interdisciplinary Education
  • Professional role versus role blurring
  • Most of us learn our roles through process of
    professional socialization within our discipline
  • Petries individual cognitive map
  • Preconceived maps of roles based on learned
    culture, beliefs, and cognitive approaches
    learned in discipline

Hall and Weaver, 2001
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