Title: AAIM ABIM PIM Project Teaching and Learning PBL
1AAIM ABIM PIM ProjectTeaching and Learning
PBLI and SBP
2Objectives
- 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
3Teaching and Learning PBLI and SBP
- What goals do you have for these competencies in
your residency?
4Teaching and Learning PBLI and SBP
5Quality 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
6IOM 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
7IOM Recommendations
- Six major aims for health care
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
8IOMs 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
9IOMs 10 Rules
- Safety as a system property
- The need for transparency
- Anticipation of needs
- Continuous decrease in waste
- Cooperation among clinicians
10Reflective 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
11Quality 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.
12Quality 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.
13Quality of Care Residency Clinic
- How well does this patients care meet the 6 IOM
criteria? - Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
14Quality of Care Residency Clinic
- Does patient care provided by your residency
clinic meet these IOM criteria? - Why or why not?
15Practiced-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
16PBL 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
17PBL 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
18PBL 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
19Systems-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
20Systems-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
21Systems-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
22IOM Competency Model
IOM, 2003
23Resident 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
24Resident 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
25Residents 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
26Residents 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
27Mission Statements
- Key ingredients for the explicit expression of
goals - Measurables
- Deliverables
- Timeline
Dembitzer, Stanford Contemporary Practice, 2004
28Effective 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
29Effective 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
30Example 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
31Measuring Quality
- Donabedian Model
- Structure the way a health care system is set up
and the conditions under which care is provided
32Micro-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)
34MODEL 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
35Measuring Quality
- Donabedian Model
- Process the activities that constitute health
care - Diagnosis, treatment, prevention, education, etc.
36Understanding 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
37Understanding 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
38Flowcharting
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
39Measuring 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
40Practice (System) Based
Patient Needs
Process of Care
Outcomes of Care
Practice Systems
41Practice (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
42Practice (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
43What 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
44PDSA 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!
45PDSA 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)
46PDSA 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!
47Data 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
48Flowcharting 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)
49Flowcharting Group Exercise
- How would you put together a team to improve the
care of patients at risk for cardiovascular
disease in your clinic?
50Working 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
51Working 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
52Interdisciplinary 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
53Interdisciplinary 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