Practice and Curricula Transformation in Residency Practices: Are We Homes Yet?

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Practice and Curricula Transformation in
Residency Practices Are We Homes Yet?
Bonnie Jortberg, MS,RD,CDE University of
Colorado Denver Department of Family
Medicine Nicole Deaner, MSW Colorado Clinical
Guidelines Collaborative
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Who is Involved?

• Funded by The Colorado Health Foundation
• University of Colorado Dept of Family Medicine
• Perry Dickinson MD Project Director
• Bonnie Jortberg Project Coordinator,
  Curriculum Redesign
• Doug Fernald, Evaluation
• Frank deGruy MD
• Larry Green MD

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Who is Involved?

• Colorado Clinical Guidelines Collaborative (CCGC)
• Nicole Deaner Practice Improvement Coach
• Caitlin ONeill Practice Improvement Coach
• Julie Schilz Manager, IPIP and PCMH
• Marjie Harbrecht CCGC Executive Medical
  Director
• Colorado Association of Family Medicine
  Residencies
• Nine Family Medicine Residencies one track
• 10 residency practices
• Tony Prado-Gutierrez Director

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What is Involved?Planning Phase

• Preparation for practice and curricular redesign
• Assistance with IT issues
• Start working on forming improvement team
• Practice/program discussions of PCMH
• Sponsoring organization look for support, try
  to remove barriers
• Prepare for cultural transformation

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Practice Coaching

• Active coaching period approximately 14 months
• Assessment with feedback 2 months
• Active coaching with practice improvement team(s)
  12 months (or more)
• Continued team meetings for PCMH changes, other
  practice improvement with coach boosters

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Collaboratives

• Meetings of representatives of all practices and
  programs
• Planning, sharing, educational highly
  interactive
• Two collaboratives per year
• First one May 2009 105 people from the
  practices
• Second in October over 130 from practices

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Whats Provided?

• Assistance with orientation to PCMH, initial
  planning, working with hospital leadership
• Coaching team provided
• IT consultation resources
• PCMH consultation and support
• NCQA PPC-PCMH certification paid for
• Direct funding for the programs

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Curricular Redesign Objectives

• Facilitation and consultation for PCMH-related
  curriculum changes
• Changes to free up residents to participate in
  PCMH and QI efforts
• Shared resource development across programs
  (lectures, modules, etc)
• Active involvement of residents in practice
  redesign process
• PCMH practices for residents to experience

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Practice Outcomes

• Achieve NCQA PPC-PCMH certification hopefully
  at least level 2
• Improve level of medical homeness
• NCQA PCMH assessment
• PCMH Clinician Assessment
• Practice Staff Questionnaire
• Improve quality measures in two clinically
  important areas to be chosen by the practices

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Curricular Outcomes

• Improved resident achievement of PCMH
  competencies
• Improved resident use of PCMH elements as
  assessed by PCMH clinician assessment
• Revision of residency curricula to allow resident
  participation in PCMH and QI efforts
• Implementation of PCMH curricular elements
• Will follow resident In-training Exam and Board
  Exam scores, but may not show up there

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Two Parts of ProjectPractice and Curriculum
Redesign

Curricular Redesign
PCMH Residency Practice
Practice Improvement
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Practice PCMH Transformation

NCQA Certification
Iterative Practice Redesign
Cultural Transformation
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Baseline Assessment Process Practice
Improvement

• NCQA Self-Assessment group or individual
• Key Informant Interviews
• Cycle Time Report
• Online surveys using survey monkey
• PCMH - Clinician Assessment (PCMH-CA)
• Practice Staff Questionnaire (PSQ)

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Baseline Assessment Report

• Structure
• Narrative explanation and assessment on 7 core
  elements
• Data tables for responses to NCQA Self-Assessment
  responses to PSQ PCMH-CA
• Recommendation section
• Approximately 10 pages long
• Appendix
• PCMH-CA PSQ graphic data (previous slides) with
  narrative explanation
• NCQA Self-Assessment Report

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Practice Redesign Lessons Learned

• Leadership buy-in prior to project launch
  critical.
• High-functioning teams build foundation for
  project.
• Clinic flow - first entrée into working on teams
  teaching QI principles.
• QI teams big cultural shift for existing
  leadership structure largest source of
  resistance.
• Building communication infrastructure for all
  staff inclusion a local and important process.
• Current choosing clinically important
  conditions registries
• Next steps Patient Involvement and Reporting
  Posting Measures

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Curriculum Redesign

• Challenges and Opportunities
• No organized, comprehensive PCMH curriculum or
  materials
• No developed curriculum competencies
• No tools to assess PCMH curricular activities or
  resident competency

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Curriculum Redesign

• Started with developing competencies
• (see handout)
• Curriculum Assessment
• Developed Residency Curriculum Semi-Structured
  Interview Template to determine current PCMH
  curricular activities identify gaps set goals
  and establish plan

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Curriculum Assessment

• Competencies
• Who, what, where, when, how for each
• Summary Questions
• Strengths/weaknesses of curriculum
• What do they need the most help with for the
  curriculum?
• Resource for other programs
• How do they characterize their sponsors interest
  and support for this project?
• Residents interest and support (scale 1-5)
• Staff and faculty support

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Resident PCMH Curriculum Competency Survey

• Developed to assess resident baseline competence
  (See handout)

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Results and Lessons Learned

• Interview completed with 3 programs so far
• Emerging Themes
• Interview process is an intervention for the
  program
• Makes them take comprehensive look at what they
  are teaching
• We want to go from reactive teaching to
  intentional teaching
• Revealing that they are teaching many of the
  elements of the PCMH, just not in an organized
  manner
• Resident participation on the QI teams an
  important curricular component

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Results and Lessons Learned

• Common areas meeting competencies (through
  resident involvement in QI teams)
• Team approach
• Integrated and coordinated care
• Quality Improvement
• Leadership skills
• Common areas not meeting competencies
• Population management
• Access to care
• Information systems to support PCMH
• Self-management support

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Results and Lessons Learned

• Time-consuming process
• Great qualitative data
• Quantitative data still to be determined

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Curriculum Redesign Next Steps

• Review feedback report
• Goal setting for each practice
• Actively developing curricular modules and tools
• Integration of curricular modules and tools
• Continuous evaluation

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Questions?

• Contact Information
• Bonnie Jortberg
• bonnie.jortberg_at_ucdenver.edu
• Nicole Deaner
• ndeaner_at_coloradoguidelines.org