Transcript A reivew of PBLI and SBP competencies and QI tools.

AAIM – ABIM PIM Project
Teaching and Learning PBL&I and SBP
Objectives
 Teach residents:
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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
Teaching and Learning
PBL&I and SBP
What goals do you have for these
competencies in your residency?
Teaching and Learning
PBL&I and SBP
What is quality of care?
Quality of Care: What Is It?
 Institute of Medicine, 1990:
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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
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
IOM Recommendations
 Six major aims for health care:
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable
IOM’s 10 Rules
1. Care should be based on continuous healing
relationships
2. Customization based on patient needs and
values
3. The patient as the source of control
4. Shared knowledge and free flow of information
5. Evidenced-based decision making
IOM’s 10 Rules
6.
7.
8.
9.
10.
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
Cooperation among clinicians
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
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Accountability
Self-assessment
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.
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.
Quality of Care: Residency Clinic
 How well does this patient’s care meet
the 6 IOM criteria?
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Quality of Care: Residency Clinic
Does patient care provided by your
residency clinic meet these IOM criteria?
Why or why not?
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
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
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
PBL and I
 Two major themes:
 Effective application of EBM
to patient care
 Diagnostics,
therapeutics, etc
 Includes clinical skills!
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Quality improvement
 Individual
improvement: reflective practice
 Systems improvement: active participant
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
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
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
IOM Competency Model
IOM, 2003
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
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
Residents and QI skills
 Understand key definitions and IOM rules
 Defining aim and mission statement
 How to measure quality
 Understand micro-systems
 Process tools:
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PDSA
Flowcharts
Residents and QI skills
 Role of physician leadership
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What is a physician opinion leader/champion?
 Working in inter-disciplinary teams
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Move beyond the ward team concept
Mission Statements
Key ingredients for the explicit expression of goals:
 Measurables
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Deliverables
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Timeline
Dembitzer, Stanford Contemporary Practice, 2004
Effective Mission Statements
 Clear and concise and unambiguous
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Define the “problem” to be fixed
 Measurable and specific
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Context, target population, duration
Outcome-based (explicit positive rate or failure rate
target)
Dembitzer, Stanford Contemporary Practice, 2004
Effective Mission Statements
 Reasonable, worthwhile, relevant, important topic
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Issue around which to rally
Reality-based goal for broad buy-in
 Related to baseline status for comparison
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”
Measuring Quality
Donabedian Model
1. Structure: the way a health care system is
set up and the conditions under which care
is provided
Micro-system: Definition
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Small group of people who work together on a
regular basis to provide care to discrete
subpopulations of patients
 Shares:
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Clinical and business aims
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Linked processes
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Information
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Produces performance outcomes
Nelson, 2003
MODEL FOR EFFECTIVE CHRONIC CARE: MACROSYSTEM
Community resources
and policies
Informed
Activated
Patient
Health System: Organization of care
Delivery
System
Design
Decision
Support
Productive
Interactions
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Measuring Quality
Donabedian Model
2. Process: the activities that constitute health
care
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Diagnosis, treatment, prevention, education,
etc.
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
Understanding a Process
 An explicit model
Allows shared understanding and approach
 Allows criticism, comparison, and improvement
 Indicates what and when to measure
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 Documenting the process
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Flow charts: conceptual block diagrams or decision
flows
Rudd, Stanford Contemporary Practice, 2004
Flowcharting
Pt makes appt
Pt processed
by checkout staff
Pt checks in
Pt brought
to room
MD completes
papers
Pt examined
by MD
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
Rudd, Stanford Contemporary Practice, 2004
Measuring Quality
Donabedian Model
3. Outcomes: the changes (desired or
undesired) in individuals that can be
attributed to healthcare
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Change in health status
Change in knowledge among patients
Change in patient behavior
Patient satisfaction
Practice (System) Based
Patient
Needs
Process of
Care
Practice Systems
Outcomes of
Care
Practice (System) Based
Patient
Needs
Demographics
Co-morbidity
Process of
Care
Outcomes of
Care
Practice Systems
Clinical
Functional
Risk Factors
Satisfaction
Barriers to
Self-Care
Safety
Access
Cost
Evaluation
DX
RX
P. Activation
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
Model for Improvement
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?
Act
Plan
Study
Do
IHI: Nolan
PDSA Cycle
 Plan:
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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!
PDSA Cycle
 Do
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Implement the solution of process change
 Study
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Review and evaluate the result of the change
Will almost always require some form of data
collection (medical record audit, patient
satisfaction, etc)
PDSA Cycle
 Act
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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!
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
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:
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Hypertension
Family history of AMI (Father – age 52)
Flowcharting:
Group Exercise
 How would you put together a team to
improve the care of patients at risk for
cardiovascular disease in your clinic?
Working in Teams
 Multi-disciplinary
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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
Working in Teams
 Inter-disciplinary
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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
Interdisciplinary Education
Important principles:
 Idea dominance
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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
Interdisciplinary Education
 Professional role versus role blurring
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Most of us learn our roles through process of
professional socialization within our discipline
 Petrie’s individual “cognitive map”
 Preconceived “maps” of roles based on
learned culture, beliefs, and cognitive
approaches learned in discipline
Hall and Weaver, 2001