Transcript Slide 1

Linking Outcomes of Care
and the ACGME Core
Competencies:
A Matrix Solution
John W. Bingham, MHA
Director, Center for Clinical Improvement
Vanderbilt University Medical Center
Nashville, TN
Doris Quinn, PhD
Assistant Professor, Division of Medical Education
Vanderbilt University School of Medicine
Director, Improvement Education
Center for Clinical Improvement
Vanderbilt University Medical Center
The Healthcare
Matrix
Note from the Authors:
This slide presentation was created to assist learners complete the
Matrix. This tool helps teach the competencies while identifying
opportunities for improvements in care and education. It is our best
thinking thus far, but with more organizations using the Matrix, we
learn better and easier ways to complete it. We hope you will assist
us in the improvement of our tool.
To learn the competencies, it is best to have individuals complete the
Matrix for a patient, especially in preparation for a case presentation
or M&M conference.
Vanderbilt University Medical Center
Introduction to the Matrix
• The Matrix was partially inspired by the IOM report,
Crossing the Quality Chasm, which states that there
is a chasm between the healthcare that healthcare
providers now provide and the healthcare that they
are capable of providing. In the Matrix, the resulting
IOM Aims for Improvement are linked with the
ACGME Core Competencies to form the Healthcare
Matrix.
• The Matrix provides a way for users to examine their
patient care through every facet of the Aims and
Competencies, thus identifying improvement
opportunities.
Vanderbilt University Medical Center
Introduction to the Matrix
As medical students, residents and faculty
work with the Matrix, they begin to identify
the facilitators and barriers to quality
education and quality of care. For example,
unsafe care is often attributed to individuals
but it is more often a result of the interaction
of people and systems. This tool makes
these interdependencies explicit, and more
importantly, forces the users to identify what
was learned and what might be improved
from completing the Matrix.
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PATIENT CARE that is…
Safe
“Avoiding injuries to patients from the care
that is intended to help them”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
“Reducing waits and sometimes harmful
delays for both those who receive and
those who give care”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
“Providing services based on scientific
knowledge to all who could benefit and
refraining from providing services to
those not likely to benefit”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
“Avoiding waste, including waste of
equipment, supplies, ideas, and energy”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
“Providing care that does not vary in
quality because of personal characteristics
such as gender, ethnicity, geographic
location, and socio-economic status”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
Patient-Centered
“Providing care that is respectful of and
responsive to individual patient
preferences, needs and values and
ensuring that patient values guide all
clinical decisions.”
Vanderbilt University Medical Center
What must we know?
EDUCATION focuses on..
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
“…about established and evolving biomedical,
clinical, and cognate sciences, (e.g.
epidemiological and social-behavior) and the
application of this knowledge to patient care”
Vanderbilt University Medical Center
What must we say?
EDUCATION focuses on.. Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
“…that result in effective information exchange
and teaming with patients, their families, and
other health professionals.”
Vanderbilt University Medical Center
How must we behave?
EDUCATION focuses on.. Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
“…as manifested through a commitment to
carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to
a diverse patient population.”
Vanderbilt University Medical Center
What is the Process?
On whom do we depend?
Who depends on us?
EDUCATION focuses on.. Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
“…as manifested by actions that demonstrate an
awareness of, and responsiveness to, a larger context
and system of healthcare and the ability to effectively
call on system resources to provide
care that is of optimal value.”
Vanderbilt University Medical Center
What have we learned?
What will we improve?
EDUCATION focuses on.. Safe
Timely
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
Practice-Based
Learning &
Improvement
Vanderbilt University Medical Center
Effective
Efficient
Equitable
Patient Centered
Preparation for Matrix






History
Physical Exam
Labs
Diagnosis
Tests
Consults
Etc.
Vanderbilt University Medical Center
Care of
Patient
(Matrix)
The Case
•
A patient with multiple comorbidities presented to the ER with
trouble swallowing, shortness of breath, and fever for two days.
An exam was performed and several oral problems were
identified, including a mouth infection that can cause difficulty
breathing. She underwent a tracheotomy.
•
She was transferred to the MICU where treatment for sepsis was
begun. She slowly improved over the following seven days and by
day ten she was breathing on her own. After a scheduled trach
tube change, the patient went into respiratory arrest. Mask
ventilation was unsuccessful. A code was called, and the MICU
team responded. The airway was suctioned and a blockage was
detected.
•
Although the MICU and anesthesia teams had been informed by
Otolaryngology team members that she was a difficult intubation
and that the tracheotomy site had a distal obstruction, they both
attempted to intubate orally and proved unsuccessful.
•
Despite undergoing a bronchoscopy which identified and broke
up a hard mucous crust, the patient could not be revived.
Vanderbilt University Medical Center
Care of Patient(s) with…
Competencies
Aims
Aims
Safe
Timely
Effective
Assessment of Care
Efficient
Equitable
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
Fill in diagnosis or
event
(What must we know?)
Interpersonal &
Communication
Skills
“respiratory distress
Otolaryngology: Head and Neck
Surgery”
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
PatientCentered
Care of Patients with respiratory distress
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Safe
Timely
Effective
Assessment of Care
Efficient
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
The first ACGME competencies is Patient Care.
How do we measure this? The IOM defines it
as care that is: safe, timely, effective, efficient,
equitable, and patient-centered. The Matrix
begins with a global assessment of these 6
aims for improvement.
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Safe
Timely
Effective
Assessment of Care
Efficient
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
Definition: Avoiding injuries
to patients from the care that
is intended to help them.
In this case the answer is
“No”
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Safe
Timely
Effective
Assessment of Care
Equitable
No
Medical
Knowledge &
Skills
Definition: Medical knowledge about
established and evolving biomedical,
clinical and cognate sciences and the
application of this knowledge to patient
care.
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
“Red rubber catheters too flexible and
can bend easily – may be hard to remove
or suction hardened secretions (unknown
frequency of suctioning and use of saline
to loosen secretions)”
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Efficient
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Safe
Timely
Effective
Assessment of Care
Efficient
Equitable
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Interpersonal &
Communication
Skills
Definition: Skills that result in effective
information exchange and teaming
with patients, their families and other
health professionals.
Professionalism
“Better way to communicate likelihood
of obstruction and difficult airway
anatomy.”
(What must we say?)
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Safe
Timely
Effective
Assessment of Care
Equitable
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Better way to
communicate
likelihood of
obstruction and
difficult airway
Professionalism
Definition: A commitment to
carrying out professional
responsibilities, adherence to
ethical principles, and sensitivity
to a diverse patient population.
(How must we behave?)
“MICU/anesthesia ignore
otolaryngology advice about
securing airway.”
System-Based
Practice
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Efficient
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
Safe
Timely
Effective
Assessment of Care
Equitable
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
System-Based
Practice
Definitions: Actions that
demonstrate an awareness of and
responsiveness to the larger
context and system of health care
and the ability to effectively call
on system resources to provide
care that is of optimal value.
(This information was the same as
the last comment.)
(On whom do we depend
and who depends on us?)
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Efficient
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
Equitable
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Better way to
communicate
likelihood of
obstruction and
difficult airway
Definition: Involves
investigation and evaluation of
their own patient care, appraisal
and assimilation of scientific
evidence, and improvement of
patient care.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
(This is a synthesis of the cells
above, however, it is best to
finish the rest of the Matrix and
Improvement
complete this last.)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Efficient
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
Equitable
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Definition: Avoiding injuries
to patients from the care that
is intended to help them.
Better way to
communicate
likelihood of
obstruction and
difficult airway
“No”
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Efficient
Vanderbilt University
All rights reserved.
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Effective
Assessment of Care
Better way to
communicate
likelihood of
obstruction and
difficult airway
PatientCentered
“Delay in obtaining flexible bronchoschope
during oral attempts at intubation.”
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
Vanderbilt University
Equitable
Definition: Medical knowledge about
established and evolving biomedical,
clinical and cognate sciences and the
application of this knowledge to patient
care.
Practice-Based
Learning &
Improvement
© 2004 Bingham, Quinn
Efficient
All rights reserved.
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Effective
Assessment of Care
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
PatientCentered
Definition: Skills that result in effective
information exchange and teaming with
patients, their families and other health
professionals.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
Vanderbilt University
Equitable
“Patient with poor lung reserve, time
wasted during oral attempts – patient
unable to tolerate prolonged apnea”
Practice-Based
Learning &
Improvement
© 2004 Bingham, Quinn
Efficient
All rights reserved.
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
“MICU responsive to code
initially”
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
PatientCentered
Definition: A commitment to
carrying out professional
responsibilities, adherence to
ethical principles, and sensitivity
to a diverse patient population.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Practice-Based
Learning &
Improvement
Efficient
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
PatientCentered
“Knowledge of where
bronchoscopes are located for
each ICU”
Improvement
(What have we learned?
What will we improve?)
Equitable
Definitions: Actions that
demonstrate an awareness of and
responsiveness to the larger
context and system of health care
and the ability to effectively call
on system resources to provide
care that is of optimal value.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Practice-Based
Learning &
Improvement
Efficient
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Effective
Assessment of Care
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
(What have we learned?
What will we improve?)
“No”
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
PatientCentered
Definition: Avoiding injuries
to patients from the care that
is intended to help them.
Improvement
Practice-Based
Learning &
Improvement
Efficient
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
(What have we learned?
What will we improve?)
Vanderbilt University
All rights reserved.
PatientCentered
Definition: Medical
knowledge about
established and evolving
biomedical, clinical and
cognate sciences and the
application of this
knowledge to patient care.
“Airway obtained through
tracheotomy site with
apparent distal obstruction,
oral intubation unlikely to
bypass obstruction”
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Equitable
No
Improvement
Practice-Based
Learning &
Improvement
Efficient
Care of Patients with respiratory distress
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Timely
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Definition: Skills that
result in effective
information exchange
and teaming with
patients, their families
and other health
professionals.
Knowledge of where
bronchoscopes are
located for each ICU
“Poor communication
about steps required to
secure airway”
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Efficient
Equitable
PatientCentered
Safe
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
Safe
Timely
Effective
Assessment of Care
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Poor communication
about steps required
to secure airway
Efficient
Equitable
PatientCentered
Definition: A commitment to
carrying out professional
responsibilities, adherence to
ethical principles, and
sensitivity to a diverse patient
population.
(No information entered here)
System-Based
Practice
(On whom do we depend
and who depends on us?)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
PatientCentered
Definitions: Actions that
demonstrate an awareness of
and responsiveness to the
larger context and system of
health care and the ability to
effectively call on system
resources to provide care that
is of optimal value.
“Determine role of nurses,
respiratory therapists, and
physician in managing
tracheotomy patients”
Improvement
Practice-Based
Learning &
Improvement
Efficient
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
Effective
Assessment of Care
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Efficient
Equitable
PatientCentered
Definition: Avoiding
injuries to patients
from the care that is
intended to help them.
“No”
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
Safe
Timely
Effective
Assessment of Care
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Definition: Medical
knowledge about
(What must we know?)
established and evolving
Interpersonal & Better way to biomedical,
clinical
and
Patient with poor
lung
Poor communication
reserve, time wasted
Communication communicate
likelihood of
about steps required
cognate
sciences
during
oral attempts at and the
obstruction and
to secure airway
Skills
intubation
difficult airway
application of this
(What must we say?)
knowledge to patient
MICU/Anesthesia
care.to
MICU responsive
Professionalism ignore otolaryngology
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
advice about securing
airway.
code initially
“Time delay due to oral
Determine role of
intubation
attempts
that
nurses,
respiratory
MICU/Anesthesia
therapists, and
Knowledge of where
ignore otolaryngology
predictably
would
not be
physician
in managing
bronchoscopes
are
advice about securing
tracheotomy patients
located for each ICU
airway.
successful in restoring
airway” Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Efficient
No
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Safe
Timely
No
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
Effective
Assessment of Care
Definition: Skills that
result in effective
Interpersonal & Better way to information
Patient with poor
lung
exchange
Poor communication
reserve, time wasted
Communication communicate
likelihood of
about steps required
oral attempts at
andduring
teaming
with
obstruction and
to secure airway
Skills
intubation
difficult airway
patients, their families
(What must we say?)
and other health
MICU/Anesthesia
MICU responsive to
Professionalism ignore otolaryngology professionals.
(What must we know?)
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
advice about securing
airway.
code initially
“Inefficient attempts at
Determine role of
nurses,
respiratory
oral
intubation
=
time
lost
MICU/Anesthesia
therapists, and
Knowledge of where
ignore otolaryngology
physician in managing
for patient”
bronchoscopes
are
advice about securing
airway.
located for each ICU
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Efficient
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Safe
Timely
No
No
Effective
Assessment of Care
No
Definition: A commitment to
Airway obtained
Medical
carrying
professional
Delay out
in obtaining
through tracheotomy
flexible bronchoscope
site with apparent
Knowledge &
responsibilities,
adherence
tooral
during oral attempts
at
distal obstruction,
Skills
intubation
unlikely to
ethical
principles,intubation
and
bypass
obstruction
(What must we know?)
sensitivity to a diverse patient
Interpersonal & Better way to
Patient
with poor lung
population.
communicate
Poor communication
reserve, time wasted
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
likelihood of
obstruction and
difficult airway
during oral attempts at
intubation
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
about steps required
to secure airway
(No information entered here)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Efficient
No
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Inefficient attempts at
oral intubation = time
lost for patient
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Safe
Patient Care
(Overall Assessment)
Yes/No
Timely
Effective
Assessment of Care
No
Definitions: No
Actions that No
ability
system
secretions to effectively call on
bypass
obstruction
resources to provide care that is of
Interpersonal & Better way to
Patient with poor lung
Poor communication
optimal
value.
reserve, time
wasted
Communication communicate
(What must we know?)
likelihood of
obstruction and
difficult airway
during oral attempts at
intubation
about steps required
to secure airway
“Inefficient system for tracheotomy
care
(i.e. supplies, specified nursing
MICU/Anesthesia
MICU responsive to
Professionalism ignore otolaryngologyinstructions)”
advice about securing
code initially
(What must we say?)
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Equitable
No
No
demonstrate an awareness of and
Red rubber catheters
Airway obtained
Medical
responsiveness
the larger
context
too flexible and can
Delayto
in obtaining
through
tracheotomy
Knowledge & bend easily – may be flexible bronchoscope site with apparent
and
system
of
health
care
and
the oral
hard to remove
or
during
oral attempts
at
distal
obstruction,
Skills
suction hardened
intubation
intubation unlikely to
Skills
Efficient
Vanderbilt University
All rights reserved.
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Inefficient attempts at
oral intubation = time
lost for patient
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
No
Knowledge of where
bronchoscopes are
located for each ICU
Poor communication
about steps required
to secure airway
“No”
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
Vanderbilt University
No
Definition:
Avoiding
Airway obtained
Time delay due to oral
through tracheotomy
intubation attempts
injuries to
patients
from
site with apparent
that predictably would
distal obstruction, oral
not be successful in
the careintubation
that unlikely
is intended
to
restoring airway
bypass obstruction
to help
them.
Practice-Based
Learning &
Improvement
© 2004 Bingham, Quinn
Efficient
All rights reserved.
Inefficient attempts at
oral intubation = time
lost for patient
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Equitable
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
Safe
Timely
Effective
Assessment of Care
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
during oral attempts at
intubation
to secure airway
Efficient
Equitable
No
No
Time delay due to oral
Definition: Medical knowledge about
intubation attempts
that predictably would
established and evolving not be successful in
restoring airway
(What must we know?)
biomedical, clinical and cognate
and the application of this
Interpersonal & Better way to sciences
Patient with poor lung
communicate
Poor communication
Inefficient attempts at
reserve, time wasted to patient care.
knowledge
Communication likelihood of
about steps required
oral intubation = time
Skills
(What must we say?)
obstruction and
difficult airway
lost for patient
“Approach to tracheotomy care and
airway emergencies differ depending
MICU/Anesthesia
MICU responsive to
Professionalism ignore otolaryngology
on experience,
training, and hospital
code initially
(How must we behave?) advice about securing
airway.
ward”
System-Based
Practice
(On whom do we depend
and who depends on us?)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Effective
Assessment of Care
Efficient
Equitable
No
No
No
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Definition: Skills that result
in effective information
exchange and teaming with
patients,
Patient with their
poor lung families and
Poor communication
reserve, time wasted
about steps required
other
health
professionals.
during
oral attempts
at
to secure airway
intubation
Inefficient attempts at
oral intubation = time
lost for patient
(No information entered
MICU/Anesthesia
to
Professionalism ignore otolaryngology MICU responsivehere)
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
code initially
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
Efficient
Equitable
No
No
No
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Definition: A commitment to
carrying out professional
responsibilities,
adherence
Patient with
poor lung
reserve, time wasted
Poor principles,
communication
Inefficient
to ethical
andattempts at
during oral attempts
at
about steps required
oral intubation = time
intubation – patient
to secure
lost for patient
sensitivity
toairway
a diverse
unable to tolerate
prolonged apnea
patient population.
MICU responsive to
code initially
(No information entered
here)
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
Efficient
Equitable
No
No
No
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Definitions: Actions that
demonstrate
an awareness of and
Patient with poor lung
Poor communication
Inefficient attempts at
reserve, time wasted
about
steps
required
oral intubation
= time
responsiveness
to
the
larger
context
during oral attempts at
to secure airway
lost for patient
intubation
and system of health care and the
ability to effectively call on system
resources
to provide care that is of
MICU responsive to
code initially optimal value.
Determine role of
“Trach care may
vary depending
nurses, respiratory
Inefficient system for
therapists, and
Knowledge of where
upon
patient
floor”
tracheotomy care (i.e.
physician
in
managing
bronchoscopes are
located for each ICU
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
supplies, specified
nursing instructions)
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No/?
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
Knowledge of where
bronchoscopes are
located for each ICU
(What have we learned?
What will we improve?)
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Equitable
No
No
Definition: Avoiding
Approach to
Time delay due to oral
tracheotomy care and
intubation
attempts
injuries
to patients
from
airway emergencies
that predictably would
differ depending on
not be
successful
the care
that
isinintended
experience, training,
restoring airway
to help them. and hospital ward
Improvement
Practice-Based
Learning &
Improvement
Efficient
Inefficient attempts at
oral intubation = time
lost for patient
“?”
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Trach care may vary
depending on patient
floor
PatientCentered
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Effective
Assessment of Care
Definition: Medical knowledge about
established and evolving
biomedical, clinical and cognate
Patient with poor lung
reserve, time wasted
sciences
and the application
Poor communication
Inefficient attempts at of this
during oral attempts at
about steps required
oral intubation = time
intubation – patient
knowledge
tolostpatient
care.
to secure airway
for patient
unable to tolerate
prolonged apnea
“Patients may receive different
MICU responsive to
levels of tracheotomy care
code initially
depending on nursing staff, hospital
ward,
and managing service”
Determine role of
Knowledge of where
bronchoscopes are
located for each ICU
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Trach care may vary
depending on patient
floor
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Effective
Assessment of Care
Definition: Skills that result in
effective information exchange
and teaming with patients, their
Patient with poor lung
reserve, time wasted
families
and other
health
Poor communication
Inefficient attempts at
during oral attempts at
about steps required
oral intubation = time
intubation – patient
professionals.
to secure airway
lost for patient
unable to tolerate
prolonged apnea
“Contacted family after death –
both MICU and ENT present for
MICU responsive to
code initially
discussion”
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Trach care may vary
depending on patient
floor
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Effective
Assessment of Care
Definition: A commitment
to carrying out
professional
Poor communication
Inefficient attempts at
about stepsresponsibilities,
required
oral intubation = time
adherence
to secure airway
lost for patient
to ethical principles, and
sensitivity to a diverse
patient population.
(No information entered)
System-Based
Practice
(On whom do we depend
and who depends on us?)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Trach care may vary
depending on patient
floor
Contacted family after
death – both MICU
and ENT present for
discussion
Care of
Patients
respiratory
distress
Care
of awith
Patient
with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Effective
Assessment of Care
Definitions: Actions that
Poor communication
Inefficientan
attempts
at
demonstrate
awareness
of
about steps required
oral intubation = time
to secure
airway
lost for patient
and
responsiveness
to the larger
context and system of health
care and the ability to effectively
call on system resources to
provide care that is of optimal
value.
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Trach care may vary
depending on patient
floor
(No information entered)
Improvement
Practice-Based
Learning &
Improvement
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Contacted family after
death – both MICU
and ENT present for
discussion
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Efficient
Equitable
PatientCentered
No
No
No
?
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
Inefficient attempts at
oral intubation = time
lost for patient
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Effective
Assessment of Care
Definition: Involves investigation
and evaluation of their own patient
care, appraisal
and
assimilation
of
Determine role
of
Inefficient system for
Knowledge of where
nurses, respiratory
Trach care may vary
tracheotomy
care (i.e.
scientific
evidence,
and
bronchoscopes are
therapists, and
depending on patient
supplies, specified
located for each ICU
physician in managing
floor
nursing
instructions)
improvement
of patient care.
tracheotomy patients
Improvement
Practice-Based
Learning &
Improvement
.
(What have we learned?
What will we improve?)
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Contacted family after
death – both MICU
and ENT present for
discussion
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Efficient
Equitable
PatientCentered
No
No
No
?
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
Inefficient attempts at
oral intubation = time
lost for patient
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Effective
Assessment of Care
Safe: Avoiding injuries to
patients from the care
that is intended to help them
“Need variety of suction
catheters available.
Determine
the essential
Determine
role of
Inefficient system for
nurses, respiratory
Trach care may vary
tracheotomy
care (i.e.
equipment
for
tracheotomy
therapists, and
depending on patient
supplies, specified
physician in managing
floor
nursing
instructions)
tracheotomy patients care.
Improve
ENT communication
Improvement
with other departments.”
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Contacted family after
death – both MICU
and ENT present for
discussion
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Effective
Assessment of Care
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Timely: Reducing waits
and sometimes
harmful delays for
both those who
Poor communication receive
Inefficient attempts
andatthose who
about steps required
oral intubation = time
give care
to secure airway
lost for patient
“Need clear steps to be
taken for airway
emergency in patients
with tracheostomy
with poor pulmonary
Determine role of
reserve
and
difficult
Inefficient system
for
nurses, respiratory
Trach care may vary
tracheotomy care (i.e.
anatomic
airway.
therapists, and
depending on patient
supplies, specified
physician in managing
tracheotomy patients
Improvement
Need variety of suction
catheters available
.Determine the essential
equipment for
tracheotomy care.
Improve ENT
communication with other
departments.
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
nursing instructions)
floor
Know location of
bronchoscope/light
source in units.”
Contacted family after
death – both MICU
and ENT present for
discussion
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Efficient
Equitable
PatientCentered
No
No
No
?
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Knowledge of where
bronchoscopes are
located for each ICU
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Effective
Assessment of Care
Determine role of
nurses, respiratory
therapists, and
physician in managing
tracheotomy patients
“Method to succinctly
communicate whether
patient can be orally
intubated
to minimize
Inefficient system
for
Trach care may vary
tracheotomy care (i.e.
depending on patient
unsuccessful
attempts at
supplies, specified
floor
nursing instructions)
securing airway.
Improvement
Need variety of suction
catheters available
.Determine the essential
equipment for
tracheotomy care.
Improve ENT
communication with other
departments.
Need clear steps to be taken
for airway emergency in
patients with tracheostomy
with poor pulmonary reserve
and difficult anatomic airway.
Know where broncboscopes
are for each unit
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Effective: Providing
services based on scientific
knowledge to all who could
family after
and refrainingContacted
from
Inefficientbenefit
attempts at
death – both MICU
oral intubation = time
ENT present for
providing services toand
those
lost for patient
discussion
not likely to benefit
Vanderbilt University
All rights reserved.
Define clear roles for trach
cases.”
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Efficient
Equitable
PatientCentered
No
No
No
?
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
Inefficient attempts at
oral intubation = time
lost for patient
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Better way to
communicate
likelihood of
obstruction and
difficult airway
Effective
Assessment of Care
Contacted family after
death – both MICU
and ENT present for
discussion
Effective: Avoiding waste,
including waste of
MICU/Anesthesia
MICU responsive
to
Professionalism ignore otolaryngology
equipment,
supplies,
code initially
(How must we behave?) advice about securing
airway.
ideas, and energy
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
role of
“CreateKnowledge
order
set toDetermine
of where
nurses, respiratory
bronchoscopes are
and
specify
supplies therapists,
located for each ICU
physician in managing
necessary, as well astracheotomy patients
Improvement
initial steps if airway lost.”
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Need variety of suction
catheters available
.Determine the essential
equipment for
tracheotomy care.
Improve ENT
communication with other
departments.
Need clear steps to be taken
for airway emergency in
patients with tracheostomy
with poor pulmonary reserve
and difficult anatomic airway.
Know where broncboscopes
are for each unit
Method to succinctly
communicate whether
patient can be orally
intubated to minimize
unsuccessful attempts at
securing airway.
Define clear roles for
trach cases.
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Inefficient system for
tracheotomy care (i.e.
supplies, specified
nursing instructions)
Trach care may vary
depending on patient
floor
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Better way to
communicate
likelihood of
obstruction and
difficult airway
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Need variety of suction
catheters available
.Determine the essential
equipment for
tracheotomy care.
Improve ENT
communication with other
departments.
Efficient
Equitable
PatientCentered
No
No
No
?
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Effective
Assessment of Care
Equitable: Providing care that
does not vary in quality
Patient with
poor lung
because
of personal
reserve, time wasted
Poor communication
attempts at
duringcharacteristics
oral attempts at
such asInefficient
about steps required
oral intubation = time
intubation – patient
to secure airway
lost for patient
unable to tolerateethnicity, geographic
gender,
prolonged apnea
location, and socio-economic
status
MICU responsive to
code initially
“Have standard order set
available for all ICU’s and
Determine role of
Inefficient system for
floors.
Knowledge of where
nurses, respiratory
tracheotomy care (i.e.
bronchoscopes are
therapists, and
supplies,
Make
order
set
easy
to use
so specified
located for each
ICU
physician
in managing
nursing instructions)
tracheotomy patients
different services may
Improvement
implement.”
Method to succinctly
Need clear steps to be taken
for airway emergency in
patients with tracheostomy
with poor pulmonary reserve
and difficult anatomic airway.
Know where broncboscopes
are for each unit
communicate whether
patient can be orally
intubated to minimize
unsuccessful attempts at
securing airway.
Define clear roles for
trach cases.
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
Contacted family after
death – both MICU
and ENT present for
discussion
All rights reserved.
Create order set to
specify supplies
necessary, as well as
initial steps if airway lost.
Trach care may vary
depending on patient
floor
Care of Patients with respiratory distress
Care of a Patient with…
Otolaryngology: Head and Neck Surgery
Competencies
Aims
Aims
Patient Care
(Overall Assessment)
Yes/No
Medical
Knowledge &
Skills
(What must we know?)
Interpersonal &
Communication
Skills
(What must we say?)
Professionalism
(How must we behave?)
System-Based
Practice
(On whom do we depend
and who depends on us?)
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Efficient
Equitable
PatientCentered
No
No
No
?
Delay in obtaining
flexible bronchoscope
during oral attempts at
intubation
Airway obtained
through tracheotomy
site with apparent
distal obstruction, oral
intubation unlikely to
bypass obstruction
Time delay due to oral
intubation attempts
that predictably would
not be successful in
restoring airway
Approach to
tracheotomy care and
airway emergencies
differ depending on
experience, training,
and hospital ward
Patients may receive
different levels of
tracheotomy care
depending on nursing
staff, hospital ward,
and managing service
Better way to
communicate
likelihood of
obstruction and
difficult airway
Patient with poor lung
reserve, time wasted
during oral attempts at
intubation – patient
unable to tolerate
prolonged apnea
Poor communication
about steps required
to secure airway
Inefficient attempts at
oral intubation = time
lost for patient
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
MICU responsive to
code initially
Safe
Timely
No
No
Red rubber catheters too
flexible and can bend easily –
may be hard to remove or
suction hardened secretions
(unknown frequency of
suctioning and use of saline to
loosen secretions)
MICU/Anesthesia
ignore otolaryngology
advice about securing
airway.
Need variety of suction
catheters available
.Determine the essential
equipment for
tracheotomy care.
Improve ENT
communication with other
departments.
Effective
Assessment of Care
Patient-Centered: Providing care that
is respectful of and responsive to
individual patient preferences, needs
Determine role of
Inefficient that
system for
ensuring
patient
Knowledgeand
of wherevalues
nurses, and
respiratory
Trach care may vary
tracheotomy care (i.e.
bronchoscopes are
therapists, and
depending on patient
supplies, specified
values
guide
all clinical
decisions.
located for each
ICU
physician
in managing
floor
nursing instructions)
tracheotomy patients
Improvement
(No information
Need clear steps to be taken
for airway emergency in
patients with tracheostomy
with poor pulmonary reserve
and difficult anatomic airway.
Know where broncboscopes
are for each unit
Method to succinctly
communicate whether
patient can be orally
intubated to minimize
unsuccessful attempts at
securing airway.
Define clear roles for
trach cases.
Vanderbilt University Medical CenterInformation Technology
© 2004 Bingham, Quinn
Vanderbilt University
Contacted family after
death – both MICU
and ENT present for
discussion
All rights reserved.
here)
Create order set to
specify supplies
necessary, as well as
initial steps if airway lost.
Have standard order set
available for all ICU’s and
floors.
Make order set easy to
use so many different
services may implement.
Using Data
from the Matrix
 Prioritize what needs to be done
 Create an Action Plan
 Use Tools and Methods for
Improvement
Vanderbilt University Medical Center
Closing the Loop
• Start with diagnosis as basis for assessment
• Identify issues of care related to Aims and
Competencies
• Identify lessons learned and improvement needed
• Complete action plan for improvements with
accountabilities and timeline
Vanderbilt University Medical Center
Using Data from an Individual
Matrix
• After creating this Matrix, the ENT resident was prompted to
ask if there were standardized trach orders already in place
throughout the hospital. There were, but the orders were out of
date and few staff were aware they existed.
• It was also determined that the red rubber catheters used for
suction are too flexible and thus insufficient for the task.
• As you can see, he found the problems not with the
participants, but within the hospital’s system. The lack of
orders led to inadequate care.
Vanderbilt University Medical Center
Improvement
Practice-Based
Learning &
Improvement
(What have we learned?
What will we improve?)
Need variety of suction
catheters available.
Determine the essential
equipment for
tracheotomy care.
Know location of
bronchoscope/light
source.
Need clear steps to be
taken for airway
emergency in patients
with tracheostomy with
poor pulmonary reserve
and difficult anatomic
airway.
Method to succinctly
communicate whether
patient can be orally
intubated to minimize
unsuccessful attempts at
securing airway.
Create order set to
specify supplies
necessary, as well as
initial steps if airway lost.
Have standard order set
available for all ICU’s and
floors.
Make order set easy to
use so many different
services may implement.
Information Technology
© 2004 Bingham, Quinn
Vanderbilt University
All rights reserved.
Questions to ask of the Practice-Based Learning &
Improvement row when creating an action plan:
•What is the procedure/system/issue you want to improve?
•How are you going to improve it?
•Who is involved with this issue? Who should be involved?
•In what time frame will the change take place?
Action Plan
Action
for Tracheotomy
Plan for … After-care
Item #
1
What needs to be
done?
By
whom?
Time frame
Create a new set of
standardized trach orders
ENT Service
2005
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Comments
Completion
Date
Resulting Action Plan for Trach
Case
Action Plan for Tracheotomy After-Care
Item
#
What needs to be done?
By whom?
Timeline
1
Determine what
materials are best for
trach tube change
ENT
2005
10/05
2
Create new set of
trach orders
ENT
2005
10/05
3
Ensure that orders
are known
throughout all depts
ENT
2005
10/05
4
Ensure effective
communication
between ENT and
other depts
ENT
2005
continuous
Notes:
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Comments
Completion
Date
Improvement Model
What are we trying to accomplish?
- AIM -
How will we know that a change is an improvement?
- Data Over Time –
(Tools: Run Charts, Control Charts)
What changes can we make that will result in an improvement?
- Process Analysis –
(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)
Act
(Stay on course
or try something
new)
Plan
Improvement
PDSA Cycle
Study
Do
Results
Improvement
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•Analyze Matrix
•Determine
improvements needed
•Formulate action plan
•If the change is an
improvement,
implement it
permanently, on a
widespread basis
Act
Plan
Study
Do
•Is this change an
improvement?
•Use data over time
to find out
Vanderbilt University Medical Center
•Carry out changes
ACITON PLAN
Item #
What needs to be
done?
By whom?
Timeline
Comments
Completion
Date
1
Determine what materials are best
for trach tube change
ENT
2005
10/05
2
Create new set of trach orders
ENT
2005
10/05
3
Ensure that orders are known
throughout all depts
ENT
2005
10/05
4
Ensure effective communication
between ENT and other depts
ENT
2005
ongoing
Notes:
• Through this example, we can see how
the Matrix encourages users to continue
through the care analysis loop, both
analyzing and identifying gaps in care,
and planning improvements.
• From here, we can continue to the Plan-Do-Study-Act
(PDSA) cycle. We have completed the plan
requirement, now on to do. Once the orders have
been implemented over an appropriate sample of
cases, we can study the results.
A
P
S
D
• Analysis of the results allows us to find out how to act: should we
keep the new procedures and implement them on a wider scale?
Or, if the new measures failed to improve care, what else can be
done? Are the results below or above expectations? Clearly a
change is needed, and this cycle allows us to find the best one.
Vanderbilt University Medical Center
What happened after analysis and
planning?
• In response to his findings, the resident
went on to collaborate with other
Otolaryngology specialists to create a
standardized order set that requires,
among other things, more rigid suction
catheters.
• This order set has been publicized
throughout Vanderbilt Hospital.
Vanderbilt University Medical Center
New ENT Trach Orders
•
Treatment
1.
Ambu bag and identical replacement trach tube or #6 endotracheal tube to be at hob at all times.
2.
Have suction kits with #14 French suction cathaters, yankauer, and red rubber catheters at bedside.
3.
Do not change trach tape or trach holders, even if soiled.
4.
Suction trach tube with/ns instillation every 2 hours and prn for 48 hours, then every 4 hours and prn.
5.
Stoma care every 8 hours post-op with hydrogen peroxide and bacitracin ointment.
6.
Remove and clean inner cannula with brushes every 2 to 4 hours for 24 hours and then every 4 to 8.
7.
If trach falls out, call a code and doctor, and replace tube if possible; if not possible, bag per mask and
intubate (if patient is intubateable).
8.
If trach falls out call a code and a doctor, replace tube if possible or place #6 ET tube through trach site (if
patient is not intubateable).
9.
•
Notify house officer if problem passing suction catheter, cuff deflating, bleeding, sob. or low sats.
Patient/Family Teaching by nursing
10.
Instruct patient how to communicate as directed.
11.
Nursing: Prior to discharge patient must demonstrate adequate trach suction with and without saline flush,
remove inner cannula and clean or replace with new inner cannula, communicate verbally or written as
directed.
12.
Print out and review home trach instructions with patient/significant other prior to discharge.
13.
Patient must have suction machine and humidifier at home or delivery scheduled for discharge day.
14.
Return to previous list
Vanderbilt University Medical Center
Using the Data
from Many Matrices
• Another use of the Matrix is that data from many
Matrices can be aggregated in a database (a
web application is currently in development) and
sorted by ACGME Competency, IOM Aim,
diagnosis, and positive or negative outcome.
• Thus problems can be realized in areas of
patient care, education, teamwork, handoffs,
diagnoses, and hospital processes, etc.
Vanderbilt University Medical Center
Using the Data
from Many Matrices
For example, the many matrices we’ve
collected from the Vanderbilt Neurology
department demonstrate that the
Neurology Dept. has many processes;
some work well, some not so well. The
“diagnosis” seems to be the basic unit of
analysis that works the best.
Vanderbilt University Medical Center
Using Data
from the Matrix
The following slides include:
• Example of a page from Excel database
(Table 1)
• Example of a report on care of patients
with stroke diagnoses (Table 2)
• Explanation of stroke report
Vanderbilt University Medical Center
Excel Database for Matrix Analysis
Table 1
ID
Aim
Competency
Content
Diagnosis
Primary
Code
Secondary
Code
(+positive, negative,
improvement)
3
Safe
Professionalism
Decisions were made based on
accepted algorithms and
consensuses within the team.
19
Timely
Interpersonal
Communication
Skills
4
Effective
18
Stroke
+Positive
EBM
Delays in communication increased
the time it took to get an initial head
CT and begin treatment.
Pregnancy &
Intercerebral
Hemorrhage
-Negative
Teamwork
Practice-Based
Learning &
Improvement
We could have taken the time to do
a better initial H&P to better discern
what patient’s condition was like at
initial presentation to compare it to
discharge condition.
Stroke
^Improvement
Care Plan
Efficient
Systems-Based
Practice
Repeated imaging and brain
biopses were unneccessary.
Reduce switching primary
neurologists to avoid repeat testing.
Celiac Sprue
-Negative
EBM
12
Equitable
Interpersonal
Communication
Skills
The patient spoke Spanish. Skilled
interpreters were not available.
Medical students and amily were
used often as interpreters, which
was not ideal.
Hydrocephalus
-Negative
translators
2
PatientCentered
Medical
Knowledge
Team took the time to know the
patient and her desire for treatment
Lung cancer
with brain
metastases
+Positive
Patient/
Physician
Communication
Vanderbilt University Medical Center
Table 8:
Table
2
Care of patients with Stroke
Medical Students N=6 Department of Neurology
AIMS for assessing Patient Care
Safe
One patient fell because he did not understand instructions.
Resident did not know if nurses would follow-up.
Timely
MRI ordering confusion caused delays, but most other care and tests were timely.
Effective
When protocols in place, EBM is practiced.
Efficient
Protocols help decide what needs to be done without wasting resources. CT scans and consults were too slow at VA.
Equitable
No equity issues were identified in this patient population.
Patient-Centered
Education of family was both positive (well done) and negative (too complex for one family).
COMPETENCIES for providing Patient Care
Medical Knowledge
When EBM protocols in place, they helps define the care.
Interpersonal and Communication
Skills
Very few problems with stroke pts. Most of the time this works very well unless the care of patients involves other specialties.
Professionalism
No issues except for minor frustration with family not understanding.
System-based practice
Team members know protocol and have clear roles. There were only a few comments about not using the team effectively.
IMPROVING Patient Care
Practice-based Learning and Improvement
Safe
We need to define who is responsible for addressing functional limitations, hospital or rehab.
Timely
Prepare care plans early and share with everyone for quick follow up.
Evaluating pt through chain of command (student, resident, attending) can delay care.
Good communication between EMS and ED, especially with stroke pts, could speed up treatment.
Effective
Follow EBM guidelines when available. All team members need to know care plan and understand the reason for tests.
Efficient
Standard work-up for stroke patients decreased the unnecessary tests.
MRI/MRA confusion caused repeat of test. Can we clean up the confusion in WIZ Order?
Equitable
There were no gender, ethnic or social biases identified.
Patient Centered
Instructions need to be clear and simple for patients, especially for immediate care of patients should they have future events.
Vanderbilt University Medical Center
Using the Data
from the Matrix
• The story behind the stroke report:
– When 28 matrices were analyzed for Neurology, we saw
positive and negative trends. Care of stroke pts (n=6) had
very few communication or professional issues, care was
deemed effective and efficient and comments about
systems-based practice were often positive. When we
explored the reasons why, we found that they had a “stroke
team” with clear protocols and guidelines which made the
care much better. We found that when the care crossed
departments and there were not “teams”, the care was
significantly more problematic.
Vanderbilt University Medical Center
Conclusion
• Use of the Matrix teaches learners a broader view
of quality patient care and safety and makes clear
opportunities for improvement.
• The Matrix data helps analyze gaps in resident
education around the ACGME core competencies,
and facilitates improvements in education.
• The Matrix can be used to study any facet: Aim,
Competency, diagnosis, service, etc. and is useful
as a quality improvement tool for both individual
patient case studies and panel studies.
Vanderbilt University Medical Center