Transcript What is Systems-Based Care? What is Practice Based Learning and Improvement? Why these competencies? Richard J.

What is Systems-Based Care?
What is Practice Based Learning and
Improvement? Why these
competencies?
Richard J. Simons, M.D.
Acting Vice Dean for Educational
Affairs
Penn State College of Medicine
CORE PREMISE
• The American healthcare delivery
system is in need of fundamental
change
• The current systems cannot do the job
• Trying harder will not work
• Changing systems is necessary
We’re Driving a Powerful Vehicle,
but it has no:
• Map
• Compass
• Speedometer
• Odometer, or
• Clock
Yet the pedal’s to the
floor
Aims for Improving Healthcare
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable
To Err is Human: Building a
Safer Health System
Why start with errors?
• Burden of injury
• Understandable to providers and
consumers
• Avoidable
• Experience in other industries
Many People are Harmed
• Adverse event – an injury caused by
medical management
• Adverse events occur among 3-4% of
hospitalized patients
• About 1 in 10 results in death
• Over half are preventable
Key Findings
• Errors occur because of system
failures
• Preventing errors means designing a
safer system of care
“Few newly qualified physicians have the
necessary skills to improve health care and
safety. These include the ability to perceive
and work effectively in interdependencies, the
ability to understand work as a process, skill in
collecting, aggregating, analyzing, and
displaying data on the processes and
outcomes of care, skills in designing health
care processes, an ability to work in teams and
collaboration with managers and patients, and
the willingness to examine honesty and learn
from mistakes”
Professional Competence: a
definition
The habitual and judicious use of
communication, knowledge,
technical skills, evidence-based
decision-making, emotions, values
and reflection to improve the
health of the individual patient and
the community
Systems-Based Practice
“Residents must 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.”
Why Systems-Based Practice?
• Prepare physicians to work in the
current system
• Optimize cost and outcomes
• Improve the system
• Transform the health care system
“Very few doctors understand
what is happening to the health
care system in which they
practice, why the system is
changing so rapidly, and what
they can do about it”
-- Relman, Acad Med, 73, 1998
Why Systems-Based Care?
“A systems view is critical to
understanding patient outcomes,
safety, values and quality”
What are the components of
Systems-Based Care?
• For your Residency Program?
• For your institution/hospital?
Some components of SystemsBased Practice
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System resources
Patient advocacy
Health care economics
Teamwork
Cost-benefit
considerations
• Healthcare economics
• Healthcare Financing
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Practice management
Insurance Types
Medical-Legal Issues
Coordination of health
care
• Documentation Issues
• Social and political
history of US health
care system
Elements of Systems: The
Resident-System Interface
Within the hospital/clinic
• Admitting/scheduling
• Documentation
• Other clinical services
• Ancillary services
• Nursing
• Pharmacy
Outside the hospital/clinic
• Referring physicians
• Insurers, HMO’s
• Community services
• External laboratory and
radiological services
• Legal system
Systems Thinking Principles and
Concepts
• Interdependence
• Structure drives behavior
• Cause and effect are separated by time
and place
• Any change in a system has
unintended consequences
“The prominence of physicians
in highly interdependent medical
systems confers tremendous
power on them, individually and
as a profession. With this power
comes an ethical responsibility
to be deeply concerned about
medical systems.”
--Nolan, Annals Intern Med, 1998
Practice-Based Learning and
Improvement
“Residents must be able to
investigate and evaluate their
patient care practices, appraise
and assimilate scientific evidence,
and improve their patient care
practices.”
Practice-Based Learning and
Improvement
• Analyze practice and improve using
systematic methodology
• Locate, appraise and apply scientific
evidence
• Apply knowledge of study designs and
statistics
• Obtain and use patient population data
• Use information technology
• Facilitate the learning of others
Practice-Based Learning and
Improvement
Residents must internalize the value of
on-going, self-directed learning and
improvement of practice
• Reflect on and analyze practice
experience
• Locate and apply scientific evidence
• Take steps to improve practice
• Demonstrate improvement
“Whatever we measure we tend
to improve.”
“We measure what we value.”
Practice-Based Learning and
Improvement
Where should we start?
• Begin with what
you have in place
– your resident
interactions with
their patients
What data can be gathered about a
resident’s knowledge of Systems-Based
Practice and Practice Based Learning
through a patient encounter?
Questions from the attending?
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Was the care based on a healing relationship?
Was the care customized based on patient’s needs?
Was evidence-based decision making used?
Was safety a system property of the care?
How did you anticipate the needs of the patient?
How could waste be diminished?
Other venues for SBP and PBL
Teaching and Evaluation
• Case analysis – focus on processes of
care
• Construction of a flow chart of a
hospitalized patient to analyze systems
of care
• Root cause analysis of an adverse
event
• Activity based cost analysis of a
hospital bill
Reasons this is hard
• Competence is a habit
• Medicine is a cooperative not a productive
art
• The important things are hard to measure
• Residents seek practical wisdom
• To become competent you have to “feel bad”
• Learning occurs in microsystems
• Becoming competent is a complex process
Helpful Hints for Program
Directors
• Use current activities already in place
(rounds, conferences, grand rounds,
discharge planning rounds) to teach and
evaluate SBP and PBL
• Issues related to SBP and PBL abound in
resident experiences
• Involve the residents in the process of
deciding how to incorporate these
competencies into your curriculum
• Faculty development is a key to success
“Residents live in the fault
lines of health care
systems and give voice to
what life is like there.”