INTEGRATING QUALITY IMPROVEMENT AND MEDICAL EDUCATION Stephanie Parks Taylor MD Department of Internal Medicine Division of Hospital Medicine OBJECTIVES Overview of Quality Improvement Importance of QI in residency training QI Principles and tools we need to be teaching WHAT IS QUALITY Institute of Medicine definition
Quality consists of the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (evidence) Blumenthal, NEJM DOES QUALITY NEED IMPROVING? To Err is Human: Building a safer healthcare system Errors account for between
44,000 and 98,000 deaths per year in the US More people die from medical errors than breast cancer, AIDS, or MVAs Errors occur because of system failures, not individual failures IOM RECOMMENDATIONS Six major goals for health care Safe
Effective Patient-centered Timely Efficient Equitable IOM RECOMMENDATIONS Ten rules for healthcare 1. Care should be based on continuous healing relationships
2. Customization based on patient needs and values 3. The patient as the source of control 4. Shared knowledge and free flow of information
5. Evidenced-based decision making IOM RECOMMENDATIONS Ten rules for healthcare 6. Safety as a system property 7.
The need for transparency 8. Anticipation of needs 9. Continuous decrease in waste 10. Cooperation among clinicians
REFLECTIVE PRACTICE Definition Reflective practice simply refers to a systematic approach to review ones clinical practice, including errors, seek answers to problems, and make changes in practice habits, styles, and approaches based on self-reflection and review. Value Accountability Self-assessment
QUALITY OF CARE: EXAMPLE 47 year-old unemployed Spanish-speaking only male with HTN, HLD, and DM is admitted to the hospital for uncontrolled blood glucose. He has been admitted 6 times in the past year Current meds are HCTZ 25 mg daily Bystolic (nebivolol) 10 mg daily Byetta (exenatide) 10 mcg SC BID Metformin 1000 mg BID QUALITY OF CARE: EXAMPLE Admission data: BP 170/95, glucose 350, Creatinine 1.8
Record review shows he has been treated by a different ward team each of his last 6 visits Glucose and BP were improved during last hospitalizations but no medication changes were made Patient has never made any follow up appointments at 30 th street clinic QUALITY OF CARE: EXAMPLE How well does this patients care meet the 6 IOM criteria? Safe Effective Patient-centered
Timely Efficient Equitable QI IN RESIDENCY PROGRAMS Why is it important to involve residents in quality improvement? WHY INVOLVE RESIDENTS IN QI? Residents are invisible in the quality improvement process, because the attending physician is the physician of record and ultimately responsible
Carol M. Ashton, MD, MPH 1993 article in Academic Medicine On the national level, residents are invisible on the patient safety journey Jim Conway, Sr Vice President Institute for Healthcare Improvement WHY INVOLVE RESIDENTS IN QI? Residents are frontline workers They see all the issues and know what works and does not work in the hospital In most teaching hospitals, residents provide the bulk of inpatient
care, write most orders, and drive day to day care of inpatients Many important metrics and JCAHO national patient safety goals involve work that is done chiefly by residents Residents often have great ideas and want to improve the process, but have traditionally felt powerless or ignored Residents are the future clinical leaders WHY INVOLVE RESIDENTS IN QI? Because we HAVE to! ACGME core competencies Medical knowledge Patient care
Professionalism Interpersonal and communication skills Practice-based learning and improvement Systems-based practice WHY INVOLVE RESIDENTS IN QI? Residency programs integrate QI as one way to incorporate the Practice-based learning and improvement and Systems-based learning into curricula PBLI and SBP require residents to reflect on the outcomes of their practice and to understand principles of improving the process of care
PRACTICE-BASED LEARNING AND IMPROVEMENT Residents are expected to use scientific evidence and methods to investigate, evaluate, and improve patient care practices Internal medicine working group PRACTICE-BASED LEARNING AND IMPROVEMENT Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care
Use information technology to access and manage information, support patient care decisions and enhance both patient and physician education PRACTICE-BASED LEARNING AND IMPROVEMENT Identify areas for improvement and implement strategies to enhance knowledge, skills, and attitudes and processes of care Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice
PRACTICE-BASED LEARNING AND IMPROVEMENT Two major themes Effective application of EBM to patient care Diagnostics, therapeutics Clinical skills, too! Quality improvement Individual improvement: reflective practice Systems improvement: active participation
SYSTEMS-BASED PRACTICE Residents are expected to demonstrate both an understanding of the contexts and systems in which healthcare is provided, and the ability to apply this knowledge to improve and optimize healthcare Internal medicine working gtoup SYSTEMS-BASED PRACTICE Understand, access, and utilize the resources, providers, and systems necessary for optimal care Understand the limitations an opportunities inherent in various delivery systems, and develop strategies to
optimize care for the individual patient SYSTEMS-BASED PRACTICE Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease Collaborate with other members of the healthcare team to assist patients to deal effectively with complex systems and improve systematic processes of care RESIDENT COMPETENCY: PBL&I Customer knowledge: Able to identify needs specific to residents patient population
Making change: demonstrate how to use several cycles of change to improve care delivery Measurement: Use balanced measures to show changes have improved patient care Developing local knowledge: apply continuous quality improvement to discrete population or different subpopulations Ogrinc Acad Med, 2003 RESIDENT COMPETENCY: SBP Healthcare as system: Understand and describe the reactions of a system perturbed by change initiated by the resident Collaboration: contribute to interdisciplinary effort
Social context/accountability: demonstrate business case for QI and identify community resources Ogrinc Acad Med, 2003 RESIDENTS AND QI SKILLS Understand key definitions and IOM rules Defining aim and mission statement How to measure quality Understand micro-systems Process tools: PDSA Flowcharts
RESIDENTS AND QI SKILLS Role of physician leadership What is a physician opinion leader/champion? Working in interdisciplinary teams Move beyond the ward team concept MISSION STATEMENTS Key ingredients for the explicit expression of goals Measurables Deliverables
Timeline Dembitzer, Stanford Contemporary Practice, 2004 EFFECTIVE MISSION STATEMENTS Clear and concise, unambiguous Define the problem to be fixed Measurable and specific Context, target population, duration Outcome-based (explicit target positive rate or failure rate)
Reasonable, worthwhile, relevant topic Important issue that will bring broad buy-in MISSION STATEMENT EXAMPLE Do better with vaccine compliance in the hospital VERSUS Within the next 12 months, 80% of our COPD patients will receive influenza vaccination before hospital discharge, increased from current rate of 45% MEASURING QUALITY
What are we measuring? Donabedian model Structure Process Outcome MEASURING QUALITY Structure The way a healthcare system is set up and the conditions under which care is provided STRUCTURE: MICROSYSTEM
Microsytem: small group of people, working together regularly to provide care to a discrete population of patients Shares Clinical and business aims Linked processes Information Produces performance outcomes Nelson, 2003 STRUCTURE: MICROSYSTEM
Nelson, 2003 MEASURING QUALITY Donabedian model Structure Process Outcome MEASURING QUALITY: PROCESS Process: the activities that constitute healthcare Diagnosis, treatment, prevention ,counseling, etc
MEASURING QUALITY: PROCESS Importance of understanding a process Frontline test Processes tend to be hierarchical Step A Step B Step C Helps manage complexity without drowning in detail Allows focus within context Rudd, Stanford Contemporary Practice, 2004 UNDERSTANDING PROCESS: FLOWCHARTS TIPS
MD MD decides decides patient patient needs needs ICU ICU transfer transfer ICU ICU nurse nurse
assigned assigned to to accept patient accept patient Patient Patient arrives arrives in in
ICU unit ICU unit MD MD places places transfer transfer orders orders
Nurse Nurse to to nurse nurse communication communication prior prior to to transport transport ICU
ICU staff staff notified notified of of patient patient arrival arrival Bed Bed control control notified
notified for for ICU ICU bed bed Patient Patient transported transported by by appropriate
staff appropriate staff MD MD to to MD MD report report Patient Patient is
is under care under care of of ICU ICU team team Flowchart a process, not a
system Avoid too much detail Process should reflect mission statement
Get all necessary information Show process as it actually occurs, not in ideal state Critical stage: take as much time as needed
Show the flowchart to front line people for input Look for areas of delay, hassles, complaints MEASURING QUALITY
Donabedian model Structure Process Outcome MEASURING QUALITY: OUTCOMES Outcomes: changes (desired or undesired) occurring in individuals that can be attributed to healthcare Changes in health status Changes in knowledge among patients Changes in patient behavior Patient satisfaction
SYSTEM BASED APPROACH TO OUTCOMES Patient Patient Needs Needs Process Process of of Care
Care Practice Systems Outcomes Outcomes of of Care Care SYSTEM BASED APPROACH TO OUTCOMES Patient
Patient Needs Needs Demographics Demographics Co-morbidity Co-morbidity Process Process of of Care Care
Outcomes Outcomes of of Care Care Practice Systems Clinical Clinical Functional
Functional Risk RiskFactors Factors Barriers Barriersto to Self-Care Self-Care Access
Satisfaction Satisfaction Safety Safety Cost Cost Evaluation DX RX
P. Activation MODEL FOR IMPROVEMENT What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act
Plan Study Do PDSA CYCLE PLAN: Identify the problem/process that needs improvement (may require data!) Describe current processes around improvement opportunity
Describe possible causes of the problem and agree on root causes Develop effective and workable action plan- select targets! PDSA CYCLE DO Implement the proposed solution on a small scale STUDY Review and evaluate the result of the change Will almost always require some form of data collection (medical record review, patient satisfaction, etc)
PDSA CYCLE ACT Reflect and act on what was learned reflective practice for the team Assess the results, recommend changes Continue improvement process where needed, standardize when possible Celebrate successes! NOW WHAT?
How do we close the gap from invisible residents to meeting ACGME competencies and the expectations of heath systems for newly hired physicians? FUTURE NEEDS Curriculum design to integrate QI Educate program directors and core faculty get them excited about PBLI and SBP competencies Residency curriculum must be adjusted to allow time for didactic and experiential QI learning Not an add-on or squeeze-in Provide residents with tools and authority to
implement changes FUTURE NEEDS Consider residents as part of the healthcare team Train and learn QI in teams Use residents as a resource for improving systems Educate residents to become faculty and leaders in QI FINAL THOUGHT: THE TRIPLE AIM IHI Triple Aim: Improve the health of the population
Enhance the patient experience of care (including quality, access, and reliability) Reduce, or at least control, the per capita cost of care QUESTIONS? Thank you!
