integrating quality improvement and medical education

Stephanie Parks Taylor MDDepartment of Internal Medicine

Division of Hospital Medicine

INTEGRATING QUALITY IMPROVEMENT AND MEDICAL EDUCATION

OBJECTIVES• Overview of Quality Improvement

• Importance of QI in residency training

• QI Principles and tools we need to be teaching

WHAT IS QUALITYInstitute 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

• 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

DOES QUALITY NEED IMPROVING?

To Err is Human: Building a safer healthcare system

IOM RECOMMENDATIONSSix major goals for health care• Safe• Effective• Patient-centered • Timely • Efficient • Equitable

IOM RECOMMENDATIONSTen “rules” for healthcare1. Care should be based on continuous healing

relationships2. Customization based on patient needs and values3. The patient as the source of control4. Shared knowledge and free flow of information5. Evidenced-based decision making

IOM RECOMMENDATIONSTen “rules” for healthcare6. Safety as a system property7. The need for transparency8. Anticipation of needs9. Continuous decrease in waste10. Cooperation among clinicians

REFLECTIVE PRACTICE• Definition Reflective practice simply refers to a systematic

approach to review one’s clinical practice, including errors, seek answers to problems, and make changes in practice habits, styles, and approaches based on self-reflection and review.

• Value• 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 patient’s care meet the 6 IOM criteria?

• Safe• Effective• Patient-centered• Timely• Efficient• Equitable

QI IN RESIDENCY PROGRAMSWhy 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 front‐line 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

resident’s 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 outcomesNelson, 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

• 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

MD decides patient needs ICU transfer

MD places transfer orders

Bed control notified for ICU bed

Nurse to nurse communication

prior to transport

ICU nurse assigned to

accept patient

Patient transported by

appropriate staff

ICU staff notified of patient arrival

Patient arrives in ICU unit

MD to MD report

Patient is under care

of ICU team

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 Needs

Process of Care

Practice Systems

Outcomes of Care

SYSTEM BASED APPROACH TO OUTCOMES

Patient Needs

Practice Systems

Outcomes of Care

Access Evaluation DX RX P. Activation

Demographics

Co-morbidity

Risk Factors

Barriers to Self-Care

Clinical

Functional

Satisfaction

Safety

Cost

Process of Care

MODEL FOR IMPROVEMENTWhat are we trying to

accomplish?

How will we know that achange is an improvement?

What change can we make thatwill 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!