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Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A Matrix Solution 3:15 pm – 3:25 pmIntroduction Berend Mets,

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Presentation on theme: "Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A Matrix Solution 3:15 pm – 3:25 pmIntroduction Berend Mets,"— Presentation transcript:

1 Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A Matrix Solution 3:15 pm – 3:25 pmIntroduction Berend Mets, MB, Ph.D., Moderator 3:25 pm – 3:55 pmEmbedding the Core Competencies Using the Matrix John Bingham Director, Center for Clinical Improvement Vanderbilt University Medical Center Nashville Tennessee 3:55 pm – 4:10 pmQuestion & Answer Session 4:10 pm – 4:40 pmPractical Examples of the Matrix Doris Quinn, Ph.D. Assistant Professor, Division of Medical Education Vanderbilt University Medical Center Nashville Tennessee 4:10 pm – 4:55 pmQuestion & Answer Session

2 Vanderbilt University Medical Center Linking Outcomes of Care and the ACGME Core Competencies: A Matrix Solution John Bingham, MHA Director Center for Clinical Improvement SAAC/AAPD Annual Meeting Washington, DC November 5, 2005 Doris Quinn, PhD Assistant Professor Division of Medical Education

3 Vanderbilt University Medical Center Objectives for today: 1.Discuss the Institute of Medicine (IOM) Aims for Improvement and the ACGME Core Competencies. 2.Describe how the Healthcare Matrix helps link outcomes of care to learning the core competencies. 3.Provide examples of how the Healthcare Matrix is used to improve education and the delivery of care.

4 Vanderbilt University Medical Center Emerging public reporting of quality measures “Hospital Compare” “Kyros” Events in Healthcare:

5 Vanderbilt University Medical Center Extrapolated study results imply that between 44,000-98,000 U. S. hospital patients die each year as a result of medical errors. March 2000

6 Vanderbilt University Medical Center “Five Years After To Err is Human: What Have We Learned?” Lucian L. Leape, MD; Donald M. Berwick, MD JAMA, May 18, 2005 “If the experience of the past 5 years demonstrates anything, it is that neither strong evidence of ongoing serious harm nor the activities, examples, and progress of a courageous minority are sufficient to generate the national commitment needed to rapidly advance patient safety.” And what about today?

7 Vanderbilt University Medical Center Patient Care should be: Safe, Timely, Effective, Efficient, Equitable, Patient-Centered (STEEEP)

8 Vanderbilt University Medical Center Phase IPhase IIPhase IIIPhase IV 7/20016/20027/20027/20116/20067/20066/2011Beyond Improve the evaluation processes for all six of the Competencies. Provide aggregated resident performance data for Internal Review Process. Use resident performance data as the basis for improvement. Begin to use external quality measures to verify resident and program performance levels. Identify benchmark programs. Involve community in building knowledge about good GME. Define specific objectives for residents to demonstrate learning of the competencies. Begin integrating the teaching and learning of competencies into residents’ didactic and clinical experiences.

9 Vanderbilt University Medical Center “Clinical education simply has not kept pace with or been responsive enough to: shifting patient demographics, changed health system expectations, evolving practice requirements, new information, a focus on improving quality, new technologies.”

10 Vanderbilt University Medical Center –Reporting of CMS Quality Measures tied to Annual “CMS Market Basket Update” November 2004 –“Recommend to Congress that it adopt pay-for-performance for physicians, hospitals, and home health agencies” Medicare Payment Advisory Commission: March 2005 “Hospital Compare” Emerging public reporting of quality measures

11 Vanderbilt University Medical Center Patient Care (Assessing it …and getting ready for physician report cards!) The first Core Competency:

12 Vanderbilt University Medical Center Patients with Needs Patients with Needs Met What are you measuring to evaluate the quality of Anesthesia care? How and where are these data reported? How is the information utilized to improve: the education of residents? the quality of care provided? AccessDiagnosisTreatmentFollow-upAssessment

13 Vanderbilt University Medical Center Patient Care should be: Safe, Timely, Effective, Efficient, Equitable, Patient-Centered (STEEEP)

14 Vanderbilt University Medical Center PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with….

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16 “Avoiding injuries to patients from the care that is intended to help them” PATIENT CARE that is…Safe

17 Vanderbilt University Medical Center PATIENT CARE that is…Safe What is our Anesthesia performance for: % Patients with appropriate prophylactic antibiotic? % Cardiac Surgical Patients with controlled perioperative serum glucose (200 mg/dL) % Cases with documented Time Out? Intra- or postoperative: Cardiac arrest during hospitalization? PE during hospitalization? DVT during hospitalization? Anesthesia Complications/1000 surgeries?

18 Vanderbilt University Medical Center Is Care Safe ? VUMC Goal: Achieve lowest mortality in nation VUMC 2004 VUMC 2005 Observed to Expected Mortality: 53 UHC AMCs with Level I Trauma Centers

19 Vanderbilt University Medical Center VUMC Observed to Expected Mortality and Actual Number of Mortalities

20 Vanderbilt University Medical Center “Reducing waits and sometimes harmful delays for both those who receive and those who give care” PATIENT CARE that is…TimelySafe

21 Vanderbilt University Medical Center PATIENT CARE that is…TimelySafe What is our Anesthesia performance for: % Patients with Anesthesia Prep Time < 15 Minutes? % Patients with on-time prophylactic antibiotics? % Patients with prophylactic antibiotics? discontinued <24 hours after surgery end time? % cases completed < 15% of scheduled length? % cases with surgical consent before day of surgery? Average time between cases (Gap Time)? Average time between “room ready” and “in room”?

22 Vanderbilt University Medical Center Percentage of Surgery Patients Who Received Preventive Antibiotic (s) One Hour Before Incision Top Hospitals: 93% AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE VANDERBILT UNIVERSITY HOSPITAL 69% 64% 47% Top Hospitals represents the top 10% of hospitals nationwide (Data displayed are from data reported July-Dec.04)

23 Vanderbilt University Medical Center What is the infection rate for surgical patients (in total, by procedure, by specialty, by surgeon; by site of surgery) ? Exceptions by procedure, by specialty, by surgeon; by site of surgery ? Received the appropriate antibiotic? Received prophylactic antibiotics? Received within one hour prior to surgical incision?% % with Infection No Yes No % with Infection Yes No Yes Exceptions Patients with Needs Patients with Needs Met AccessDiagnosisTreatmentFollow-upAssessment

24 Vanderbilt University Medical Center Percentage of Surgery Patients Whose Preventive Antibiotics are stopped Within 24 Hours After Surgery Top Hospitals: 100% AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE VANDERBILT UNIVERSITY HOSPITAL 64% 58% 78% Top Hospitals represents the top 10% of hospitals nationwide (Data displayed are from data reported July-Dec.04)

25 Vanderbilt University Medical Center “Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit” PATIENT CARE that is… TimelyEffectiveSafe

26 Vanderbilt University Medical Center PATIENT CARE that is…TimelyEffectiveSafe What is our Anesthesia performance for: % Patients that received preoperative prophylaxis for VTE? % non-cardiac vascular surgery patient receiving beta-blockers during perioperative period % Patients with CAD who received beta blockers during perioperative period? % Patients on a ventilator whose post op orders included elevating bed >= 30 degrees?

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28 “Avoiding waste, including waste of equipment, supplies, ideas, and energy” PATIENT CARE that is…TimelyEfficientEffectiveSafe

29 Vanderbilt University Medical Center PATIENT CARE that is…TimelyEfficientEffectiveSafe What is our Anesthesia performance (over time) for: Total cost per case? Supply cost per case? Supply waste per case? OR non-billable time delays due to Anesthesia? Rate of increase in revenue vs. expenses?

30 Vanderbilt University Medical Center “Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status” PATIENT CARE that is…TimelyEfficientEffectiveEquitableSafe

31 Vanderbilt University Medical Center Is Care Equitable? AHRQ 2004 National Healthcare Disparities Report Released 2/22/2005 Blacks: 40% of access measures had worse access than whites for about 40% of access measures 66% of quality measures received poorer quality for about 66% of quality measures Asians: 33% of access measures had worse access than whites for about 33% of access measures 10% of quality measures received poorer quality than whites for about 10% of quality measures Hispanics: 90% of access measures had worse access than non-Hispanic whites for about 90% of access measures 50% of quality measures received lower quality of care than non-Hispanic whites for 50% of quality measures Poor people: 80% of access measures had worse access for about 80% of access measures than those with high incomes 60% of quality measures received lower quality of care for about 60% of quality measures

32 Vanderbilt University Medical Center “Providing care that is respectful of, and responsive to: individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” PATIENT CARE that is…TimelyEfficientEffectiveEquitablePatient CenteredSafe

33 Vanderbilt University Medical Center Is Care Patient Centered? HCAPS/CMS Patient Perception Surveys Effective in 2006-Public in 2007 What are our patients’ perceptions of: Communications with Nurses? Communications with Doctors? Communications about medications? Nursing services? Pain management? The hospital environment? Adequacy of discharge information? Our system overall? Their willingness to recommend us?

34 Vanderbilt University Medical Center “…about established and evolving biomedical, clinical, and cognate sciences, (e.g. epidemiological and social-behavior) and the application of this knowledge to patient care” Medical Knowledge PATIENT CARE that is… TimelyEfficientEffectiveEquitablePatient CenteredSafe What must we know?

35 Vanderbilt University Medical Center Medical Knowledge Interpersonal and Communication Skills PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe “…that result in effective information exchange and teaming with patients, their families, and other health professionals.” What must we say?

36 Vanderbilt University Medical Center “…as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” Medical Knowledge Interpersonal and Communication Skills Professionalism PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe How must we behave?

37 Vanderbilt University Medical Center “…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.” Medical Knowledge Interpersonal and Communication Skills Professionalism System-Based Practice PATIENT CARETimelyEfficientEffectiveEquitablePatient CenteredSafe What is the Process? On whom do we depend? Who depends on us?

38 Vanderbilt University Medical Center “…involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.” Medical Knowledge Interpersonal and Communication Skills Professionalism System-Based Practice Practice-Based Learning & Improvement PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe What have we learned? What will we improve?

39 Vanderbilt University Medical Center Patients with Needs Patients with Needs Met AccessDiagnosisTreatmentFollow-upAssessment Linking it all together…. -Medical Knowledge -Interpersonal and Communication Skills -Professionalism -Practice-Based Learning & Improvement TimelyEfficientEffectiveEquitablePatient CenteredSafe -System-Based Practice Clinicians competent in: Patient Care that is…

40 Vanderbilt University Medical Center QUESTIONS?

41 Vanderbilt University Medical Center “Residents live in the cracks of our health care systems and give voice to what life is like there.” Paul Batalden, MD Dartmouth Medical School

42 Vanderbilt University Medical Center Five Applications of the Matrix I.Individual Resident Learning II.Case Presentations III.M & M Conference IV.Panel of Patients for Group Learning V.Medical Students

43 Vanderbilt University Medical Center Individual Learning Case Presentation

44 Vanderbilt University Medical Center IOM ACGME SAFETYTIMELINESS EFFECTIVE- NESS EFFICIENCY EQUITA- BILITY PATIENT CENTERED- NESS PATIENT CARE MEDICAL KNOWLEDGE & APPLICATION X X PROFESSIONALISM INTERPERSONAL & COMMUNICATION SKILLS SYSTEMS- & TEAMS-BASED PRACTICE X PRACTICE-BASED LEARNING & IMPROVEMENT (Process to Improve) Anesthesia: One resident’s learning Case presentation preparation before expose to the Matrix

45 Vanderbilt University Medical Center IOM ACGME SAFETY TIMELINESS EFFECTIVE- NESS EFFICIENCY EQUITA- BILITY PATIENT CENTERED- NESS PATIENT CARE MEDICAL KNOWLEDGE X X X X PROFESSIONALISM XX XX INTERPERSONAL & COMMUNICATION SKILLS X X XX X SYSTEMS- & TEAMS-BASED PRACTICE X XXXX PRACTICE-BASED LEARNING & IMPROVEMENT (Process to Improve) P and P changed for Mom/Child in trouble Changed STAT pages to Anes. From OB Class on care of Mom with DIC Procedure outlined for fastest prep for OR Assure Mom aware of what is happening. Communication with father. Case presentation after dialogue with faculty using the Matrix.

46 Vanderbilt University Medical Center Patient with Pregnancy and D.I.C (Disseminated Intravascular Coagulopathy) Case Presentation IOM ACGME SAFETIMELYEFFECTIVEEFFICIENTEQUITABLEPATIENT-CENTERED Assessment of Care PATIENT CARE (Overall Assessment) NO Patient nearly died NO Life saving treatment was delayed for variety of reasons NO Delays in treatment impaired effectiveness of therapy NO Resources (blood products, staff time) were not utilized in an efficient manner. NO Language was a problem NO Patient was not adequately apprised of her own health problems and did not participate fully in her care decisions MEDICAL KNOWLEDGE (What must we know) Priorities in hemorrhagic shock are ABC: ensure oxygen delivery, support BP, aggressive IV resuscitation, treat cause Hemorrhagic shock is life-threatening emergency: Prompt diagnosis, recognize urgency, initiate therapy, incl. timely transport to OR. Diagnosis was made late. No urgency to treat. Delay in contacting Anesth. Inadequate assistance in transport to OR D.I.C. in pregnancy: Physiology, diagnosis, causes, treatment. Regional v. General Anesth? Post resuscitation pulmonary edema. Hypocalcemia due to massive transfusion. Invasive monitoring indications. Pharmacology of uterotonic drugs. Survival in postpartum hemorrhage requires aggressive IV resuscitation: always consider combining procedures (start 2 nd IV while drawing blood sample for transfusion cross match). INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) Safety is jeopardized unless team members are fully apprised of patient’s condition (blood loss following delivery, vital signs, plans for intervention). Orders (blood cross match) must be prioritized and fully implemented in a timely fashion. Effectiveness of life- saving intervention depends on effective communication between team members. Communications of a defensive or argumentative nature are counter-productive to efficient and safe care. The focus should be patient care, with analysis of misunderstandings at a later time. Must communicate patient’s condition and intended interventions (blood transfusion, emergency hysterectomy), and in a way that is understandable and useful to the patient, respecting patient autonomy. PROFESSIONALISM (How must we act) Professional duty to accompany critically ill patient to the OR, to ensure safety, and to expedite therapy. Patient’s ethnic, socio-economic, “service patient” status should have no effect on quality of care. Professional duty to attempt to preserve patient autonomy (make sure patient understands situation and interventions)

47 Vanderbilt University Medical Center SYSTEM- BASED PRACTICE (On whom do we depend and who depends on us) System must ensure that appropriate consultants are notified when needed to ensure safety in life- threatening medical condition. During postpartum bleeding, type & cross match must be drawn, sent, and verified promptly. Failure to do so threatens life. Failures to draw, send, and verify cross match blood sample jeopardizes effectiveness of life- saving therapy. Standard of care should not vary due to differences in staffing that result from time of day / night (availability of lab medicine physician, timely transport of blood samples, adequate number & expertise of obstetrics, anesthesiology, & nursing staff) Improvement PRACTICE- BASED LEARNING AND IMPROVEMEN T (How must we improve) Policy and Procedures changed for Mother/Baby in trouble Revise the criteria for and system of communicating urgent / emergent request for Anesthesiology consultation Departmental Teaching Conference on management of parturient with D.I.C. Procedure outlined for fastest prep for OR Increased awareness of need to consider patient centeredness even in emergent or crisis situations. Communication with father / family members when appropriate and possible. © Bingham, Quinn Vanderbilt University (Used with permission from Anesth. Dept)

48 Vanderbilt University Medical Center Patient with Coronary Artery Disease (Internal Medicine Residents Ambulatory Rotation)

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50 Panel of Patients with Coronary Artery Disease

51 Vanderbilt University Medical Center Panel Management of CAD Patients: (AHA Guidelines) Medications: –Aspirin –Beta Blocker, –Statin if LDL > 100 Blood Pressure Control ACE-Inhibitor/ARB Smoking Cessation Diabetes Screen / HgA1c

52 Vanderbilt University Medical Center Internal Medicine Residents Ambulatory Rotation

53 Vanderbilt University Medical Center Practice-based learning and Improvement (based on care of patients with CAD )

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57 Improvements From Medicine Residents: Pat Covington RN, Manager  EMR: We can now text message across departments.  Use of pt waiting time: Have Kiosk in exam room to fill in review of systems. Questionnaires being sent to pts ahead of time. Those with get questionnaire and can return via .  Availability of techs: Modified schedule of techs to improve service. Residents’ schedules were also changed to better utilize staff.  Patient visit survey and phone calls will now be done after visit.  Patient Letter revised: “Bring old records, come 15 minutes before appt.”

58 Vanderbilt University Medical Center Transforming M&M Conferences into Practice-based Learning and Improvement

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61 System Based Practice (What is the process? On whom do I depend? Who depends on me?) The Team did not always know what was going on. Hand-offs were not well managed All steps of the process of care were not known (including who was key in each step) therefore delays occurred. Plan of care should have been shared with all (Pharmacy, surgeons, residents, support services to make system work for pt rahter than hinder care. Needless variation among clinicians is a problem and caused inefficiency of care. Team should advocate for pt in a complex system. Care was not coordinated and integrated. Expectations and comfort of pt were not known and addressed. Improvement PRACTICE- BASED LEARNING AND IMPROVEMENT (How must we improve) Residents need to know principles of flowcharting and RCA to address these issues. Anesthesia residents should take the lead in getting the team to discuss pain mgmt and changes needed while pt still in our system. Team could share talk of lit review for this complex pt. Run chart of pain scale could be one metric to determine results of care. Patient and family should be included in improvement and monitoring of his own care. Feedback to be sought and used for further improvement. Information Technology © Bingham, Quinn Vanderbilt University (Used with permission from Anesth. Dept)

62 Vanderbilt University Medical Center Healthcare Matrix: Care of Patient with postpartum respiratory arrest OB M&M April 29, 2005 AIMS Competencies SAFETIMELYEFFECTIVEEFFICIENTEQUITABLE PATIENT- CENTERED Assessment of Care PATIENT CARE (Overall Assessment) Yes/No No Resp arrest during awake intubation. YesYes: had proper tx. No: Tx could have been better. YesYes until arrest occurred. ? MEDICAL KNOWLEDGE and SKILLS (What must we know?) DDX eval and Tx for ooCO abd SOB:PE/MI/CHF / flashpulm edema/ pneumonia Pt evaluation and work-up organized and timely. Appropriate tx given the DDx and evolving clinical picture (CxR #1 read as c/w pneumonia w no edema. Lasix Tx. Anesthesia initially used CPAP/OUOAO to manage low O2 sats. Unfamiliar modality in this clinical setting. INTERPERSONAL AND COMMUNICATION SKILLS (What must we say?) Awake intubation choice by anesthesia 2/2 airway edema. Order given and executed promptly. Pt did not fill Rx for BP meds. despite d/c instructions given. PROFESSIONALISM (How must we behave?) Emotional reaction to stressful situation took the staff by surprise. Managing the family’s hysteria during code situation was very challenging. SYSTEM-BASED PRACTICE (On whom do we depend and who depends on us?) Nurses on 4E assessed situation and contacted MDs promptly. Timely anesthesia consult and response. Did busy service delay Tx? (don’t think so) Monitor malfunction might have shown arrest when she wasn’t. The team worked very well together. Good procedure of nurses reviewing meds and discharge instructions. Getting meds filled after reg hours a problem. Improvement PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned? What will we improve?) Could we have prevented the resp arrest? C. Osmotic pressures need to be done. Could have transferred to L&D faster. Reviewed lit on non- cardiogenic Pulm Edema. Need to be more aggressive with Lasix. Be mindful of cultures that tend to react more physically and emotionally to stressful events. Can anything be done about getting a few doses of meds for pts being discharged at odd times? © 2004 Bingham, Quinn Vanderbilt University All rights reserved.

63 Vanderbilt University Medical Center Care of Patient with Femoral Vein Cannulation AIMS Competencies SAFETIMELYEFFECTIVEEFFICIENTEQUITABLE PATIENT- CENTERED Assessment PATIENT CARE (What must I do) NO Pt not always safe as evidence by several adverse events YesNo Need to find/learn best method. Evidence of Ultrasound for dialysis line placement. Yes Not Sure How informed is patient/family? No post procedure instructions. MEDICAL KNOWLEDGE (What must I know) Need additional anatomy lessons for performing this procedure. Need to know what to do with arterial punctures. What to do when patient cannot be still? No guidelines in literature for Fem. Cannulation. HCT not efficient way to monitor bleeding INTERPERSONAL AND COMMUNICA-TION SKILLS (What must I say) Nurses need to know when cannula has been pulled in order to have more observation Communicating use of Niagra cath that other areas have found less favorable. Use of patches used on other specialties for punctures not well known. Better instructions for patient and family. Nephrology M&M 4/2/04

64 Vanderbilt University Medical Center PROFESSIONAL- ISM (How must I act) Sharing complications and near misses among all specialties will increase learning. Sharing expertise from colleagues in surgery, radiology and cardiac cath for most effective and efficient way to do cannulation. SYSTEM-BASED PRACTICE (On whom do I depend and who depends on me) No nursing orders for post- procedure care. Change of shift dangerous time for patients. Improvement PRACTICE-BASED LEARNING AND IMPROVEMENT (How can I improve) Keep QA log on all procedures to detect trends. Need to monitor near misses and complications to learn. Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation. © Bingham, Quinn Vanderbilt Univ. (Used with Permission from Nephrology Dept.) (Femoral Cannulation Cont’d) Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation

65 Vanderbilt University Medical Center ACTION PLAN

66 Vanderbilt University Medical Center Medical Students (Neurology Clerkship)

67 Vanderbilt University Medical Center Healthcare Matrix: Care of Patient with stroke - occlusion of the ICA of unknown origin. AIMS Competencies SAFETIMELYEFFECTIVEEFFICIENTEQUITABLE PATIENT- CENTERED Assessment of Care I. PATIENT CARE (Overall Assessment) Yes/No YesNoYesYes, from VUMC, No for placement. Yes from VUMC No b/c of insurance issues Yes – patient was informed and incorporated in decision making process II. A MEDICAL KNOWLEDGE (What must we know) Yes. Everyone on the stroke service was on top of the latest in knowledge. Yes. II. B INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) Yes. Communication between neuro and surgery was clear. Attendings and residents were in contact Yes – phone calls and meetings were used when things couldn’t wait for note in chart Yes and no – comm. Between medical teams was great. Ins issues led to placement problems though Yesyes Yes – always kept in mind patients perspective II. C PROFESSIONALISM (How must we act) Yes There was no breakdown in safety due to pro problems Yes – there were never any delays in doing anything for the pt in terms of pro Yes Yes and no – pt was on service for a while,– but not really treated much better than others Yes – II. D SYSTEM-BASED PRACTICE (On whom do we depend and who depends on us) Yes – patient was monitored and kept in system Yes and no – no delays in providing emergent care, but getting rehab was hard. Yes No– consultants used appropriately. Problem was not in Vanderbilt system, but in insurance system Yes Yes – all resources were used according to pts own goals for rehab Improvement III. PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned and what do we improve) Patient safety was maintained at all times. We still don’t know what caused stroke after surgery though. Rehab placement took too long – everyone worked hard, but maybe could have worked harder Care was administered effectively within limits – not much treatment for strokes like this yet A lot of energy and time was used ineffectively trying to place him Everyone worked hard for him because he was there so long and trying hard to rehab. not more than everyone else Pt was very involved in his own care and course and his wishes were always respected.

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69 Practice-based Learning and Improvement Tools and Methods

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71 Operating Room Team AIM: Reduce “Start Time” Delays in O.R. ©VUMC2001

72 Vanderbilt University Medical Center Run Chart of Delays ©VUMC2001

73 Vanderbilt University Medical Center Process Flowchart ©VUMC2001

74 Vanderbilt University Medical Center Cause and Effect Diagram ©VUMC2001 OR Start Time Delays PEOPLEPROCEDURES EQUIPMENTPOLICY Surgeon Late Anesthesia late Patient complications Consultation not done Consult notes not in chart No pre-op education Meds not given Tests not done H&P not done Nursing evaluation not done Anesthesia evaluation not done Test results not in chart Double booked Instruments not ready Not available Medical record missing Instruments not available No patient consent No authorization Registration not complete No pre-op check list

75 Vanderbilt University Medical Center Pareto Chart # of errors Cum Freq Cum. Freq. ©VUMC2001

76 Vanderbilt University Medical Center New Aim (Based on Data) To reduce the number of preoperative tests performed so that only those which are important to the medical mgmt of adult surgical pt during pre- op period are ordered. ©VUMC2001

77 Vanderbilt University Medical Center How Will We Know a Change Is an Improvement? Measurement: Percentage Excess Tests Per Specialty Based Upon Agreed Upon Guidelines ©VUMC2001

78 Vanderbilt University Medical Center What Changes Can We Make? Develop disease and surgical procedural testing guidelines for: -laboratory testing, -electrocardiography -chest radiography in adult surgical patients ©VUMC2001

79 Vanderbilt University Medical Center ©VUMC2001

80 Vanderbilt University Medical Center ©VUMC2001

81 Vanderbilt University Medical Center System-Based Practice at the Organization Level

82 Vanderbilt University Medical Center When organizations are not “Systems”

83 Vanderbilt University Medical Center Lab Manager Residents Hospital CEO

84 Vanderbilt University Medical Center  History  Physical Exam  Labs  Tests  Consults  Etc. Diagnosis Care of Patient (Matrix) Using the Matrix

85 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

86 Vanderbilt University Medical Center Upcoming Matrix Enhancements

87 Vanderbilt University Medical Center © 2004 Bingham, Quinn Vanderbilt University PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with Stroke An Oracle Database is being built that will collect data from each cell and allow analysis and reports to be generated by: Institution Department Diagnosis IOM Aim Competency

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89 Matrix as “Front Door” to Data and Education

90 Vanderbilt University Medical Center © 2004 Bingham, Quinn Vanderbilt University PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement Process Flowcharts SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) Evidence based Order sets MEDICAL KNOWLEDGE (What must we know) Pt and family satisfaction data Outcomes by race, gender, SES Cost per discharge Outcomes data Time Studies FMEA Events PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with Stroke Data linked directly to cells in the Matrix

91 Vanderbilt University Medical Center © 2004 Bingham, Quinn Vanderbilt University PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement Process Flowcharts* SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) Evidence based Order sets MEDICAL KNOWLEDGE (What must we know) Pt and family satisfaction data Outcomes by race, gender, SES Cost per discharge Outcomes data Time Studies FMEA Events PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with Stroke Link to Web based Education

92 Vanderbilt University Medical Center How to Flowchart a Process On-line web site for Improvement education (Dr. Quinn’s current course being redesigned for managers and physicians)

93 Vanderbilt University Medical Center On Transformation : “And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous to administer than to introduce a new system of things; for he who introduces it has all those who profit from the old system as his enemies, and he has only lukewarm allies in all those who might profit from the new system.” Machiavelli

94 Vanderbilt University Medical Center Healthcare Matrix Summary Points: Is a framework for integrating competencies into existing educational activities Provides a new mental model for Clinicians analyzing patient care Facilitates use of “resident performance data as the basis for improvement” Encourages use of “external quality measures to verify resident and program performance levels”

95 Vanderbilt University Medical Center Thank You!

96 Vanderbilt University Medical Center Implementation of Healthcare Matrix

97 Vanderbilt University Medical Center Internal Review Questionnaire Core Competencies 1.How does your program provide education that develops patient care practice that is compassionate, appropriate and effective? How effective is that training? 1 Not effective 2 Somewhat effective 3 Moderately Effective 4 Effective 5 Very effective

98 Vanderbilt University Medical Center Implementation Internal Review Process: –Analyze responses to competency questionnaire and discuss with program director; suggest improvements if needed –Provide information on competencies and use of Matrix –Offer to assist in the integration of competencies in M&M and case conferences, etc.

99 Vanderbilt University Medical Center Implementation Introduction to Matrix: Program Director or Dept. Chairs invite us to do lecture or Grand Rounds to introduce competencies and Matrix. Using the Matrix: –Attend M&M or case conferences as observers –Note the discussion on a blank Matrix showing which cells/competencies were discussed and which were omitted –Send Matrix to program director and discuss next steps

100 Vanderbilt University Medical Center Implementation Residents and the Matrix: –Residents fill in Matrix on their own –Best to let them struggle a little with the competencies as they think about care of their patient –Get someone (coach) to review Matrix with them –If the situation/case is difficult, Dept Chair, Program Director and mentors may assist with filling out Matrix and presentation Helpful hint: –Find a “coach” to help residents. At the outset, we work with the residents and faculty. Then Chief residents or interested faculty take the lead. Sometimes nurses can be coaches such as in Psychiatry at VU.

101 Vanderbilt University Medical Center Phase IPhase IIPhase IIIPhase IV 7/20016/20027/20027/20116/20067/20066/2011Beyond Improve the evaluation processes for all six of the Competencies. Provide aggregated resident performance data for Internal Review Process. Use resident performance data as the basis for improvement. Begin to use external quality measures to verify resident and program performance levels. Identify benchmark programs. Involve community in building knowledge about good GME. Define specific objectives for residents to demonstrate learning of the competencies. Begin integrating the teaching and learning of competencies into residents’ didactic and clinical experiences.

102 Vanderbilt University Medical Center Research Agenda to Validate Matrix (Based on Kirkpatrick, Evaluation of Training, 1994) Does the Matrix provide a useful framework for teaching and evaluating the performance of clinicians around the competencies? Phase I of ACGME : –Define objectives for learning –Begin integrating the teaching and learning of competencies into didactic and clinical educational experiences

103 Vanderbilt University Medical Center Research Agenda to Validate Matrix What are we learning about the care (columns) and education (rows) from completed matrices? Phase II of ACGME: –Improve the evaluation processes for all six of the Competencies –Provide aggregated resident performance data for Internal Review Process

104 Vanderbilt University Medical Center Are the behaviors of clinicians changing based on their completion of practice- based learning and improvement? Phase III of ACGME: –Use resident performance data as the basis for improvement –Begin to use external quality measures to verify resident and program performance levels Research Agenda to Validate Matrix

105 Vanderbilt University Medical Center Are the processes and outcomes of care improving? Phase III of ACGME: –Begin to link clinical quality indicators and patient surveys with education Phase IV of ACGME: –Adapt and adopt generalizable information about emerging models of excellence. Involve community building knowledge about good GME. Research Agenda to Validate Matrix

106 Vanderbilt University Medical Center Learning Core Competencies Evaluation of Evaluation of Residents (2006) Tools (2011) Care of Patient with …… Suggested Tools based on Matrix data Appropriate tools? AIMS Competencies SafeTimelyEffectiveEfficientEquitablePatient- Centered Assessment Patient Care Medical Knowledge Interpersonal Communication Skills Professionalism System-based Practice Improvement Practice-based learning and Improvement Information Technology (Dr. Paul Batalden provided the idea for this graph) Based on matrices for a dept or diagnosis, which evaluation tools best fit the need?

107 Vanderbilt University Medical Center Care of Patient with …… Suggested Tools based on Matrix data Appropriate tools? AIMS Competencies SafeTimelyEffectiveEfficientEquitablePatient- Centered Assessment Patient Care Medical Knowledge Interpersonal Communication Skills Professionalism System-based Practice Improvement Practice-based learning and Improvement Information Technology (Dr. Paul Batalden provided the idea for this graph) Are the evaluation tools appropriate and providing useful data? Learning Core Competencies Evaluation of Evaluation of Residents (2006) Tools (2011)


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