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3:15 pm – 3:25 pm Introduction Berend Mets, MB, Ph.D., Moderator

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

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

3 Objectives for today: Discuss the Institute of Medicine (IOM) Aims for Improvement and the ACGME Core Competencies. Describe how the Healthcare Matrix helps link outcomes of care to learning the core competencies. Provide examples of how the Healthcare Matrix is used to improve education and the delivery of care. Initiated in July 2001 for all Residencies and initial Board Certification (10 year phase-in process). Applicable to all subsequent Board Maintenance of Certification applications.

4 “Kyros” Events in Healthcare:
1999 2001 2002 2003 2004 Emerging public reporting of quality measures “Hospital Compare”

5 Extrapolated study results imply that between 44,000-98,000 U. S
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 And what about today? “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.”

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

8 Phase I Phase II Phase III Phase IV 7/2001 6/2002 7/2002 6/2006 7/2006
6/2011 7/2011 Beyond Phase I Phase II Phase III Phase IV 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. 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.

9 “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 Emerging public reporting of quality measures
“Hospital Compare” Emerging public reporting of quality measures 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

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

12 Patients with Needs Met
What are you measuring to evaluate the quality of Anesthesia care? Patients with Needs Patients with Needs Met Access Diagnosis Treatment Follow-up Assessment How and where are these data reported? How is the information utilized to improve: the education of residents? the quality of care provided?

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

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

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

17 What is our Anesthesia performance for:
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 Is Care Safe ? Observed to Expected Mortality:
VUMC Goal: Achieve lowest mortality in nation VUMC 2004 VUMC 2005 Observed to Expected Mortality: 53 UHC AMCs with Level I Trauma Centers

19 VUMC Observed to Expected Mortality and Actual Number of Mortalities 2003-2005

20 PATIENT CARE that is… Timely Safe “Reducing waits and sometimes harmful delays for both those who receive and those who give care”

21 What is our Anesthesia performance for:
PATIENT CARE that is… Safe Timely 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 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 Patients with Needs Met
Access Diagnosis Treatment Follow-up Assessment What is the infection rate for surgical patients (in total, by procedure, by specialty, by surgeon; by site of surgery) ? Received prophylactic antibiotics? Yes No Exceptions by procedure, by specialty, by surgeon; by site of surgery ? Received within one hour prior to surgical incision?% Yes No Received the appropriate antibiotic? % with Infection % with Infection No Yes Exceptions % with Infection % with Infection

24 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 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”

26 What is our Anesthesia performance for:
PATIENT CARE that is… Safe Timely Effective 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 PATIENT CARE that is… Safe Timely Effective Efficient “Avoiding waste, including waste of equipment, supplies, ideas, and energy”

29 What is our Anesthesia performance (over time) for:
PATIENT CARE that is… Safe Timely Effective Efficient 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 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”

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

32 “Providing care that is respectful of, and responsive to:
PATIENT CARE that is… Timely Efficient Effective Equitable Patient Centered Safe “Providing care that is respectful of, and responsive to: individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions”

33 Is Care Patient Centered? What are our patients’ perceptions of:
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 What must we know? PATIENT CARE that is… Timely Efficient Effective Equitable Patient Centered Safe 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”

35 What must we say? PATIENT CARE Timely Efficient Effective Equitable Patient Centered Safe Medical Knowledge Interpersonal and Communication Skills “…that result in effective information exchange and teaming with patients, their families, and other health professionals.”

36 How must we behave? PATIENT CARE Timely Efficient Effective Equitable Patient Centered Safe 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.”

37 What is the Process? On whom do we depend? Who depends on us?
PATIENT CARE 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.”

38 What have we learned? What will we improve?
PATIENT CARE Timely Efficient Effective Equitable Patient Centered Safe Medical Knowledge Interpersonal and Communication Skills Professionalism System-Based Practice Practice-Based Learning & Improvement “…involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.”

39 Linking it all together…. Patients with Needs Met
Access Assessment Diagnosis Treatment Follow-up -Medical Knowledge -Interpersonal and Communication Skills -Professionalism -Practice-Based Learning & Improvement Timely Efficient Effective Equitable Patient Centered Safe -System-Based Practice Clinicians competent in: Patient Care that is…

40 QUESTIONS?

41 “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 Five Applications of the Matrix
Individual Resident Learning Case Presentations M & M Conference Panel of Patients for Group Learning Medical Students

43 Individual Learning Case Presentation

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

45 IOM Case presentation after dialogue with faculty using the Matrix.
ACGME SAFETY TIMELINESS EFFECTIVE-NESS EFFICIENCY EQUITA-BILITY PATIENT CENTERED-NESS PATIENT CARE MEDICAL KNOWLEDGE X PROFESSIONALISM INTERPERSONAL & COMMUNICATION SKILLS SYSTEMS- & TEAMS-BASED PRACTICE 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.

46 Patient with Pregnancy and D. I
Patient with Pregnancy and D.I.C (Disseminated Intravascular Coagulopathy) Case Presentation IOM ACGME SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED Assessment of Care PATIENT CARE (Overall Assessment) NO Patient nearly died Life saving treatment was delayed for variety of reasons Delays in treatment impaired effectiveness of therapy Resources (blood products, staff time) were not utilized in an efficient manner. Language was a problem 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 2nd 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 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 IMPROVEMENT (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 Patient with Coronary Artery Disease (Internal Medicine Residents Ambulatory Rotation)

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50 Panel of Patients with Coronary Artery Disease

51 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 Internal Medicine Residents Ambulatory Rotation

53 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 Transforming M&M Conferences into Practice-based Learning and Improvement

59 Care of Child with Hyperleukocytosis M&M 3/25/04 (Peds Hem/Onc)
IOM ACGME SAFE 1 TIMELY 2 EFFECTIVE 3 EFFICIENT 4 EQUITABLE 5 PATIENT - CENTERED 6 Assessment I. PATIENT CARE 7 Mostly yes (Toxicity of chemo needed better monitoring) Yes Yes (but variation exists) WBC dropped from 324K to 37K by midnight Family told of possible Dx within 2 hours of ED visit. II. A MEDICAL KNOWLEDGE 8 (What must I know) Hypercalcemia led to hypotension. Respiratory di stress secondary to fluid overload and atelectasis required intubation Complications of Leukopheresis was discussed. Full dose Chemotherapy started quickly Management of Hyperleukocytosis: was major discussion for M&M conference. Discussed lack of b enefit and increase cost of cranial irradiation How to tell family bad news (lecture at VU). Pediatrics Oncologists have a lot of experience and are very family centered. Family was well informed of likely dx and plan of action. II. B PROFESSIONALIS M 9 (How must I act) PCP referred child to ED for evaluation very quickly (from community 40 miles away). Feedback to PCP was done as soon as a concern was voiced. Some physician variation noted at VU for treatment. Can we standardize with pathway? Able to talk to family and PCP in professional and evidenced based manner. II. C INTERPERSONAL AND COMMUNICATION SKILLS 10 (What must I say) Experienced physicians and researchers communicated well. Hand offs were smooth and well executed. Pare nts felt comfortable providing inform consent by 7 PM the same day. II. D SYSTEM BASED PRACTICE 11 (On whom do I depend and who depends on me) Toxicity was an issue and the team needed to do a better job of recording what was happening. Quick response by VCH to PCP. hyperleukocytosis 5 hours to Dx 8 hours to start of Tx Discussed issue of dialysis for treatment. Consulted nephrology and PICU. Dialysis nurse notified early and circuit primed. Lab results were done quickly from ED. Team worked well to have treatment begin quickly with good results within 10 hours ED good communication with House Officer. Social worker met with family to explain what was happening. Improvement III. LEARNING AND IMPROVEMENT 12 (How can I improve) Be s ure everyone knows the toxicity and complications and document. Create pathway for hyperleukocytosis to decrease variation © Bingham, Quinn Vanderbilt University

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61 Information Technology
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 Healthcare Matrix: Care of Patient with postpartum respiratory arrest
OB M&M April 29, 2005 AIMS Competencies SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED Assessment of Care PATIENT CARE (Overall Assessment) Yes/No No Resp arrest during awake intubation. Yes Yes: had proper tx. No: Tx could have been better. Yes 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 Care of Patient with Femoral Vein Cannulation COMMUNICA-TION SKILLS
AIMS Competencies SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED Assessment PATIENT CARE (What must I do) NO Pt not always safe as evidence by several adverse events Yes No Need to find/learn best method. Evidence of Ultrasound for dialysis line placement. 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 Improvement (Femoral Cannulation Cont’d)
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. Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation © Bingham, Quinn Vanderbilt Univ. (Used with Permission from Nephrology Dept.)

65 ACTION PLAN

66 Medical Students (Neurology Clerkship)

67 Healthcare Matrix: Care of Patient with stroke - occlusion of the ICA of unknown origin.
AIMS Competencies SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED Assessment of Care I. PATIENT CARE (Overall Assessment) Yes/No Yes No Yes, from VUMC, No for placement. Yes from VUMC 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  Yes yes   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 and no – pt was on service for a while,– but not really treated much better than others 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.  No– consultants used appropriately. Problem was not in Vanderbilt system, but in insurance system  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 Run Chart of Delays ©VUMC2001

73 Process Flowchart ©VUMC2001 Nursing evaluation done? Surgery H&P done?
Yes Surgical consent signed? Anesthesia Risk & medicolegal issues addressed? Need pre-op lines in holding? OR ready? Perform nursing weight No Perform H&P Obtain signed Perform evaluation: H&P Indicated tests: labs ECG CXR Cancel Place indicated lines Wait ©VUMC2001

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

75 Pareto Chart Cum. Freq. # of errors Cum Freq ©VUMC2001

76 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 How Will We Know a Change Is an Improvement? Measurement:
Percentage Excess Tests Per Specialty Based Upon Agreed Upon Guidelines ©VUMC2001

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

79 ©VUMC2001

80 ©VUMC2001

81 System-Based Practice at the Organization Level

82 When organizations are not “Systems”

83 Residents Hospital CEO Lab Manager

84 Using the Matrix History Physical Exam Labs Tests Consults Etc.
Care of Patient (Matrix) Diagnosis

85 “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 Upcoming Matrix Enhancements

87 Healthcare Matrix: Care of Patient(s) with Stroke
© 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 EQUITABLE EFFICIENT EFFECTIVE TIMELY SAFE 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 Healthcare Matrix: Care of Patient(s) with Stroke
© 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 EQUITABLE EFFICIENT EFFECTIVE TIMELY SAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with Stroke Data linked directly to cells in the Matrix

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

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

93 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 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” Initiated in July 2001 for all Residencies and initial Board Certification (10 year phase-in process). Applicable to all subsequent Board Maintenance of Certification applications.

95 Thank You!

96 Implementation of Healthcare Matrix

97 Internal Review Questionnaire Core Competencies
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 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 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 Implementation Residents and the Matrix: Helpful hint:
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 Phase I Phase II Phase III Phase IV 7/2001 6/2002 7/2002 6/2006 7/2006
6/2011 7/2011 Beyond Phase I Phase II Phase III Phase IV 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. 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.

102 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 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 Research Agenda to Validate Matrix
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

105 Research Agenda to Validate Matrix
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.

106 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 Safe Timely Effective Efficient Equitable Patient- 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 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 Safe Timely Effective Efficient Equitable Patient- 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?


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