1. Integrating quality improvement and medical education
Stephanie Parks Taylor MD
Department of Internal Medicine
Division of Hospital Medicine

2. objectives Overview of Quality Improvement
Importance of QI in residency training
QI Principles and tools we need to be teaching

3. 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

4. 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

6. IOM recommendations Six major goals for health care Safe Effective
Patient-centered
Timely
Efficient
Equitable

7. IOM recommendations Ten “rules” for healthcare
Care should be based on continuous healing relationships
Customization based on patient needs and values
The patient as the source of control
Shared knowledge and free flow of information
Evidenced-based decision making

8. IOM recommendations Ten “rules” for healthcare
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
Cooperation among clinicians

9. 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 S

10. 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

11. 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 30th street clinic

12. Quality of care: example
How well does this patient’s care meet the 6 IOM criteria?
Safe
Effective
Patient-centered
Timely
Efficient
Equitable

13. Qi in residency programs
Why is it important to involve residents in quality improvement?

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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
Specific components of this competency include

20. 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
Specific components of this competency include

21. 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

22. 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

23. 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
Speific componetns are

24. 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
So given these criteria for PBL&I, SBP competensies, what exactly would constitute “competence” for a resident graduating from your program?

25. 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

26. 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
What do you think of these benchmarks?

27. 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

28. 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

29. Mission statements
Key ingredients for the explicit expression of goals
Measurables
Deliverables
Timeline
Dembitzer, Stanford Contemporary Practice, 2004

30. 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

31. 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%”

32. Measuring quality What are we measuring? Donabedian model Structure
Process
Outcome

33. Measuring quality Structure
The way a healthcare system is set up and the conditions under which care is provided

34. 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

35. Structure: microsystem
Nelson, 2003

36. Measuring quality
Donabedian model
Structure
Process
Outcome

37. Measuring quality: process
Process: the activities that constitute healthcare
Diagnosis, treatment, prevention ,counseling, etc

38. 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

39. 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
ICU nurse assigned to accept patient
Nurse to nurse communication prior to transport
Patient transported by appropriate staff
Here is an abridged version of a flowchart.
Important tips to consider in the flowcharting process include the following:
-Flowchart a clinical process, not the entire medical care system
-Avoid too much detail at this early stage of planning
-Process should reflect Project Team’s mission statement
-Get all necessary information to ensure that the flowchart contains all the principal steps contained in the existing clinical process
-Show the process as it actually occurs, not in the ideal state of how it should or could be
-Remember that this is a critical stage of planning: take as much time as needed to get it right
-Show the flowchart to other front line people for input and modification as needed
-Look particularly for areas of delay, rework loops, hassles, complaints from “customers” of the process
We will work with flowcharting a process in a few minutes.
Patient arrives in ICU unit
ICU staff notified of patient arrival
MD to MD report
Patient is under care of ICU team

40. Measuring quality Donabedian model Structure Process Outcome
The third and final element of measuremet is outomes, defined as the changes (desired or undesired), that can be attributed to healthcare

41. 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
The third and final element of measuremet is outomes, defined as the changes (desired or undesired), that can be attributed to healthcare

42. System based approach to outcomes
Patient Needs
Process of Care
Outcomes of Care
Practice Systems

43. System based approach to outcomes
Patient Needs
Process of Care
Outcomes of Care
Demographics
Co-morbidity
Risk Factors
Barriers to Self-Care
Clinical
Functional
Satisfaction
Safety
Cost
Practice Systems
This slide shows in greater detail the various elements.
For this slide, focus on the patient needs side and point out that processes of care involve multiple steps as discussed in earlier slides.
Access
Evaluation DX RX
P. Activation

44. Model for improvement Act Plan Study Do 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
Finally, lets spend a few minutes of methods we can acutally use to bring about change in the structure, process, and outcomes of healthcare using our target of improved vaccination for an example. This is the famous (or infamous) Plan Do Study Act cycle developed by Shewart and Deming over a half century ago and modified by Nolan and his colleagues at IHI
In this model of improvement, we start with three questions:
What are we trying to accomplish? This is the mission statement!
How will we know that a change is an improvement? Thus the need for measurement!
What change can we make that will result in improvement?
These questions help drive the PDSA process. PDSA stands for Plan, Do, Study, Act.
Let’s walk through each step of this cycle.

45. 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!

46. Pdsa cycle DO STUDY Implement the proposed solution on a small scale
Review and evaluate the result of the change
Will almost always require some form of data collection (medical record review, patient satisfaction, etc)

47. 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!

49. 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?

50. 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

51. 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

52. 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

53. Questions?
Thank you!