What is Systems-Based Care? What is Practice Based Learning and Improvement? Why these competencies? Richard J. Simons, M.D. Acting Vice Dean for Educational Affairs Penn State College of Medicine

CORE PREMISE The American healthcare delivery system is in need of fundamental change The current systems cannot do the job Trying harder will not work Changing systems is necessary

We’re Driving a Powerful Vehicle, but it has no: Map Compass Speedometer Odometer, or Clock Yet the pedal’s to the floor

Aims for Improving Healthcare Safe Effective Patient-centered Timely Efficient Equitable

To Err is Human: Building a Safer Health System Why start with errors? Burden of injury Understandable to providers and consumers Avoidable Experience in other industries

Many People are Harmed Adverse event – an injury caused by medical management Adverse events occur among 3-4% of hospitalized patients About 1 in 10 results in death Over half are preventable

Key Findings Errors occur because of system failuresErrors occur because of system failures Preventing errors means designing a safer system of carePreventing errors means designing a safer system of care

“Few newly qualified physicians have the necessary skills to improve health care and safety. These include the ability to perceive and work effectively in interdependencies, the ability to understand work as a process, skill in collecting, aggregating, analyzing, and displaying data on the processes and outcomes of care, skills in designing health care processes, an ability to work in teams and collaboration with managers and patients, and the willingness to examine honesty and learn from mistakes”

Professional Competence: a definition The habitual and judicious use of communication, knowledge, technical skills, evidence-based decision-making, emotions, values and reflection to improve the health of the individual patient and the community

Systems-Based Practice “Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.”

Why Systems-Based Practice? Prepare physicians to work in the current system Optimize cost and outcomes Improve the system Transform the health care system

“Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it” -- Relman, Acad Med, 73, 1998

Why Systems-Based Care? “ A systems view is critical to understanding patient outcomes, safety, values and quality”

What are the components of Systems-Based Care? For your Residency Program?For your Residency Program? For your institution/hospital?For your institution/hospital?

Some components of Systems- Based Practice System resources Patient advocacy Health care economics Teamwork Cost-benefit considerations Healthcare economics Healthcare Financing Practice management Insurance Types Medical-Legal Issues Coordination of health care Documentation Issues Social and political history of US health care system

Elements of Systems: The Resident-System Interface Within the hospital/clinic Admitting/scheduling Documentation Other clinical services Ancillary services Nursing Pharmacy Outside the hospital/clinic Referring physiciansReferring physicians Insurers, HMO’sInsurers, HMO’s Community servicesCommunity services External laboratory and radiological servicesExternal laboratory and radiological services Legal systemLegal system

Systems Thinking Principles and Concepts InterdependenceInterdependence Structure drives behaviorStructure drives behavior Cause and effect are separated by time and placeCause and effect are separated by time and place Any change in a system has unintended consequencesAny change in a system has unintended consequences

“The prominence of physicians in highly interdependent medical systems confers tremendous power on them, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about medical systems.” --Nolan, Annals Intern Med, 1998

Practice-Based Learning and Improvement “Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.”

Practice-Based Learning and Improvement Analyze practice and improve using systematic methodologyAnalyze practice and improve using systematic methodology Locate, appraise and apply scientific evidenceLocate, appraise and apply scientific evidence Apply knowledge of study designs and statisticsApply knowledge of study designs and statistics Obtain and use patient population dataObtain and use patient population data Use information technologyUse information technology Facilitate the learning of othersFacilitate the learning of others

Practice-Based Learning and Improvement Residents must internalize the value of on-going, self-directed learning and improvement of practice Reflect on and analyze practice experienceReflect on and analyze practice experience Locate and apply scientific evidenceLocate and apply scientific evidence Take steps to improve practiceTake steps to improve practice Demonstrate improvementDemonstrate improvement

“Whatever we measure we tend to improve.”

“We measure what we value.”

Practice-Based Learning and Improvement

Where should we start? Begin with what you have in place – your resident interactions with their patientsBegin with what you have in place – your resident interactions with their patients

What data can be gathered about a resident’s knowledge of Systems-Based Practice and Practice Based Learning through a patient encounter? Questions from the attending? Was the care based on a healing relationship?Was the care based on a healing relationship? Was the care customized based on patient’s needs?Was the care customized based on patient’s needs? Was evidence-based decision making used?Was evidence-based decision making used? Was safety a system property of the care?Was safety a system property of the care? How did you anticipate the needs of the patient?How did you anticipate the needs of the patient? How could waste be diminished?How could waste be diminished?

Other venues for SBP and PBL Teaching and Evaluation Case analysis – focus on processes of care Construction of a flow chart of a hospitalized patient to analyze systems of care Root cause analysis of an adverse event Activity based cost analysis of a hospital bill

Reasons this is hard Competence is a habit Medicine is a cooperative not a productive art The important things are hard to measure Residents seek practical wisdom To become competent you have to “feel bad” Learning occurs in microsystems Becoming competent is a complex process

Helpful Hints for Program Directors Use current activities already in place (rounds, conferences, grand rounds, discharge planning rounds) to teach and evaluate SBP and PBL Issues related to SBP and PBL abound in resident experiences Involve the residents in the process of deciding how to incorporate these competencies into your curriculum Faculty development is a key to success

“Residents live in the fault lines of health care systems and give voice to what life is like there.”