G. Dean Cleghorn, EdD Lawrence Family Practice Residency Lawrence, MA Practice-based Learning and Improvement & Brent James’ “Essential Infrastructure for Improvement” An Introduction G. Dean Cleghorn, EdD Lawrence Family Practice Residency Lawrence, MA July 27, 2006

Objectives—PBLI Participants will: review six elements of Practice-based Learning and Improvement. learn how the Lawrence Family Practice Residency is addressing the elements of the Practice-based Learning and Improvement and Systems-based Practice competencies. review essential infrastructure for health improvement. discuss questions about how to implement PBLI.

ACGME Competency: 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.

PBLI 1-Residents are expected to: Analyze practice experience and perform practice-based improvement activities using a systematic methodology

PBLI 2-Residents are expected to: Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

PBLI 3-Residents are expected to: Obtain and use information about their own population of patients and the larger population from which their patients are drawn

PBLI 4-Residents are expected to: Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

PBLI 5-Residents are expected to: Use information technology to manage information, access on-line medical information; and support their own education

PBLI 6-Residents are expected to: Facilitate the learning of students and other health care professionals

Essential Infrastructure Elements For Health Care Delivery Improvement Culture of quality Aligned Strategies (prioritization of improvement goals) Measurement Systems Organizational Structure Creative payment mechanisms to cover costs of improvement From “Essential Infrastructure for Health Care Delivery Improvement.” Pre-conference workshop, 15th Annual National Forum on Quality Improvement in Health Care, Orlando, FL, December 13, 2004. Brent C. James, M.D., M.Stat.

Essential Infrastructure Elements-1 Culture of quality Training for medical directors, nursing directors, administrators Team training Site-based Ten-week course, 20-40 hours Front-line staff involvement

Essential Infrastructure Elements-2 Aligned Strategies (prioritization of improvement goals) Based on clinical outcomes data Selected from the largest opportunities for improvement Likelihood of success

Essential Infrastructure Elements-3 Measurement Systems Available expertise in information systems, measurement, statistics Capacity for data ware housing Capacity for online reporting available to all employees and perhaps to patients

Essential Infrastructure Elements-4 Organizational Structure Explicit duties to manage improvement for Medical Site Directors, Medical Directors, Practice Managers Shared goals for improvement including with the Board, Executive Leaders, and Local Sites

Essential Infrastructure Elements-5 Creative payment mechanisms to cover costs of improvement Grants Payers Increased margin from results

Implementation Questions How can improvement be embedded in the daily work of caring for patients? In addition to an “embedded improvement process” how can residents learn about PBLI given the limits on their time? How can we limit the need for residents to learn a new vocabulary in order to gain the needed improvement knowledge?

Implementation Questions How do we create a culture of data-based decision making? What resources are available to give point-of-care access to national and local medical data and information? How do we create a culture of openness about clinical outcomes? How do we measure competence as a result of educational events?