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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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

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?

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

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

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

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

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%”

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

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

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

Structure: microsystem Nelson, 2003

Measuring quality Donabedian model Structure Process Outcome

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

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

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

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

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

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

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

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.

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!

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)

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!

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?

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

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

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

Questions? Thank you!