1. Quality Improvement Projects: Utilizing the Power of Students in the Primary Care Setting Donald L. Clark, MD Wright State University Boonshoft School Of Medicine Dayton, Ohio

2. Disclosures Dr. Clark has no financial or non financial disclosures to report

3. Learning Objectives On completion of this session, participants should be able to: –Complete short PDSA cycles for quality improvement within primary care practice –Utilize student energy and commitment to help drive change with a practice –Implement specific interventions that improve quality within a practice

4. Patient Centered Medical Home (PCMH) Form of revolutionizing primary care to better focus on the Triple Aim Triple Aim: Patient Experience of Care, Cost of Care, Quality of Care

5. Triple Aim

6. Joint Principles of Primary Care 1. Personal physician -coordinates care for patients and leads team 2. Physician-directed – coordinated team of professionals who work together to care for patients 3. Whole person orientation – providing comprehensive care 4. Coordinated care –helps patients negotiate the complex health care process 5. Quality and safety – voluntarily engage in quality improvement activities to ensure/improve patient safety 6. Enhanced access to care – such as through open-access scheduling and communication mechanisms. 7. Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.

7. External Support Ohio House Bill 198- Ohio’s Medical Home Statute –Enacted in June 2010 –Project to establish medical homes in Ohio –Pilot projects: initial practices to be resources for other primary care practices in Ohio to become PCMH

8. Educational Focus Ohio Department of Health PCMH Educational Advisory Group –Chartered by Ohio House Bill 198 –Goal: to help revise curriculum in Medical Schools and Nursing Schools to include PCMH principles –Medical Schools participating: Wright State University University of Toledo Northeast Ohio Medical University (NEOMED) Ohio University

9. Quality Improvement Challenges Help students understand PCMH Involve students in primary care quality improvement Use mechanisms of real world primary care to teach students Make it practical for community physicians

10. Quality Improvement Projects in Primary Care Education Lack of definitive research How do you teach students about quality improvement? How do you accomplish this with limited resources?

11. Quality Improvement Projects in Family Medicine Clerkship Orientation to PCMH for 3 rd year students in Clerkship Review Quality Improvement Process (PDSA cycles) Empower students and community preceptors to come up with quality improvement projects Report on QI projects at the end of their 6 week clerkship to community practice and to fellow students

12. Plan, Do, Study, Act (PDSA) Plan –Decide on a problem to address –Collect baseline data –Design an intervention Do –Implement the intervention –Collect follow-up data Study –Disseminate and discuss outcomes Act –Determine if additional work is needed

13. PDSA Cycle Discuss topic with your preceptor, gather data –Consider resources available, team functioning at highest levels of training, do something that is measurable PLAN what intervention you can reasonably begin at your site, can continue with an ongoing project DO the intervention (at least begin) STUDY how the intervention went Recommend a future ACT that would revise the intervention Present your PDSA to the class, your preceptor

14. Benefits to QI Projects Provides help and support to community practices –Helping develop QI projects using PCMH principles –Provides student as a resource to the practice –Energy of students to feel helpful Provides students with quality improvement experiences –Helps them understand real world challenges –Can be expanded into posters or papers –Can be used as CV material for residency applications –Helps them “make a difference” during their educational experiences

15. Examples of Projects Diabetic management markers –Glucose control, Foot exams, eye exams, microalbuminuria screening Asthma management Smoking cessation(rate of smokers, asking about quitting) Mammograms Hypertension control Immunizations (flu vaccine, etc.) Hand hygiene Patient self management (discharge summaries) AAA screening Process issues in office (no shows, late patients)

16. Limitations Time- only 6 weeks to collect initial data, develop intervention, and measure outcomes Complexity of the intervention Direct benefit to students- i.e. exam scores Students lack of understanding/ examples of PCMH principles Practices not yet implementing PCMH principles Availability of resources to implement interventions at practices

17. QI Project Student Ratings 1 (poor) – 5 (superb) 1 2 3 4 5 0% 4% 12% 36% 48%

18. Student Feedback “found it helpful to see what sorts of things should be implemented in practice.” “surprised at how successful a simple project can be” “maybe it should be ongoing project at each site for the entire year.” “while the idea is good, the data are not really valid or useful over a 6-week period.” “doesn’t help me with shelf exam”

19. Goals Acheived? Improved student understanding of PCMH Improved understanding of barriers to quality improvement Improved quality outcomes for patients?

20. Survey of Preceptors *On a scale of 1-10, has the student quality improvement project been useful for you in your practice? 1(not at all helpful) 10 (extremely helpful)__________ How have they been useful or not useful? * Does your practice have ongoing QI projects outside the student QI project? (Yes or No) * Have you or the student(s) utilized non-physician members of the health care team in implementing the student quality improvement project? (Yes or No) * Has the student(s) shared the results of the QI project with you? (Yes or No)

21. Survey of Preceptors * Has the student(s) shared the results of the QI project with other members of your staff? (Yes or No) * Does your practice have a designated QI staff member ( Yes or No) * Is your practice required to report any ongoing quality metrics to outside agencies? (Yes or No) If yes, what metrics have you reported? * Have you used the quality improvement projects as a way to satisfy the requirements of the American Board of Family Medicine Maintenance of Certification Part IV? (Yes or No)

22. Survey of Preceptors * How many different QI projects have you or your practice undertaken in the last year including student projects?_______ Please list the projects: * How do you usually identify topics for quality improvement? (Circle all that apply) –Your choice –Student’s choice –Combination of your interests and student interests –Ongoing projects –Other organizations (Hospitals, employers, etc.) –American Board of Family Medicine –Ohio Academy of Family Physicians –Other, please specify * Do you have an Electronic Health Record (EHR)? (Yes or No)

23. Survey of Preceptors Have you begun using your EHR to develop patient registries? (Yes or No) –If yes, what patient registries have you used? Are students able to use these registries for their QI projects? Are you able to get metric reports from your EHR? (Yes or No) If No, then discuss why? – Are students able to use these metrics for their QI projects? Does your EHR provide meaningful data? (Yes or No) –Discuss why or why not: Have the student projects improved the quality of care for patients? (Yes, No, Unsure) –Discuss why you answered the way you did

24. Preceptor Feedback Used to accomplish Part IV of ABFM MOC “Improved quality for patients because students are here”

25. Preceptor Feedback

26. Questions? donald.clark@wright.edu

27. Summary Students can complete quality improvement projects using PDSA cycle Meaningful information can be achieved to help accomplish change Value remains to be determined

28. Please evaluate this session at: stfm.org/sessionevaluation