1. First Do No Harm: Optimizing Quality and Safety Training STFM May 2017
Lance Fuchs, MD FAAFP
Vidush Athyal, MD FAAFP
Kaiser Permanente San Diego
Family Medicine Residency

3. Introductions Your Name Where are you from? Your role
One goal from this discussion

4. Goals and Objectives
Understand important components of a quality, safety and performance improvement curriculum
Understand strategies to integrate quality and safety training into your residency curriculum
Understand strategies to implement panel management activities into your residency curriculum
Discuss what other programs are doing to achieve the same goals

5. Our Residency Large HMO community-based program 6 residents per year
Level 3 PCMH

6. What are we discussing? Quality Improvement (QI)
Performance Improvement (PI)
Patient Safety (PS)

7. ACGME requirements
VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs. (Core)
VI.A.4. The learning objectives of the program must:
VI.A.4.a) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and, (Core)
VI.A.4.b) not be compromised by excessive reliance on residents to fulfill non-physician service obligations. (Core)

8. ACGME requirements IV.B. Residents’ Scholarly Activities
IV.B.1. The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. (Core)
IV.B.2. Residents should participate in scholarly activity. (Core)
IV.B.2.a) Residents should complete two scholarly activities, at least one of which should be a quality improvement project. (Outcome)

9. Kaiser Permanente
Company culture includes emphasis on quality care and employee/patient safety
Advanced systems to support these efforts
“Culture of excellence”
A high level of expectation of effort by every team member is needed for this work. Successful team: people/relationships, effective processes, results

10. Kaiser Permanente
Coordinating efforts with your hospital, medical group, department or faculty goals
What can residents do to help?
Is there educational value for the residents?
What is required?

11. The Basics of Quality Work
Health Care must be:
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable

12. An Outline of Our Curriculum
Next we will summarize the components of our curriculum.

13. Teaching Evidence-Based Care
USPSTF guidelines
Choosing Wisely Campaign
KP Regional Clinical Guidelines
PICO exercise
Monthly journal club to evaluate evidence

14. Resident Participation in Department Quality Team
Over 200 family physicians in our department
Quality team = 5 leaders and other physicians rotate through
Rate cases
Provide education to department
All residents participate
1-2 residents attend each month

15. Reporting Process for Patient Care Cases Involving Residents
“Culture of Safety”
Recognize/respond/disclose adverse events and near misses
Safe reporting
Tracking
Educating
Standardization of clinical processes

16. Monthly Quality Didactics/Discussions
The resident(s) who attended the department quality meeting present the cases
Highlight recurrent themes where providers make errors
Discuss importance of effective communication between team members

17. Peer Chart Review
Clinic visits, telephone appointment visits and messages
Expectation of high quality documentation in EMR

18. Safety Net for Clinical Advice
In-basket coverage calendar with assigned faculty to call every day/any time

19. Teaching Safe Habits Hand washing Not recapping needles
Wearing goggles/masks for high-risk procedures

20. Panel Management EMR-based care gap reminders (in-reach)
Registries/Report cards
Team-based care/defined roles
Pod-based efforts
Learn processes/best practices for clinical strategic goals
Participate in PBM outreach efforts
Whole person care as a health care system: flu shot everywhere (even in Ortho), get them where they are

21. Studying a Process/Changing a Process
Experiences in PDSA cycles
Using SMART criteria
Root-cause analysis/fishbone diagrams
From report cards to improved performance
Experiencing efforts to reduce errors
formal approach to performance analysis and systematic efforts to improve it

22. Institute of Health Care Improvement (IHI) Open School
All of our residents complete IHI Open School Basic Certificate on their own time
KP Southern California has an IHI residency network with 6 FM programs – resident led
Collaborative QI projects

23. Late in the first year of residency
KP Southern California Regional Resident Performance Improvement Workshop
Late in the first year of residency
Provide guidance for class-based project

24. Scholarly Projects Class-based projects Individual projects:
Literature review
Clinical PI/QI/PS project
Publishable/presentable scientific research

25. What are your expectations of residents’ quality and safety education?
Learn the process
Experiential is better
Those more interested can do more
Need to provide them support (time, faculty)

26. Assessing Our Residents
Do residents enter training feeling ill-equipped to handle issues of QI/PS?
Does training improve knowledge and skill?
What parts are most and least useful?

27. Discussion Common challenges and strategies to overcome them:
Faculty time
Faculty interest and expertise
Sustainability of projects
Others?

28. References IHI Open School: www.ihi.org
Improving Resident Education in Quality Improvement and Patient Safety. Ramon Cancino, MD. STFM 2011.
Creating and sustaining a culture of safety in a Family Medicine residency. E. Btkiewicz et al. STFM.

29. References
How Doctors Think: Contributions to Medical Errors. T. Munzing et al. STFM.
“How Doctors Think”. Jerome Groopman
To Err is Human: Building a Safer Health System for the 21st Century, IOM, 2001.
Leadership Guide to Patient Safety, Institute of Health Improvement

30. References
How to measure quality and improvement of panel manager’s work in the PCMH in a residency practice. D. Yamashita et al. STFM.
A Bridge to Safety: A curriculum for creating a safety state of mind. C. Gleit et al. STFM 2016.
ACGME Program Requirements for Graduate Medical Education in Family Medicine