1. Practice Re-design in Residency Training
Highland Hospital/University of Rochester Family Medicine Residency
Rochester, New York
Colleen T. Fogarty, MD, MSc; Stephen J. Lurie, MD, PhD; Stephen H. Schultz, MD
Our Learning
Introduction
The Highland Hospital/University of Rochester Family Medicine Residency has a long history of innovation. Our Preparing Personal Physicians for Practice (P4) project will implement and compare two approaches to teaching the New Model of Family Medicine within Family Medicine residency practice.
We are redesigning one of our four existing residency suites within our Family Medicine Center, and we will establish a new inner-city teaching Ideal Micro Practice (IMP).
Methods
We will teach and model:
The Chronic Care Model
Team development
Leadership skills
Plan-Do-Study-Act (PDSA) cycles
Idealized Micro-practice for Family Physicians
Using team methodology, we will implement quality improvement projects focused around chronic disease management, beginning with diabetes. Our aim is to improve individual and aggregate clinical measures for patients with diabetes. We will measure patient, resident and practice outcomes in both these practice models using quantitative and qualitative methods.
Accomplishments
Initiated team functioning &
Introduced Team Huddles
Suite 700
Brown Square Red Team (resident team)
Implemented front-end manager position across the practice.
Added Teaching content to support New Model Skills~
Resident Teaching:
Chronic Care Model
Team Huddles
Plan/Do/Study/Act cycles (PDSA)
Leadership curriculum
Staff Teaching:
Community meeting focus on P4 project
Team development—process & content
Re-designed resident teaching curriculum to put team meetings in central place in FM teaching time. (start July 2008)
Conducted successful residency and practice retreat 4/10/2008 to begin to stimulate practice re-design across the center.
Next Steps
Initiate PDSA cycles on clinical teams with focus on diabetes quality improvement measures.
Work with new data mining software (Analytics) to choose quality measures for Diabetes.
Pilot new teaching structure to improve ability of residents to participate in team function, and share learning across teams
Refine leadership curriculum to meet residents’ developmental needs.
Our experience with practice re-design has taught us many lessons about the process of change. The process of change is as important as the content of the change. Neither can be accomplished without the other.
At the project proposal stage of P4, our image of change looked like this:
Timeline – at time of P4 proposal submission
Initiate really cool innovations in practice redesign and quality improvement
Start of project
“Failure is Impossible”
Susan B. Anthony
Literature cited
1. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice?. JAMA Mar 10;291(10):
2. Stewart EE, Johnson BC. Improve office efficiency in mere minutes. Family Practice Management. 2007;14(6). 3.
A year-plus later, our diagram looks like this:
Timeline – as we begin the actual work…
Initiate really cool innovations in practice redesign and quality improvement
Start of project
Data collection
Improving team communication and function
Tension in practice: Standardization vs. innovation
Pent-up staff demands for change
Basic teaching on chronic disease and QI
CONTENT WORKSHEET
AIM: what are we as a team trying to accomplish to improve the diabetes care we provide?
CHANGES: What changes will we try to achieve that aim?
MEASURES: how will we know that a change is an improvement?
PROCESS WORKSHEET
AIM: what are we as a team trying to accomplish to improve the functioning of our team?
CHANGES: What 1-2 changes can we agree to try as a team to achieve that aim?
MEASURES: how will we as a team know if our changes have achieved our aim?
Acknowledgments
We acknowledge Deb Peartree, RN, MS, Clinical Director of the Monroe Plan for Medical Care, and the staff of Monroe Plan, for her support of the practice re-design changes described herein.
Thank you to all the residents and staff who have worked with a system in change and embraced both process and content!
p4 Selected Residency