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Results Examples from the pre- and post-tests: Conclusions • Quality improvement (QI) can be present in all phases of undergraduate medical education. • There exists a need for experiential learning of QI as it really occurs at the front lines. • Emory faculty developed an innovative simulation of a longitudinal QI curriculum in the M3 year providing students with experience applying the Model for Improvement to solve real-world problems. • Diverse and interactive teaching modalities enhance the delivery of the QI curriculum. • Preliminary outcomes data demonstrate at least short-term improvement in knowledge, skills, and students’ attitudes about quality improvement. Acknowledgments We thank the Office of Medical Education and Student Affairs at Emory University School of Medicine for funding. In addition, we acknowledge the contributions of the other faculty leads for the Quality Improvement curriculum, Dr. Nurcan Ilksoy and Dr. Joyce Doyle. Contact Information Emma Johns ([email protected]) 0 10 20 30 40 50 60 A quantifiable goal A specific deadline Specific accountability A defined population Pretest 0 10 20 30 40 50 60 A quantifiable goal A specific deadline Specific accountability A defined population Posttest The following are necessary for a complete aim statement, EXCEPT: 0 5 10 15 20 25 30 35 Strongly Disagree Disagree Not sure Agree Strongly Agree Pretest 0 5 10 15 20 25 30 35 Strongly Disagree Disagree Not sure Agree Strongly Agree Posttest Principles of quality improvement are core skills that I will use in my future practice of medicine: ACB$QI$Exercise$ 1$ Version$2.0$ Ambulatory+Quality+ Improvement+Exercise+ $ BACKGROUND:$$You$are$a$member$of$a$primary$care$practice$and$each$member$of$ your$five$physician$office$ just$received$a$report$card$from$Aetna$that$shows$ measures$of$the$care$of$your$diabetic$patients.$$You$are$very$disappointed$ in$your$ performance,$because$you$were$a$great$resident$and$know$all$of$the$diabetes$ guidelines.$$$ At$ lunch,$one$of$your$partners$mentions$that$they$were$surprised$at$how$ low$their$ measures$of$diabetes$care$were$on$the$report$card.$$With$the$ ice$broken,$all$the$docs$ speak$up$and$admit$to$their$disappointment$ in$their$overall$performance.$$$ Fortunately,$you$went$to$Emory$and$ learned$how$to$do$process$ improvement$ projects.$$You$say$that$you$ learned$about$the$Model$for$Improvement$and$the$group$ decides$that$the$office$will$embark$on$an$ improvement$project$to$ improve$diabetes$ care.$$$ You$set$up$regular$weekly$meetings$ in$your$office$and$at$the$first$meeting$the$group$ engages$ in$a$bit$of$a$free$for$all$and$finally,$you$get$to$the$root$of$the$complaints.$$No$ one$ in$the$room$believes$the$Aetna$data$and,$before$ investing$too$much$time,$the$ group$tries$to$prove$that$there$ is$no$need$for$ improvement.$$$ First,$your$colleague$who$has$an$ interest$ in$Endocrinology$creates$a$test$to$see$ if$ there$are$any$knowledge$deficits.$$Just$as$everyone$expected$all$scored$almost$ perfectly$on$the$knowledge$of$the$diabetes$guidelines$and$some$simple$management$ questions$on$diabetes,$and$blood$pressure$control.$$The$group$feels$good$that$there$ is$no$knowledge$deficit,$which$further$reinforces$their$ impression$that$the$Aetna$ data$must$be$wrong,$since$you$know$personally$that$all$of$the$diabetics$that$you$see$ get$all$the$care$they$should.$$$ Next,$you$decide$to$measure$your$care$with$a$chart$review.$$Based$on$the$billing$ software,$there$are$about$135$diabetics$per$doc$ in$the$practice.$$Fortunately,$your$ group$ invested$ in$an$electronic$medical$record$about$4$years$ago$and$ it$has$a$robust$ data$querying$function.$$You$replicate$the$Aetna$report$with$all$of$the$diabetics$ in$ the$practice$for$each$doctor.$$To$everyone’s$chagrin,$the$overall$performance$ is$ consistent$with$the$Aetna$report$and$fairly$consistent$from$doctor$to$doctor$(Exhibit$ 1).$$$ Finally$convinced$that$the$data$are$correct,$the$team$agrees$to$follow$the$Model$for$ Improvement.$$In$preparation$for$the$next$meeting,$you$have$a$staff$meeting$and$ describe$the$Model$for$Improvement.$$The$whole$practice$commits$to$supporting$the$ improvement$activities.$$But,$the$group$realizes$that$having$a$team$meeting$with$26$ people$would$be$difficult$to$manage,$so$the$staff$decides$the$following:$$$ 1) Every$member$of$the$practice$commits$to$support,$ in$any$way$they$can,$the$ activities$of$the$team.$$ Simulation Exercise Create an aim statement (quantifiable, time-specific, defined population) Longitudinal Curriculum for Teaching Quality Improvement Emma Johns, Danielle Jones, MD, Richard Gitomer, MD, MBA Emory University School of Medicine, Emory Healthcare Background • Quality improvement (QI) is best learned through a longitudinal experience, as the complexities are not readily apparent when learning the techniques in abstract. • Experiencing the real-world iterative nature of improvement activities helps to reinforce key features of improvement projects such as responding to data and rapid-cycle testing. • Emory University School of Medicine faculty utilize a case-based discussion of the Model for Improvement and a simulation exercise during the M3 ambulatory care block to deliver a longitudinal LCME- competency based QI curriculum. Methods • Faculty members identified the need to build on the introductory M1 and elective M2 QI curricula and integrate the practice of quality improvement into the clinical training of medical students. • The module was placed in the M3 ambulatory block, a three-month clerkship in which students rotate through a variety of outpatient practices. Core competencies: • medical knowledge • patient care • practice-based learning and improvement • communication and interpersonal skills • professionalism • health care systems and system-based practice • Research Teaching Modalities: • reading • seminar • group discussion • workshop • self-directed project proposals Evaluation • pre-tests and post-tests to assess knowledge, skills, and attitudes • team workshop presentations • individual student project proposals • QI scholarship • student feedback Measure outcomes Process improvement tools: Instructions: 1) Divide into 4 teams of about 8 participants. 2) From the case, identify an opportunity for improvement and write an aim statement. 3) Describe the data collection and dissemination strategy for the project. 4) Create a fishbone diagram using the “sticky note” technique. 5) The fishbone is used to create a tally sheet. 6) The facilitator then assigns data to the tally sheet and returns a histogram. 7) Guided by the histogram, the team develops a test of change guided by the PowerPoint template. 8) The facilitator reviews the test of change and assigns upward, neutral, or downward run chart based on human factors. 9) Based on run chart, the team designs a second test of change. Case-based Discussion Physician Scorecard Provider Provider # 91013144043 Measurement Period: 9/1/2009 - 9/30/2010 Number of Patients: 2,100 Condition: Diabetes # w/ Condition: 135 Intervention Number Percentage Peer Mean Process Measures Eye Exam 55 41% 55% Foot Exam 102 76% 75% A1c w/in 6 mos 72 53% 62% LDL w/in 1 year 96 71% 70% Microalbumin 60 44% 46% Outcome Measures BP < 135/85 80 59% 52% LDL < 100 53 39% 61% A1c < 7.0 55 41% 50% A1c > 9.0 20 15% 10% Triple Target* 7 5% 20% * A1c < 7.0, LDL < 100, & BP < 130/80 ! Diabetes Guidelines Diabetes Care 2010 33 (Suppl 1) pp. S4-10 Element of Care Goal Blood Pressure < 130/80 LDL Cholesterol No CAD < 100 CAD < 70 HBA1c Test Controlled - 2x/Year Uncontrolled - 4x/Year HBA1c Value < 7.0 Dilated Retinal Exam Yearly Urine Microalbumin Yearly ! M3#PI#Workshop# 1# October#27,#2010# Vaccine'Improvement'Project' Background:' # In#2003# the#Center# for#Medicare#and#Medicaid#Services# (CMS)# implemented# the#Reporting#Hospital#Quality#Data# for#Annual#Payment#Update# program# (RHQDAPU).##Under# this#program#hospitals#received#a#1.5%# to#2%# increase# in# their#Medicare#payments.##The#RHQDAPU#calls# for#manual#data#abstraction#and# reporting# to#CMS.### The#results#of# these#data#are#published#on# the#Hospital#Compare# (www.hospitalcompare.hhs.gov)#web#site.### # In#addition# to# the#public#reporting#of# these#data,#many#organizations# like#Emory# Healthcare#use# them# for#quality# improvement.##Emory#Healthcare#has#set# the#goal# to# be#a# top#10#performer# in# the#University#HealthSystem#Consortium#Quality#and# Accountability#Scorecard.## In#2009,#Emory#University#Hospital,#and#Emory# University#Hospital#Midtown#were#both# in# the#3 rd #quintile#of# the#92#participating# academic#medical#center#hospitals.##A#major#shortfall#was# the#performance#on# the# Pneumonia#Core#Measures.##These#are#key#process#measures#related# to# the#care#of# patients#with#pneumonia.### Fishbone (cause-and-effect) diagram Source: https://www.mededportal.org/icollaborative/resource/567
