CHAMPCHAMPTeaching on Today’s WardsTeaching on Today’s WardsSession 4 – Systems Based Practice Session 4 – Systems Based Practice and and Practice Based Learning and Practice Based Learning and ImprovementImprovement

Chad Whelan, MDChad Whelan, MD Julie Johnson, PhD Julie Johnson, PhD Paula Podrazik, MDPaula Podrazik, MD

Learning ObjectivesLearning Objectives

• Improve comfort and skills in teaching and Improve comfort and skills in teaching and evaluating PBLIevaluating PBLI– Demonstrate teaching and evaluation of this Demonstrate teaching and evaluation of this

ACGME competencyACGME competency• Develop strategies for teaching these PBLI Develop strategies for teaching these PBLI

in clinical settingsin clinical settings– Demonstrate case and census auditsDemonstrate case and census audits

AgendaAgenda

10:00 – 10:1510:00 – 10:15 Review Homework from Session 3Review Homework from Session 310:15 – 10:2510:15 – 10:25 Introduction to Case Audit Introduction to Case Audit 10:25 – 11:0010:25 – 11:00 Videos and ConversationVideos and Conversation11:00 – 11:1511:00 – 11:15 Introduction to Census AuditIntroduction to Census Audit11:15 – 11:4511:15 – 11:45 Small group exercise – create a Small group exercise – create a

census audit toolcensus audit tool11:45 – 11:5511:45 – 11:55 DebriefingDebriefing11:55 – 12:0011:55 – 12:00 Final Comments and Take Home Final Comments and Take Home

Points Points

Review from Session 3 Review from Session 3 HomeworkHomework

• Review of the improvement area we Review of the improvement area we selectedselected– How would you assess the magnitude of How would you assess the magnitude of

the problem?the problem?– What data will you need?What data will you need?

Is there a way to bring this to Is there a way to bring this to the bedside?the bedside?

• Case Audits and Census AuditsCase Audits and Census Audits– Teach about the clinical topicTeach about the clinical topic– Teach about PBLITeach about PBLI– Collect data for improvementCollect data for improvement

Toolbox: Case AuditToolbox: Case Audit

• A structured review of clinical care A structured review of clinical care across a single patient’s hospital stayacross a single patient’s hospital stay– Relevant Clinical Care IssueRelevant Clinical Care Issue– Accepted Quality Measures ExistAccepted Quality Measures Exist– Performed by the Team Caring for the Performed by the Team Caring for the

PatientPatient– Fits PBLI ConstructFits PBLI Construct

Why a Case Audit?Why a Case Audit?

• Incorporates PBLI into formal Incorporates PBLI into formal teaching roundsteaching rounds

• Objectively review care of patient in Objectively review care of patient in high-risk situationshigh-risk situations

• Develops skills in self-assessment Develops skills in self-assessment and improvementand improvement

• Provides rich opportunities for in-Provides rich opportunities for in-depth teachingdepth teaching

Case Audit: Picking the TopicCase Audit: Picking the Topic

• Something You Care AboutSomething You Care About• Something that is “Difficult” to TeachSomething that is “Difficult” to Teach• High-Risk Issues High-Risk Issues • Explicit Quality Measures Exist that Explicit Quality Measures Exist that

Chart Review Can DetermineChart Review Can Determine• ExamplesExamples

– PCP Communication, Polypharmacy, PCP Communication, Polypharmacy, Discharge ProcessDischarge Process

Case AuditCase Audit

• VideoVideo– Part 1: Dr. SimsPart 1: Dr. Sims

• Pay attention to:Pay attention to:– Learning ClimateLearning Climate– Control of SessionControl of Session– Communication of GoalsCommunication of Goals– Promoting Understanding and RetentionPromoting Understanding and Retention– EvaluationEvaluation– FeedbackFeedback– Promoting Self Directed LearningPromoting Self Directed Learning

• Insert Video HereInsert Video Here

Discussion from Part 1, Dr. SimsDiscussion from Part 1, Dr. Sims

• What did you notice?What did you notice?– Learning ClimateLearning Climate– Control of SessionControl of Session– Communication of GoalsCommunication of Goals– Promoting Understanding and RetentionPromoting Understanding and Retention– EvaluationEvaluation– FeedbackFeedback– Promoting Self Directed LearningPromoting Self Directed Learning

Case Audit: Operationalize itCase Audit: Operationalize it

• Formal Teaching Rounds (Hour long)Formal Teaching Rounds (Hour long)• Choose your Patient Based on RiskChoose your Patient Based on Risk• Explain Purpose ExplicitlyExplain Purpose Explicitly• Assign RolesAssign Roles• Save Time to Teach and DiscussSave Time to Teach and Discuss• Discuss Plan for ImprovementDiscuss Plan for Improvement• Label it as Practice Based LearningLabel it as Practice Based Learning

Case Audit: Keys to SuccessCase Audit: Keys to Success

• Create an Environment that:Create an Environment that:– Is Blame FreeIs Blame Free– Nurtures Self-reflectionNurtures Self-reflection– Focuses on Self-improvementFocuses on Self-improvement– Emphasizes Team Based not Individual Emphasizes Team Based not Individual

Based CareBased Care– Encourages Systems ThinkingEncourages Systems Thinking

Case AuditCase Audit

• VideoVideo– Part 1, Dr. QuinnPart 1, Dr. Quinn

• Pay attention to:Pay attention to:– Learning ClimateLearning Climate– Control of SessionControl of Session– Communication of GoalsCommunication of Goals– Promoting Understanding and RetentionPromoting Understanding and Retention– EvaluationEvaluation– FeedbackFeedback– Promoting Self Directed LearningPromoting Self Directed Learning

• Insert video hereInsert video here

Discussion from Part 1, Dr. Discussion from Part 1, Dr. QuinnQuinn

• What did you notice?What did you notice?– Learning ClimateLearning Climate– Control of SessionControl of Session– Communication of GoalsCommunication of Goals– Promoting Understanding and RetentionPromoting Understanding and Retention– EvaluationEvaluation– FeedbackFeedback– Promoting Self Directed LearningPromoting Self Directed Learning

• What are barriers to conducting a case What are barriers to conducting a case audit?audit?

Case AuditCase Audit

• Video Parts 2 and 3, Dr. QuinnVideo Parts 2 and 3, Dr. Quinn

• Insert video hereInsert video here

DiscussionDiscussion

• Comments?Comments?• Other barriers?Other barriers?

Case Audit Take Home PointsCase Audit Take Home Points

• Incorporates PBLI into formal Incorporates PBLI into formal teaching roundsteaching rounds

• Objectively review care of patient in Objectively review care of patient in high-risk situationshigh-risk situations

• Develops skills in self-assessment Develops skills in self-assessment and improvementand improvement

• Provides rich opportunities for in-Provides rich opportunities for in-depth teachingdepth teaching

Case Audit LimitationsCase Audit Limitations

• TimeTime– PreparationPreparation– TeachingTeaching

• Only looks at care of one patientOnly looks at care of one patient• Difficult to assemble the entire teamDifficult to assemble the entire team• Medical culture of blame and shameMedical culture of blame and shame

Toolbox: Census AuditToolbox: Census Audit

• A review of clinical care across patientsA review of clinical care across patients– Focused Clinical Care IssueFocused Clinical Care Issue– Simple Quality MeasuresSimple Quality Measures– Performed by the Team Performed by the Team – Fits PBLI ConstructFits PBLI Construct

Why a Census Audit?Why a Census Audit?

Simple method of using PBLISimple method of using PBLI Objectively review team’s clinical Objectively review team’s clinical

care across multiple patientscare across multiple patients Develops skills in self-assessment Develops skills in self-assessment

and improvementand improvement Easy to incorporate into work-flowEasy to incorporate into work-flow Can be used to create a teachable Can be used to create a teachable

momentmoment

Census Audit: Picking the Census Audit: Picking the TopicTopic

• Something you care aboutSomething you care about• Something that is “difficult” to teachSomething that is “difficult” to teach• Common issueCommon issue• High-risk problemHigh-risk problem• Simple explicit quality measures Simple explicit quality measures

existexist

Census Audit: Operationalize Census Audit: Operationalize ItIt

• Inform team Inform team • Incorporate into work-roundsIncorporate into work-rounds• Save time to discuss/teachSave time to discuss/teach• Discuss plan for improvementDiscuss plan for improvement• Consider re-auditConsider re-audit• Label it as practice based learningLabel it as practice based learning

Census Audit: Keys to Census Audit: Keys to SuccessSuccess

• Create an Environment that:Create an Environment that:– Is blame freeIs blame free– Nurtures of self-reflectionNurtures of self-reflection– Focuses on self-improvementFocuses on self-improvement– Emphasizes team based not individual Emphasizes team based not individual

based carebased care– Encourages systems based thinkingEncourages systems based thinking

Census Audit: Create the Census Audit: Create the ToolTool

• Choose topic and quality measuresChoose topic and quality measures• Keep it short and simpleKeep it short and simple• Incorporate key problem areas Incorporate key problem areas • Consider summary sectionConsider summary section• Include a plan for improvementInclude a plan for improvement

• CENSUS AUDIT: STRESS ULCER PROPHYLAXISCENSUS AUDIT: STRESS ULCER PROPHYLAXIS

• Ulcer Prevention Agent (PPI, H2, Sulcrafate)Ulcer Prevention Agent (PPI, H2, Sulcrafate):: YesYes NoNo

• If Yes, then:If Yes, then: Where was it started? _____________________Where was it started? _____________________• If in hospital, was it for: TREATMENTIf in hospital, was it for: TREATMENT PROPHYLAXISPROPHYLAXIS• If Prophylaxis, Indication? If Prophylaxis, Indication? • Mechanical VentilationMechanical Ventilation CoagulapathyCoagulapathy• If None, then DCIf None, then DC• If Yes, Plan for DC upon discharge?If Yes, Plan for DC upon discharge? Yes Yes NoNo

• Patient Safety Issues/Systems Issues?Patient Safety Issues/Systems Issues?

• SummarySummary• Proportion of Patients with Stress Ulcer Prophylaxis (SUP) ________Proportion of Patients with Stress Ulcer Prophylaxis (SUP) ________• Proportion of Patients with SUP with appropriate indication _______Proportion of Patients with SUP with appropriate indication _______•• Patient Safety Issues/Systems Issues ThemesPatient Safety Issues/Systems Issues Themes• __________________________________________________________________________________________________________________________________________• __________________________________________________________________________________________________________________________________________• Plan for Change: _______________________________________________________Plan for Change: _______________________________________________________• ____________________________________________________________________________________________________________________________________________• Plan to Re-Measure: __________________________________________________Plan to Re-Measure: __________________________________________________

Small Group ExerciseSmall Group Exercise

• Create a Census Audit ToolCreate a Census Audit Tool– Divide into three groupsDivide into three groups– Each group choose a different one of the Each group choose a different one of the

improvement areasimprovement areas

Small Group Exercise #2Small Group Exercise #2

• DebriefingDebriefing

Final Comments and Take Final Comments and Take Home PointsHome Points

• By recognizing the triggers, we can teach By recognizing the triggers, we can teach systems based practice in real time clinical systems based practice in real time clinical teachingteaching

• We can teach and practice an We can teach and practice an improvement method as a way to teach improvement method as a way to teach practice based learning and improvementpractice based learning and improvement

• It’s possible to make small scale It’s possible to make small scale improvements during a short time periodimprovements during a short time period