37
Teaching Quality Improvement Linda A. Headrick, M.D., M.S. University of Missouri-Columbia [email protected]
How do we graduate physicians able and expecting to
improve care?
Foundation Concepts,
Skills & Values
Limited Applications
Expanded Applications
DemonstratedBasic
Competency
BeginningMedical Student
AdvancedMedical Student
BeginningResident
AdvancedResident
Educating a Physician Able andExpecting to Improve Care
Key Questions
• What should we teach?
• How should we teach?
• How will we measure the results?
Key Questions
• What should we teach?
• How should we teach?
• How will we measure the results?
Core Content Areas• Knowledge of the needs and preferences
of those we serve (“customer knowledge”)• Health care as a process, system• Variation and measurement• Leading, following and making changes in
health care• Collaboration• Developing new locally useful knowledge• Social context & accountability• Professional subject matter IHI 1998
Core Content Areas• Knowledge of the needs and preferences
of those we serve (“customer knowledge”)• Health care as a process, system• Variation and measurement• Leading, following and making changes in
health care• Collaboration• Developing new locally useful knowledge• Social context & accountability• Professional subject matter IHI 1998
Key Questions
• What should we teach?
• How should we teach?
• How will we measure the results?
Key Principles Informing Teaching Methods
• Professional knowledge must be combined with knowledge for improvement.
• It is helpful to combine didactic and experiential learning.
Methods for Medical Students
• Projects to improve medical education • Case analysis (Headrick 1992)
• Chart audit and analysis (Henley 2002)
• Interprofessional student team projects in hospital, community or rural sites (Baker 1998, Headrick 2000, Blue 2001)
• Improvement projects as part of longitudinal clinical experiences (Weeks 2000, Gould 2002)
Methods for Residents• Morbidity and mortality conferences
(Sorokin 2002, Orlander 2002, Ziegelstein 2004)• Resident teams to improve the
residency (Ellrodt 1993)• Chart audits, peer & self (Paukert 2003,
Ziegelstein 2004)• Guideline design & implementation
(Frey et al 2003)• Improvement projects
– Hospitals (Weingart 1998, Ogrinc 2004)– Resident continuity practices
(Schillinger 2000, Coleman 2003, Mohr 2003)
Key Questions
• What should we teach?• How should we teach?• How will we measure
the results?– Learner assessment– Program evaluation
Learner Assessment
• Tests of knowledge• Self assessed
attitudes & skills• Problem solving• Performance-based
assessments
Program Evaluation
• Learner performance
• Learner satisfaction
• Faculty feedback• Costs• Clinical outcomes
Foundation Concepts,
Skills & Values
Limited Applications
Expanded Applications
DemonstratedBasic
Competency
BeginningMedical Student
AdvancedMedical Student
BeginningResident
AdvancedResident
Educating a Physician Able andExpecting to Improve Care
Example: Teaching Improvement to Medical Students
• Core Curriculum Year 1-2 at the University of Missouri-Columbia– Problem Based Learning – Introduction to Patient Care (IPC)– Ambulatory Care Experience
• Year 1 White Coat Ceremony– “The health of our patients is our first priority.
The highest quality health care is the environment for the highest quality education of future physicians.”
– “Committed to improving quality and safety”
Madigosky et al 2004
Year 2 IPC Modified Root Cause Analysis: Objectives
• Identify the gaps in quality within the cases
• Participate as a team member to identify strategies to close the gap
• Demonstrate an appreciation for an interprofessional approach
Madigosky et al 2004
Year 2 IPC Modified Root Cause Analysis: Methods
• Interdisciplinary teams– Year 2 medical students– Year 4 nursing students– Year 2 MHA graduate students– Pharmacy trainees
• Each team analyzed a patient case – What happened?– Why did it happen?– What would prevent it from happening
again? Madigosky et al 2004
Year 2 IPC Modified Root Cause Analysis: Student Feedback
Madigosky et al 2004
4.39
4.16
4.54
4.41
4.16
4.64
1 2 3 4 5
Recommend
Benefit
IP Useful
1=Strongly Disagree, 5=Strongly Agree
All Students Medical Students
Foundation Concepts,
Skills & Values
Limited Applications
Expanded Applications
DemonstratedBasic
Competency
BeginningMedical Student
AdvancedMedical Student
BeginningResident
AdvancedResident
Educating a Physician Able andExpecting to Improve Care
Example: Teaching Improvement to Residents
• MetroHealth-Dartmouth non-randomized, matched controlled trial
• Internal medicine residents (11 subjects, 22 controls)
Ogrinc et al 2004
MetroHealth-Dartmouth Objectives
1. Describe the connection between professional knowledge and improvement knowledge
2. Develop and focus an aim for an improvement project
3. Understand a structured approach to improvement
4. Describe why and how various disciplines must work together to achieve improvement
MetroHealth-Dartmouth Objectives, cont.
5. Demonstrate how data can be collected under time and resource limitations; appropriately display and analyze data
6. Use diagrams to understand the process under study
7. Identify areas to change within a process and recognize whether changes are successful
Ogrinc et al 2004
MetroHealth-Dartmouth Methods
• Combination of didactic & experiential learning in a one-month elective
• Resident projects: Part of existing improvement initiatives or resident-generated
• Core faculty plus project sponsors
Ogrinc et al 2004
MetroHealth-Dartmouth Measures
• Faculty evaluation of end-of-rotation resident presentation
• Quality Improvement Knowledge Application Tool (QIKAT), pre-post
• Knowledge and skills self-assessment, pre/post & 6-8 months later
• Resident satisfaction • Project sponsor feedback• Faculty & resident time logs Ogrinc et al 2004
Example Resident Projects
• Coordinating follow-up after admission for acute pain crisis in sickle cell disease
• Decreasing barriers to advance care planning in the outpatient setting
• Assessing osteoporosis knowledge and risk factors of patients in primary care
• Increasing the use of maximum sterile barrier precautions in the MICU
Ogrinc et al 2004
Difficulty/Variation in Getting Supplies
Nurse with Keys Resident Supply Room #1(Cordis, arterial line)
Locked Cabinet(triple lumens)
Unlocked Cabinet(gowns, sheets,
individual towels)
Supply Room #2(additional suture,
masks, caps)
Patient Room(patient, gauze,
Betadine, line caps,needle drivers,
saline, syringes)
How the System Has Changed
Resident
Locked CabinetUnlocked Cabinet
Line Cart
Patient
MetroHealth-Dartmouth Results
• Faculty rated project presentations highly
• QIKAT scores for participants improved; controls showed no change
• Participants’ ratings of 9/10 self-assessment items increased and remained elevated at 6 months
Ogrinc et al 2004
ResultsQIKAT scores
7
8
9
10
11
12
13
Pretest Posttest
Aver
age
QIK
AT S
core Subjects
Controls
MetroHealth-Dartmouth Study Results, cont.
• Participants rated experience highly re: achievement of learning objectives– “Like putting on a new pair of glasses”– “This training should be mandatory for all
residents”• Project sponsors appreciated resident
assistance with projects
Ogrinc et al 2004
Cost = Time
• Subjects averaged 119 hours (range 41-232) over the four weeks
• Faculty averaged 6 hours (range 3.3 - 8) over the four weeks
• Project sponsors averaged 1-2 hours/week
Ogrinc et al 2004
Foundation Concepts,
Skills & Values
Limited Applications
Expanded Applications
DemonstratedBasic
Competency
BeginningMedical Student
AdvancedMedical Student
BeginningResident
AdvancedResident
Educating a Physician Able andExpecting to Improve Care
What’s Next?
• IHI Medical School Collaborative– Aim: Create 10 exemplar schools in 3
years and 60 schools in 6 years • Accreditation Council for Graduate
Medical Education • Professional boards and societies• Quality Improvement in Medical
Education (QIMED) faculty development workshops
References• American Academy of Pediatrics. Education in Quality Improvement for Pediatric Practice. http://www.eqipp.org.
Accessed March 24, 2004.• American Board of Internal Medicine. Recertification: Program for Continuous Professional Development Components.
http://www.abim.org/cpd/cpdhome/components.htm. Accessed March 24, 2004.• Accreditation Council for Graduate Medical Education. Outcome Project.
http://www.acgme.org/outcome/project/proHome.asp. • Accreditation Council for Graduate Medical Education Outcome Project. Toolbox of Assessment Methods, version 1.1.
September 2000. Available at http://www.acgme.org/outcome/.• Aron DC, Headrick LA. Educating Physicians Prepared to Improve Care and Safety is No Accident: It Requires a Systematic
Approach. Qual Safety Health Care 2002;11(2):168-173• Baker G, Gelmon S, Headrick L, Knapp M, Norman L, Quinn D, et al. Collaborating for Improvement in Health Professions
Education. Quality Management in Health Care 1998;6(2):1-11.• Batalden PB and Stoltz PA-C. A Framework for the Continual Improvement of Health Care: Building and Applying
Professional and Improvement Knowledge to Test Changes in Daily Work. Jt Comm Jl Qual Improv, 1993;19:424-452. • Batalden P, Berwick D, Bisognano M, Splaine M, Baker G, Headrick L. Knowledge Domains for Health Professional
Students Seeking Competency in the Continual Improvement and Innovation of Health Care. Boston, MA: Institute for Healthcare Improvement, 1998.
• Benneyan JC. Lloyd RC. Plsek PE. Statistical process control as a tool for research and healthcare improvement. Quality & Safety in Health Care. 2003;12(6):458-64.
• Berwick DM. A Primer on Leading the Improvement of Systems. British Medical Journal. 1996;312:619-622.• Blue AV, Kern DH, Chessman AW, Garr DR, Fowler SD, Lamar S, Kammermann SK, Baxley EG, Lahoz MR, White AW,
Bellack JP, West VT, Faulkner LR, McCurdy L. A Collaborative Clerkship with a Focus on Rural Community Health. Journal - South Carolina Medical Association. 2001;97:383-4, 387-9.
• Clinical Microsystems: Improving Health Care by Improving Microsystems. http://www.clinicalmicrosystem.org/. Accessed March 24, 2004.
• Coleman MT, Headrick LA, Langley AE, Thomas JX. Teaching medical faculty how to apply continuous quality improvement to medical education. Jt Comm J Qual Improv 1998;24:640-52.
• Coleman MT, Nasraty S, Ostapchuk M, Wheeler S, Looney S, Rhodes S. Introducing Practice-Based Learning and Improvement ACGME Core Competencies into a Family Medicine Residency Curriculum. Jt Comm J Quality Improv2003;29:238-47.
• Chisholm CD, Croskerry P. A case study in medical error: the use of the portfolio entry. Acad Emerg Med. 2004; 11(4); 388-92.
• Curley C, McEachern J, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Medical Care 1998;36(8 Suppl):AS4-12.
References cont’d• Deyo RA. Schall M. Berwick DM. Nolan T. Carver P. Continuous quality improvement for patients with back pain. Journal of
General Internal Medicine. 2000;15(9):647-55.• Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: Adressing this core
competency, improving systems. Acad Med. 2004; 79(10): S65-67.• Ellrodt A. Introduction of Total Quality Management (TQM) into an Internal Medicine Training Program . Acad Med
1993;68:817-23.• Frey K, Edwards F, Altman K, Spahr N, Gorman RS. The ‘Collaborative Care’ Curriculum: An Educational Model
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Improvement to Medical Students in Community-Based Practices. Acad Med 2002;77(10):1011-18.• Gould BE, O’Connell MT, Russell MT, Pipas CF, McCurdy FA. Teaching quality measurement and improvement, cost-
effectiveness, and patient satisfaction in undergraduate medical education: The UME-21 expereince. Family Medicine. 2004; 36Suppl:S57-62.
• Headrick LA, Neuhauser D, Melnikow J, Vanek E. Teaching Medical Students about Quality and Cost of Care at Case Western Reserve University. Acad Med 1992;67:157-159.
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• Henley E. A Quality Improvement Curriculum for Medical Students. Jt Comm Journal on Quality Improvement. 28(1):42-8, 2002 Jan.
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• Institute of Medicine. Health Professions Education: A Bridge to Quality. National Academies Press: Washington, D.C., 2003.
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• Madigosky W, Headrick LA, Nelson K, Anderson T, Cox K, Evans A. Using Modified Root Cause Analysis to Teach about Patient Safety. Unpublished report. University of Missouri Curators: Columbia, Missouri, 2004.
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References cont’d• Morrison LJ, Headrick LA, Ogrinc G, Foster T. The Quality Improvement Knowledge Application Tool: An Instrument to Assess
Knowledge Application in Practice-Based Learning and Improvement. (Abstract) JGIM 2003;18:250. • Nelson EC, Batalden PB, Ryer JC. Clinical Improvement Action Guide. Oakbrook Terrace, IL: Joint Commission on Accreditation of
Healthcare Organizations, 1998• Nelson EC et al. Building measurement and data collection into medical practice. Ann Int Med. 1998;128:460-66.• Neuhauser D and Diaz M. Daniel: Using the Bible to teach quality improvement methods. Qual and Safety in Health Care. 2004; 13(2):
153-3.• O’Connor GT, Plume SK, Olmstead EM, Morton JR et al. A Regional Intervention to Improve the Hospital Mortality Associated with
Coronary Artery Bypass Graft Surgery. JAMA 1996;275:841-846 • Ogrinc G, Headrick L, Mutha S, Coleman M, O'Donnell J, Miles P. A Framework for Teaching Medical Students and Residents about
Practice-Based Learning and Improvement, Synthesized from the Literature. Acad Med 2003;78:1-9.• Ogrinc G, Headrick LA, Morrison LJ, Foster T. Teaching and Assessing Resident Competence in Practice-based Learning and
Improvement. J Gen Internal Med 2004 (in press).• Orlander JD, Barber TW, Fincke BG. The Morbidity and Mortality Conference: The Delicate Nature of Learning from Error. Acad Med
2002;77:1001-06.• Paukert JL, Chumley-Jones HS, Littlefield JH. Do Peer Chart Audits Improve Residents’ Performance in Providing Preventive Care?
Acad Med 2003;78:S39-41.• Pierce-Bulger M,.Nighswander T. An approach to reducing infant mortality using quality improvement principles. Quality Management in
Health Care 2001;9:40-6.• Rivo ML, Keller DR, Teherani A, O’Connell MT, Weiss BA, Rubenstein SA. Practicing effectively in today’s health system: Teaching
systems-based care. Family Medicine. 2004; 36Suppl:S63-7.• Schillinger D, Wheeler M, Fernandez A. The Populations and Quality Improvement Seminar for Medical Residents. Acad Med
2000;75(5):562-3.• Sorokin R, Claves JL, Kane GC, Gottlieb JE. The Near Miss Resident Conference: Understanding the Barriers to Confronting Medical
Errors. Semin Med Pract 2002;5:12-19.• Swing SR. Assessing the ACGME General Competencies: General Considerations and Assessment Methods. Acad Emergency
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Education. Acad Med 2000;75(1):81-4.• Weingart S. A House Officer Sponsored Quality Improvement Initiative: Leadership Lessons and Liabilities. Jt Comm Journal on Quality
Improvement 1998;24:371-8• Wheeler DJ. Understanding Variation: The Key to Managing Chaos. 2nd edition. SPC Spress: Knoxville, TN, 2000.• Ziegelstein RC, Fiebach NH. “The Mirror” and “The Village”: A New Method for Teaching Practice-Based Learning and Improvement
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