The Ambulatory Long Block: A University of Cincinnati Educational Innovations ProjectEric J. Warm M.D., Brian Revis M.D., Sara McCune M.D., Jennifer Ernst, M.D., Yvette Neirouz, M.D., Tiffiny Diers M.D., Bradley Mathis M.D., Gregory Rouan M.D.
BACKGROUND: Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting OBJECTIVE: Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients METHODS: We created the ambulatory long-block as part of the ACGME’s Educational Innovation Project. The long-block occurs from the 17th to the 29th month of residency, and is a year-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. Long-block residents follow approximately 120-150 patients, have office hours 3 half-days per week, and are responsive to patient needs (by answering messages, refilling medications, etc.) daily. Otherwise, long-block residents rotate on electives and research experiences with minimal overnight call. Residents receive extensive instruction in chronic illness care, quality improvement, and inter-professional teams RESULTS: The long-block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. There has also been a trend towards decreased emergency department visit rates and no show rates. Additionally, the long-block resulted in a robust multi-source evaluation that identified high, intermediate, and low performing residents, and suggested specific formative feedback for each CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement
ABSTRACT
BACKGROUND• Most internal medicine graduate medical education is inpatient-based
• This historical bias towards the inpatient setting has led to dysfunctional ambulatory training settings
• Many residents receive little support for ambulatory chronic illness management, improvement science, or interdisciplinary teamwork
• The end result of these combined deficiencies has been characterized as the “training/practice gap” – few internal medicine graduates leave residency with the skills needed to function effectively in the ambulatory setting
CONTEXT• The University of Cincinnati internal medicine residency program consists of 108 residents (69
categorical) based in a large academic health center
• The categorical resident ambulatory practice is an urban safety-net practice located next to the main teaching hospital
• Residents are responsible for approximately 19,000 ambulatory visits per year
• 58% of the patients have hypertension and 32% have diabetes; only 1% have private insurance
• Residents rated their ambulatory clinic experience low during exits interviews, reported little time for learning in the ambulatory setting due to difficulty balancing ward and ambulatory duties, and reported a lack of personal reward the ambulatory setting
• The practice also had poor patient-doctor continuity, poor clinical quality markers, poor patient satisfaction, and poor staff satisfaction
HYPOTHESIS• Improving resident physician continuity within a highly functional clinical micro-system would improve
care and education
INTERVENTION• Creation of an Ambulatory Long Block (now into the fourth year)
• Part of the RRC-IM/ACGME Educational Innovations Project (EIP)
NEW RESIDENCY STRUCTURE• PGY-1-2: Months 1-16
– traditional residency, mainly inpatient based, with fixed half-day in the ambulatory practice– small patient panels (15-30)– each PGY-1 is paired with a long-block resident who serves as cross cover and mentor– when the PGY-1 rises to the long-block, he/she inherits long-block partner’s patients
• PGY 2-3: Months 17-28 – The Long Block
– 1 year of electives, paired with ambulatory care; minimal inpatient call service time– patient panels expand (120-150)– residents have ambulatory office hours three half-days per week on average – residents are responsive to patient needs (by answering messages, refilling medications, EMR) daily– a portion of one morning is reserved for an ambulatory education curriculum (AME, figure below))– balance of time is spent on electives (ambulatory, inpatient, research)
• PGY 3: Months 29-36
– residents return to primarily inpatient care– no ambulatory continuity practice– selected residents may elect to continue a portion of their practice one half-day per week
LONG BLOCK MICROSYSTEM
• Prior to each clinic session, residents review the EMR, prepare a progress note, and make a list of things that must be done during the session
• Residents and nurses then have a pre-clinic “huddle” to review the patients that will be seen , and decide on an efficient plan for the day
• The large team is broken up into mini-teams
• Each mini-team consists of a nurse leader, and a group of residents, supported by many ancillary staff
• The entire team, including residents, nurses, and support staff learn improvement skills, motivational interviewing and shared decision making at a yearly retreat
• In 2007, the nursing staff transitioned from a mostly medical assistants to all RN and LPN level staff to provide case management
• A nurse practitioner was also added
• The practice uses an electronic medical record (Centricity) and a disease registry (MQIC)
• Residents receive extensive EMR training
• Data includes quality data (above), financial performance data, patient satisfaction data, visit volume data, and the results of ongoing Plan-Do-Study-Act cycles
CLINICAL QUALITY RESULTSAmbulatory Practice Report
Initial Long Block
Practice Goal %
Cohort 1
12.1.06
Cohort 1
10.31.07PercentChange
p value
Total Number of Patients 1907 2593 36%
Diabetes Measures (31% of patients)
HbA1c < 7.0% 60 43.8 47.7 9% 0.192
Blood Pressure < 130/80 40 37.9 47.1 24% 0.002
Comprehensive foot exam in 1 year 90 35.7 59.7 67% <0.001
On ACE inhibitors or ARB's 75 76.6 80.3 5% 0.130
On statins 60 64.7 70.6 9% 0.034
LDL < 100 mg/dl 70 65 66.6 2% 0.573
On aspirin 80 75.2 86.2 15% <0.001
Pneumonia vaccination in 10 years 90 70.9 78.5 11% 0.003
Influenza vaccination in 1 year 90 64.1 50.9 -21% <0.001
Hypertension (58% of patients)
Blood Pressure < 140/90 60 47.2 58 23% <0.001
LDL < 100 mg/dl 80 82.4 82.9 1% 0.770
Prevention (all patients)
Women > 42 with mammogram in 2 years 50 41.6 63.6 53% <0.001
Patients > 51 with colonoscopy in 10 years 30 36.4 48.6 34% <0.001
Women 18-50 with pap smear in 3 years 30 7.7 61.7 701% <0.001
Men 50-70 with PSA in 1 year 60 34.4 51.7 50% <0.001
Tetanus vaccination in 10 years 60 27.9 59.9 115% <0.001
Pneumonia vaccination in 10 years 90 64.6 83.3 29% <0.001
Influenza vaccination in 1 year 90 54.5 46.6 -14% <0.001
Women > 65 with DEXA in 5 years 60 10.1 54.2 437% <0.001
• The initial data from the first long-block showed significant improvement for many process measures and intermediate outcome measures of care
• The initial improvements have held, and the resident practice now has many measures of care that are better than the larger health system
No Show Rates
Academic Year Comment Resident Practice No-show rate
2002-03 Pre-Work-Hours Restrictions 33.8
2003-04 Work-Hours Restrictions Implemented 33.2
2004-05 Pre-Long Block 28.6
2005-06 Chronic Care Model Implemented 28.2
2006-07 First Long Block Implemented 26.1
Jun07-Oct 07 Second Year of Long Block 18.3
p-value for trend <0.0001
• No show rates during the first long-block improved, and have maintained this level over 4 years
Year 2003 2008 Resident Practice/Emergency Department Interface
Number of Individual Patients in Resident Practice 7593 4047 The total number of individual patients in the
practice dropped since 2003.
Total Number of Visits In Resident Practice 18118 19539 However, the visit volume has stayed stable, or
increased over this time.
Average Number of Visits In Resident Practice Per Patient 2.39 4.82 This has resulted in a 102% increase in visits
made per year per patient in the practice.
Percent of Patients Seen 1 Time Only 30.5 17.0 The number of patients visiting the practice
only once per year dropped 44%.
Percent of Patients Seen 3 or More Times 48.1 64.2 The number of patients visiting the practice
three or more times per year increased 34%.
Average Number of Visits in ED per Year Per Resident Patient
1.46 1.54The average number of ED visits per patient per year initially dropped, then rose to baseline.
Average Number of ED visits Made by Resident Patients Resulting in Discharge
1.15 1.09However, the average number of ED visits made by Resident patients that resulted in discharge home fell...
Average Number of ED visits Made by Resident Patients Resulting in Admission
0.31 0.44...and the average number of ED visits made by Resident patients that resulted in admission has increased.
Chance of Resident Patient Being Admitted if in the ED 21 28.5
The chance of a Resident patient being admitted if seen in the ED has increased 36%, and is 61% higher than the general average
Total Resident/ED Contact Points Per Patient 3.85 6.37
The total number of contact points for the two areas of care (Resident/ED) has increased 65%, with Resident visits comprising the largest share
Learner’s Perception Survey: ComparisonPre and Post Long Block
*Scale: 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = neither, 4 = somewhat satisfied, 5 = very satisfied
Prior to First Long Block
After First Long Block paired t-test
Time for learning 2.94 4.44 0.0004
Ability to focus in clinic without interruption 3.44 4.56 0.0057
Ability to balance ward/inpatient duties on clinic days 3.00 4.59 0.0018
Overall satisfaction with the learning environment 3.65 4.24 0.0075
Overall satisfaction with the clinical environment 3.44 4.33 0.0156
Personal reward from work 3.33 4.44 0.0042
Relationships with patients 4.06 4.72 0.0001
Sense of ownership and personal responsibility 3.72 4.78 0.0002
Rate the value of the continuity clinic experience 3.29 4.44 0.0006
Total experience (on scale of 0-100) 73.23 87.50 0.0016
EDUCATIONAL RESULTS
• The Learner’s Perception Survey demonstrated significant improvement after the long-block intervention
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A B C D E F G H I J K L M N O P Q R S T U V Patient Care
Team Work
Professionalism
Efficiency
Physician Explains
Physician Listens
Physician Gives Instructions
Physicians Knows History
Physician Respects Patient
Physician is On Time
Physician Calls Back
Overall Physician Rating
Patient Would Recommend
In-Training Exam
In-House Testing
Quality Process Measures
Quality Outcome Measures
Self Evaluation
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Peer, Staff, Attending Rank
Patient Evaluation Rank
In-Training Exam Rank
Process Quality Rank
Outcome Quality Rank
Self Evaluation Rank
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B
C
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20
25
Peer, Staff, Attending Rank
Patient Evaluation Rank
In-Training Exam Rank
Process Quality Rank
Outcome Quality Rank
Self Evaluation Rank
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Q
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Peer, Staff, Attending Rank
Patient Evaluation Rank
In-Training Exam Rank
Process Quality Rank
Outcome Quality Rank
Self Evaluation Rank
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NCQA PCMH Standard University of Cincinnati Ambulatory Long Block Access and Communication Keeps written standards for patient access and communication
Reviews data weekly regarding access, visit volume and communication Patient Tracking and Registry
Functions Uses a disease registry (MQIC®) with searchable data fields Organizes clinical information and uses registry data to identify important diagnoses and conditions Generates lists of patients and creates reminders of services needed
Care Management Uses evidence based guidelines for multiple conditions (e.g. diabetes, depression, hypertension, hyperlipidemia) Uses electronic flow sheet to generate reminders to clinicians Uses non-physician staff to manage patient care (e.g. insulin titration, self management goal follow-up calls) Coordinates care for patients who receive care in inpatient facilities (e.g. shared medication reconciliation sheet)
Patient Self‐Management Support
Assesses language preference and other communication barriers (multiple translators, including for the deaf) Actively supports patient self-management (e.g. extensive inter-professional instruction of physicians and staff; use of ancillary staff including pharmacotherapy clinic; printed medication reconciliation and instruction sheet for every visit; follow-up phone calls for support)
Electronic Prescribing Uses an electronic system to write prescriptions (Centricity®), including automatic safety/interaction checks and cost checks
Test Tracking Tracks test and identifies abnormal results systematically Uses electronic system to order and retrieve tests
Referral Tracking Tracks referrals using electronic system Performance Reporting and
Improvement Measures and reports clinical performance by physician and across the practice (data reviewed monthly by care team, quarterly by hospital senior administration) Surveys patient experiences using Press-Ganey and homegrown satisfaction surveys Sets performance goals and takes action to improve performance Produces reports using standardized measures (e.g. Diabetes Physicians Recognition Program measures)
Advanced Electronic Communications
Uses electronic care management support Currently in process of obtaining electronic patient portal and e-prescribing
• The entire team meets weekly to review data and solve problems; an open agenda is set by all team members
• Every meeting starts with a patient story
• Residents receive individual reports monthly • Each report includes a ranking on each
measure compared with peers• Data is used as part of competency
evaluation
• Long Block residents receive comprehensive multisource feedback (MSF) that includes self, peer, staff, attending and patient evaluations, as well as concomitant clinical quality data and knowledge-based testing scores
• Residents are given a rank for each data point compared to peers in the class, and this data is reviewed with the chief resident and program director over the course of the long-block
• The table above shows that in a long-block class the MSF demonstrates residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%)
• Each high, intermediate and low performing resident had a least one aspect of the MSF significantly lower than the other, and this serves as the basis of formative feedback during long-block
• Residents receive radar graphs (figures A-C, below) as part of their evaluation
• Focus is given to lower scored measures (furthest from the center of the radar graph)
• Figure A represents the top three residents, Figure B represents 3 residents in the middle of the class, Figure C represents the bottom three residents
A CB
PATIENT SATISFACTION
• Patient Satisfaction is at an all time high (at left)• Resident scores have improved the most• Satisfaction dips immediately after a long-block
ends but then rebounds (above)• This may represent breaking and reforming of
therapeutic relationships
Class of 2005 Class of 2006 Class of 2007 Class of 2008 Class of 2009 Class of 2010
PGY 2 ITE v PGY 1 ITE
-1.3 -5.5 -6.5 -2.7 -9.4 -5.9
PGY 3 ITE v PGY 2 ITE
-1.3 -3.3 -0.2 6.5 13.4 14.1
-12.5
-7.5
-2.5
2.5
7.5
12.5
17.5
Average Individual Change in ITE Percentile
Δ Pe
rcen
tile
• Residents participate in long-block board review course
• Each long- block class has shown significant increases in in-training exam scores from PGY-2 to PGY-3
• Our residency is in the upper quartile for passing the ABIM certification examination
CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation
NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement
EVALUATION
• The resident ambulatory practice now meets many of the criteria for the National Committee for Quality Assurance’s Patient-Centered Medical Home
PATIENT-CENTERED MEDICAL HOME