W9 Improvement of Practice (Pooran) PDF

Introduction to Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI) “The system made me do it.” Dr. Sanjay Pooran Assistant Professor, Clinical Foundations Objectives • Describe the importance of improvement in health care systems • Know that medical knowledge must conn...

Introduction to Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI) “The system made me do it.” Dr. Sanjay Pooran Assistant Professor, Clinical Foundations Objectives • Describe the importance of improvement in health care systems • Know that medical knowledge must connect with knowledge of systems and processes to improve care • Describe & recognize the layers of systems in health care in a clinical vignette • Define & identify a quality gap in health care in a clinical vignette • Describe how the Model for Improvement is used in quality improvement efforts to help close the quality gap • Recognize the proper order of steps for improving health care in a clinical vignette 2 ACGME & AAMC Physician Competencies Patient Care Medical Knowledge Professionalism Interpersonal Skills and Communication Systems Based Practice Practice-based Learning and Improvement Inter-professional skills Personal and Professional Development 3 The Josie King Story – A Tragic System Breakdown Reducing medical errors – improving patient safety — was, and remains, a major impetus for integrating quality improvement into the healthcare industry – from a systems level to the individual provider level. https://youtu.be/JeVcXhvPvbU www.josieking.org 4 Individual Patient Care vs Systems of Care • How can you tell when a patient is ill? • Take a history and perform physical exam • Review diagnostic tests • Interpret results based upon medical knowledge • How can you tell when a system is ill? Assess Diagnose & Treat • Review outcomes data • Analyze systems using “process modeling” tools • Interpret results based on knowledge of “best practices” and knowledge of the unique system 5 Today’s Physicians Should Be Able To: The ACGME Outcome Project 1. Identify strengths, deficiencies, and limits in one’s own knowledge and expertise 2. Set learning objectives and improvement goals 3. Identify and perform appropriate learning activities for personal and professional development 4. Incorporate formative evaluation and feedback into daily practice 5. Systematically analyze practice and implement changes to improve practice 6. Locate, appraise, and assimilate evidence from scientific studies 7. Use technology to optimize learning and health care delivery 8. Participate in the education of patients, families, fellow students and other health care professionals. QI Involves Everyone and Affects Everyone Quality Improvement Definition Batalden & Davidoff Schemata “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, educators – to make changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” 7 “Three Core Pillars of Quality Improvement” (Fundamentals of Health Care Improvement) What are the interrelated systems in healthcare? - Self-Care System Community, Market, Social Policy System Macroorganization System - Individual Caregiver & Patient System Mesosystem Microsystem 8 Self-Care System The patient plus whatever resources he or she uses that are not part of the health care system • • • • Advice from family and friends Patient’s own research Prior experience Assumptions, beliefs, etc. 9 Individual Caregiver and Patient System Individual patient-provider level: This is where we spend a lot of time in med school and residency – learning how to care for patients one at a time – how to do a history, physical exam, procedures etc. 10 Microsystem A small group of people who work together on a regular basis to provide care to a discrete subpopulation of patients* (e.g., private physician office) • • • • Small group of doctors, nurses, others Some administrative support Some information technology A small population of patients *Interdependent for a common aim, purpose 11 Mesosystem • Linked microsystems • Working together for management of specific type of problem/problems • Example: Cardiac Care Organization o CCU and cardiac step-down units (inpatient) § Nursing § Clerical § Cardiologist o Cardiac catheterization lab o Cardiac rehabilitation (outpatient) 12 Mesosystem – Neonatal ICU Care Family, physicians, nurses, respiratory therapy, biomedical technology, admissions, discharge planners, laboratory 13 Macrosystem • Integrated health system that cares for a large group or community of patients Macrosystem • Links micro and mesosystems • Example: hospital or medical center • Inpatient services • Outpatient services • Home health care 14 What influences health care systems besides their level of organization? CULTURE • Patterns of learned, group-related perception o Includes values and belief o Latent, unconscious o Stable, predictable o “How things really work here!” • Plane crashes and natural disasters receive round-the-clock coverage • Patient safety death toll climbs weekly with scant media attention or public awareness Asiana Flight 214, July 6, 2013 Lack of “cultural intelligence” 15 Self-Care to MacroLevel Care And… there’s the broader context of community, market, socio-political system(s) 16 You will be involved in a wide range of improvemen t efforts 17 SystemsBased Learning & Practice Improvement ü ü ü ü Outcomes Cost savings Communication Culture https://www.who.int/patientsafety/safesurgery/faq_introduction/en/ 18 Steps for Improvement Process: 1. Identifying a Quality gap; Narrow the focus 2. Creating a focused aim statement 3. Process modeling using tools like cause- effect diagram, flow charts or root-cause analysis 4. Brainstorming a list of possible changes 5. Identifying measures 6. Performing PDSA cycles 20 Quality Gap: Is there a problem? REVIEW THE EVIDENCE • What research exists? • What is the quality of the research? • Are there clinical guidelines? • Is there consensus about “best practices”? • What is the standard of care? • Identify a quality gap* *Quality Gap = The difference between what we know we should do and what we actually do. 21 Quality Gap Example – Post AMI Prescription of β-Blockers 100% 48.8% 50% 40.3% 0% M ing h ac e rT o j a M ing h ac e rT o in 36.4% ing h ac e T no N Quality Gap Allison J.J., et al.: Quality of care at teaching and nonteaching hospitals. JAMA 284:2994–2995, Dec. 2000. Systems- Based Practice and Improvement Generalizable Scientific Evidence + Particular Context or System Measured Performance Improvement What are “best practices”? What is the quality of evidence? What is typical about this system? What is unique about this system? Balanced measures/outcomes: clinical, functional, satisfaction, costs Example: Use of surgical pre-operative checklist 23 Practice-Based Learning & Improvement Generalizable Scientific Evidence + Particular Patient or Clinical Problem Measured Performance Improvement What are “best practices”? What is the quality of evidence? What are the cultural and contextual qualities of my practice and each patient? How will we know if we’re doing a better job? Example: Reduce the overdiagnosis of ADHD in Southeastern Virginia 24 Evaluating Strength of Evidence Pyramid diagram: The quality and strength of evidence increases from the base to peak. 25 A Model for Improvement AIM • What are we trying to accomplish? • How will we know that a change is an improvement? Measures Change • What change can we make that will result in improvement? Plan Act Do Study 26 Focused Aim Statement An aim statement for an improvement project should include a change, a direction and quantity of change desired, a time-frame for the project, and some indication of the relevance or importance of the project. Focused (Good) In order to improve the post-MI survival and morbidity of our patients, we will increase the percentage of our acute MI patients discharged on beta blockers from 46% to 100% over the next 6 months. How good? By when? For whom? Unfocused (Bad) We will do better with our postMI patient survival. 27 Appropriate Measurement • You must choose measurements (data collection) that will help you discern if your project is having the impact and results for which you are aiming • This will be the focus of next semester’s systems-based practice lecture. 28 Process Modeling • Using modeling tools to look at data in various way o Cause-effect diagram o Flow diagram o Other forms of diagrams • Looking for contributing factors and root causes • Simple to complex 29 Cause-Effect Diagram aka: Ishikawa/ Fishbone Diagram 30 Possible Causes of Frustration w/ Wait Times at Drop-In Clinic People Policy Many new clinicians not familiar w/ system Variable schedules, hard to know how many clinicians will be in clinic Administrators expect patients to have drop-in access Clerk checks in patient for drop-in, continuity, & specialty clinics No defined way for patients to access clinic Methods Exam rooms not fully stocked each day Patients, staff, and clinicians are frustrated by long wait times in drop-in clinic Computer scheduling system does not keep track of drop-in appointments Materials 31 Other Types of Diagrams Flow Diagram Deployment Flow Diagram 32 Next Step? Brainstorming a List of Possible Changes • Brings people together to get diverse viewpoints. • Everything is up for discussion – no one’s ideas are maligned. • Uses a discovery method to establish ideas for change. • Creates a list of possible changes after possible problems are identified with process modeling. 33 CHALLENGE Based on your knowledge and experiences, consider a small project that might help to improve your professional development. Provide enough information that someone unfamiliar with the context would know what you propose to do, how you will do it, and why. Background Aim Intervene / Do Measure / Study Change and next steps / Act 34 Successive PDSA Cycles Over Time Focus of Semester 3X/04 35 Summary • Care of the health care system is a lot like care of the patient • Health care occurs in interconnecting layers that must work together for the good of the patient and these layers are affected by culture and context • A quality gap is the difference between what we should do and what we actually do • Process modeling lets us better understand the system in which we work • The PDSA cycle is a model for improvement similar to a treatment plan for a patient – simple to complex with as many iterations as warranted 37 A Reason to Improve Systems-Based Thinking https://www.youtube.com/watch?feature=player_detailpage&v=Di9epzNFC3s 38 Thinking Like a Systems-Based Physician About Improving Health Care https://youtu.be/PbRYSKHThWM 1. Understand the needs and assets of the population. 2. Make equity a property of the system. 3. Partner with those with lived experience. 4. Keep a close window to the ground with your measures. 5. Have a plan for scale-up 39 Recommended reading: Fundamentals of Healthcare Improvement, 2nd edition. Foreword and Chapters 1 & 5 Recommended video: Dr. Mike Evans: An illustrated Look at Quality Improvement in Health Care, https://www.youtube.com/watch?time_continue=2&v=nPysNaF1oMw 40