Transcript Slide 1

Linking Outcomes of Care to the ACGME Core
Competencies: A Matrix Solution
•
3:15 pm – 3:25 pm Introduction
Berend Mets, MB, Ph.D., Moderator
•
3:25 pm – 3:55 pm Embedding the Core Competencies Using the Matrix
John Bingham
Director, Center for Clinical Improvement
Vanderbilt University Medical Center Nashville Tennessee
•
3:55 pm – 4:10 pm Question & Answer Session
•
4:10 pm – 4:40 pm Practical Examples of the Matrix
Doris Quinn, Ph.D.
Assistant Professor, Division of Medical Education
Vanderbilt University Medical Center Nashville Tennessee
•
4:10 pm – 4:55 pm Question & Answer Session
Vanderbilt University Medical Center
Linking Outcomes of Care and
the ACGME Core Competencies:
A Matrix Solution
SAAC/AAPD Annual Meeting
Washington, DC
November 5, 2005
Doris Quinn, PhD
Assistant Professor
Division of Medical Education
Vanderbilt University Medical Center
John Bingham, MHA
Director
Center for Clinical Improvement
Objectives for today:
1. Discuss the Institute of Medicine (IOM) Aims
for Improvement and the ACGME Core
Competencies.
2. Describe how the Healthcare Matrix helps
link outcomes of care to learning the core
competencies.
3. Provide examples of how the Healthcare
Matrix is used to improve education and the
delivery of care.
Vanderbilt University Medical Center
“Kyros” Events in Healthcare:
1999
2001
2002
2003
2004
Emerging public
reporting of
quality measures
“Hospital Compare”
Vanderbilt University Medical Center
Extrapolated study results imply that
between 44,000-98,000 U. S. hospital
patients die each year as a result of
medical errors.
March 2000
Vanderbilt University Medical Center
And what about today?
“Five Years After To Err is Human: What Have We Learned?”
Lucian L. Leape, MD; Donald M. Berwick, MD JAMA, May 18, 2005
“If the experience of the past 5 years
demonstrates anything, it is that neither
strong evidence of ongoing serious harm nor
the activities, examples, and progress of a
courageous minority are sufficient to generate
the national commitment needed to rapidly
advance patient safety.”
Vanderbilt University Medical Center
Patient Care should be:
Safe, Timely, Effective,
Efficient, Equitable, Patient-Centered
(STEEEP)
Vanderbilt University Medical Center
7/2001
6/2002 7/2002
Phase I
• Define specific
objectives for
residents to
demonstrate
learning of the
competencies.
• Begin integrating
the teaching and
learning of
competencies into
residents’ didactic
and clinical
experiences.
6/2006
Phase II
7/2006
6/2011
Phase III
• Improve the
evaluation
processes for all
six of the
Competencies.
• Use resident
performance
data as the
basis for
improvement.
• Provide
aggregated
resident
performance
data for Internal
Review Process.
• Begin to use
external quality
measures to
verify resident
and program
performance
levels.
Vanderbilt University Medical Center
7/2011
Beyond
Phase IV
• Identify
benchmark
programs.
• Involve
community in
building
knowledge
about good
GME.
“Clinical education simply has not kept pace
with or been responsive enough to:
•
•
•
•
•
•
shifting patient demographics,
changed health system expectations,
evolving practice requirements,
new information,
a focus on improving quality,
new technologies.”
Vanderbilt University Medical Center
“Hospital Compare”
Emerging public
reporting of quality
measures
– Reporting of CMS Quality Measures tied to
Annual “CMS Market Basket Update”
• November 2004
– “Recommend to Congress that it adopt
pay-for-performance for physicians,
hospitals, and home health agencies”
• Medicare Payment Advisory Commission: March 2005
Vanderbilt University Medical Center
The first Core Competency:
Patient Care
(Assessing it …and getting ready
for physician report cards!)
Vanderbilt University Medical Center
What are you measuring to evaluate the
quality of Anesthesia care?
Patients
with Needs
Patients with
Needs Met
Access
Assessment
Diagnosis Treatment
Follow-up
How and where are these data reported?
How is the information utilized to improve:
•the education of residents?
•the quality of care provided?
Vanderbilt University Medical Center
Patient Care should be:
Safe, Timely, Effective,
Efficient, Equitable, Patient-Centered
(STEEEP)
Vanderbilt University Medical Center
Healthcare Matrix: Care of Patient(s) with….
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
Vanderbilt University Medical Center
EFFICIENT
EQUITABLE
PATIENTCENTERED
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
“Avoiding injuries to patients from the care
that is intended to help them”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
•What is our Anesthesia performance for:
•% Patients with appropriate prophylactic antibiotic?
•% Cardiac Surgical Patients with controlled
perioperative serum glucose (200 mg/dL)
•% Cases with documented Time Out?
•Intra- or postoperative:
•Cardiac arrest during hospitalization?
•PE during hospitalization?
•DVT during hospitalization?
•Anesthesia Complications/1000 surgeries?
Vanderbilt University Medical Center
WI
WISCSH AR D
ON
TRU MSIN
A
HEN
NEPIN
N
U CSD
A RIZ
BRI G O NA
D EN H HA M
EA LT
H
OH IO U TA H
C INC STA TE
IN N
MC O A TI
MIC H H IO
I GA N
U CLA
OR
C LEV EGO N
ELAN
V CU D
HS
CH
PEN NIC AG O
STA T
U MA E
SS
LO
KEN Y OLA
TU C K
Y
HA R
U
C
S
BO RF
UC LA
N YU
N
FRO EEV AD A
DT
U CD ER T
U CIR AV IS
V INE
IO W
R WJ
A
OHN
SON
K
V AN A N SA S
DE
N CA R BILT
RO
MA S LI NA
S
N ME G EN
X IC O
STON
M
YBROC G
01003
3 AL
OK
TJEF A BAMA
FERS
O
S
PRES CA R OLI N
N
C OL
UMB A
IA
WAK
U VA
EFO R
E
A LBA ST
HO W NY
STAN AR D
LOU FO RD
IS
FLET IA NA
MISSCH ER
O UR
EC
I
HA R A RO LINA
B
O
NIV H
R
O SP- V IEW
UMD
NJ
U SA
1.60
1.40
1.00
Is Care Safe ?
VUMC Goal: Achieve lowest mortality in nation
1.20
VUMC 2005
Vanderbilt University Medical Center
VUMC 2004
0.80
0.60
0.40
0.20
0.00
Observed to Expected Mortality:
53 UHC AMCs with Level I Trauma Centers
VUMC Observed to Expected Mortality and Actual
Number of Mortalities 2003-2005
VUMC Overall
O/E Ratio Line
(.77 for 2Q
2005)
140
1.2
VUMC Elevate
Goal: .85
14
14
9
6
13
32
13
39
37
21
36
40
30
31
3
2
21
40
3
2
Month
Vanderbilt University Medical Center
31
Other
0.2
4
4
4
3
4
3
4
3
5
2
5
2
7
2
4
4
3
2
6
4
02
8
0
4
4
Aug-05
35
Jul-05
31
25
Jun-05
11
Surgical Science
37
May-05
4
3
27
40
Apr-05
3
3
31
34
Mar-05
22
30
Medicine
VUMC O/E
34
Feb-05
0
3
2
28
40
Jan-05
26
37
35
37
Peds
Neurology
Dec-04
Aug-03
43
Nov-04
Jul-03
37
Oct-04
31
41
0.6
Sep-04
21
18
Mar-04
3
4
31 42
40
0.4
Feb-04
01
28
0.8
13
16
30
Jan-04
30
27
11
Aug-04
33
33
Jun-03
3
5
31
30
45
47
40
37
24
2
7
12
10
50
40
Jul-04
40
10
50
13
Jun-04
31
39
Dec-03
32
Apr-03
4
9
Feb-03
3
9
24
Mar-03
18
56
6
12
26
28
34
28
0
34
36
40
20
41
7
Nov-03
26
10
13
Oct-03
42
5
13
12
May-04
41
60
18
17
Sep-03
15
8
14
Apr-04
8
14
11
May-03
80
18
15
10
1
0.85
O/E Rate
100
Jan-03
Actual number of Mortalities
120
0
Best AMC
PATIENT CARE that is…
Safe
Timely
“Reducing waits and sometimes harmful
delays for both those who receive and
those who give care”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
•What is our Anesthesia performance for:
•% Patients with Anesthesia Prep Time < 15 Minutes?
•% Patients with on-time prophylactic antibiotics?
•% Patients with prophylactic antibiotics?
discontinued <24 hours after surgery end time?
•% cases completed < 15% of scheduled length?
•% cases with surgical consent before day of surgery?
•Average time between cases (Gap Time)?
•Average time between “room ready” and “in room”?
Vanderbilt University Medical Center
Percentage of Surgery Patients Who
Received Preventive
Antibiotic (s) One Hour Before Incision
Top Hospitals:
93%
AVERAGE FOR ALL
REPORTING
HOSPITALS IN
THE UNITED
STATES
AVERAGE FOR ALL
REPORTING
HOSPITALS IN
THE STATE OF
TENNESSEE
VANDERBILT
UNIVERSITY
HOSPITAL
69%
64%
47%
Top Hospitals represents the top 10% of hospitals nationwide
(Data displayed are from data reported July-Dec.04)
Vanderbilt University Medical Center
Patients
with Needs
Patients with
Needs Met
Access
Assessment
Diagnosis Treatment
Follow-up
What is the infection rate for surgical patients (in total, by procedure, by specialty, by
surgeon; by site of surgery) ?
Received prophylactic antibiotics?
Yes
No
Exceptions by
procedure, by
specialty, by
surgeon; by site of
surgery ?
% with
Infection
Received within one hour
prior to surgical incision?%
Yes
No
Received the appropriate antibiotic?
% with
Infection
No
Exceptions
Vanderbilt University Medical Center
% with
Infection
Yes
% with
Infection
Percentage of Surgery Patients Whose
Preventive Antibiotics
are stopped Within 24 Hours After Surgery
Top Hospitals:
100%
AVERAGE FOR ALL
REPORTING
HOSPITALS IN
THE UNITED
STATES
AVERAGE FOR ALL
REPORTING
HOSPITALS IN
THE STATE OF
TENNESSEE
VANDERBILT
UNIVERSITY
HOSPITAL
64%
58%
78%
Top Hospitals represents the top 10% of hospitals nationwide
(Data displayed are from data reported July-Dec.04)
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
“Providing services based on scientific
knowledge to all who could benefit and
refraining from providing services to
those not likely to benefit”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
•What is our Anesthesia performance for:
•% Patients that received preoperative
prophylaxis for VTE?
•% non-cardiac vascular surgery patient receiving
beta-blockers during perioperative period
•% Patients with CAD who received beta blockers
during perioperative period?
•% Patients on a ventilator whose post op orders
included elevating bed >= 30 degrees?
Vanderbilt University Medical Center
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
“Avoiding waste, including waste of
equipment, supplies, ideas, and energy”
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
•What is our Anesthesia performance (over time) for:
•Total cost per case?
•Supply cost per case?
•Supply waste per case?
•OR non-billable time delays due to Anesthesia?
•Rate of increase in revenue vs. expenses?
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
“Providing care that does not vary in
quality because of personal characteristics
such as gender, ethnicity, geographic
location, and socio-economic status”
Vanderbilt University Medical Center
Is Care Equitable?
AHRQ 2004 National Healthcare Disparities Report
Released 2/22/2005
•Blacks:
•Asians:
• had worse access than whites for about 40% of access measures
• received poorer quality for about 66% of quality measures
• had worse access than whites for about 33% of access measures
• received poorer quality than whites for about 10% of quality measures
•Hispanics:
• had worse access than non-Hispanic whites for about 90%
of access measures
• received lower quality of care than non-Hispanic whites for
50% of quality measures
•Poor people:
• had worse access for about 80% of access measures than
those with high incomes
• received lower quality of care for about 60% of quality measures
Vanderbilt University Medical Center
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
“Providing care that is respectful of, and
responsive to:
•individual patient preferences,
•needs and values,
•and ensuring that patient values guide
all clinical decisions”
Vanderbilt University Medical Center
Is Care Patient Centered?
HCAPS/CMS Patient Perception Surveys
Effective in 2006-Public in 2007
What are our patients’ perceptions of:
•Communications with Nurses?
•Communications with Doctors?
•Communications about medications?
•Nursing services?
•Pain management?
•The hospital environment?
•Adequacy of discharge information?
•Our system overall?
•Their willingness to recommend us?
Vanderbilt University Medical Center
What must we know?
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
“…about established and evolving biomedical,
clinical, and cognate sciences, (e.g.
epidemiological and social-behavior) and the
application of this knowledge to patient care”
Vanderbilt University Medical Center
What must we say?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
“…that result in effective information exchange
and teaming with patients, their families, and
other health professionals.”
Vanderbilt University Medical Center
How must we behave?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
“…as manifested through a commitment to
carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to
a diverse patient population.”
Vanderbilt University Medical Center
What is the Process?
On whom do we depend?
Who depends on us?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
“…as manifested by actions that demonstrate an
awareness of, and responsiveness to, a larger context
and system of healthcare and the ability to effectively
call on system resources to provide
care
that
is of optimal value.”
Vanderbilt University
Medical
Center
What have we learned?
What will we improve?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
Practice-Based
Learning &
Improvement
“…involves investigation and evaluation of
their own patient care, appraisal and assimilation
of scientific evidence, and improvements in
patient care.”
Vanderbilt University Medical Center
Linking it all together….
Patients with
Needs Met
Patients
with Needs
Access
Patient Care that is…
Assessment
Safe
Timely
Clinicians competent in:
-Medical Knowledge
-Interpersonal and
Communication Skills
-Professionalism
-System-Based Practice
-Practice-Based Learning
& Improvement
Vanderbilt University Medical Center
Diagnosis
Effective
Treatment
Efficient
Follow-up
Equitable
Patient Centered
QUESTIONS?
Vanderbilt University Medical Center
“Residents live in the cracks of our
health care systems and give voice
to what life is like there.”
Paul Batalden, MD
Dartmouth Medical School
Vanderbilt University Medical Center
Five Applications of the Matrix
I.
Individual Resident Learning
II.
Case Presentations
III. M & M Conference
IV. Panel of Patients for Group Learning
V.
Medical Students
Vanderbilt University Medical Center
Individual Learning
Case Presentation
Vanderbilt University Medical Center
Anesthesia: One resident’s learning
Case presentation preparation before expose to the Matrix
IOM
SAFETY
TIMELINESS
EFFECTIVENESS
ACGME
PATIENT CARE
MEDICAL KNOWLEDGE &
APPLICATION
X
X
PROFESSIONALISM
INTERPERSONAL &
COMMUNICATION SKILLS
SYSTEMS- & TEAMS-BASED
PRACTICE
X
PRACTICE-BASED LEARNING &
IMPROVEMENT
(Process to Improve)
Vanderbilt University Medical Center
EFFICIENCY
EQUITABILITY
PATIENT
CENTEREDNESS
Case presentation after dialogue with faculty using the Matrix.
IOM
TIMELINESS
EFFECTIVENESS
X
X
X
X
X
X
X
X
X
X
X
X
P and P
changed for
Mom/Child in
trouble
Changed
STAT pages
to Anes.
From OB
Class on
care of Mom
with DIC
Procedure
outlined for
fastest prep
for OR
SAFETY
EFFICIENCY
EQUITABILITY
PATIENT
CENTEREDNESS
ACGME
PATIENT CARE
MEDICAL KNOWLEDGE
X
PROFESSIONALISM
INTERPERSONAL &
COMMUNICATION SKILLS
SYSTEMS- & TEAMS-BASED
PRACTICE
PRACTICE-BASED LEARNING &
IMPROVEMENT
(Process to Improve)
Vanderbilt University Medical Center
X
X
X
X
X
Assure Mom aware
of what is
happening.
Communication
with father.
Patient with Pregnancy and D.I.C (Disseminated Intravascular Coagulopathy)
Case Presentation
IOM
ACGME
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENT-CENTERED
NO
Language was a
problem
NO
Patient was not
adequately apprised of
her own health
problems and did not
participate fully in her
care decisions
Assessment of Care
NO
Patient
nearly died
NO
Life saving
treatment was
delayed for
variety of reasons
NO
Delays in treatment
impaired
effectiveness of
therapy
MEDICAL
KNOWLEDGE
(What must we
know)
Priorities in
hemorrhagic
shock are
ABC: ensure
oxygen
delivery,
support BP,
aggressive IV
resuscitation,
treat cause
Hemorrhagic shock is
life-threatening
emergency: Prompt
diagnosis, recognize
urgency, initiate
therapy, incl. timely
transport to OR.
Diagnosis was made
late. No urgency to
treat. Delay in
contacting Anesth.
Inadequate
assistance in
transport to OR
D.I.C. in pregnancy:
Physiology, diagnosis,
causes, treatment.
Regional v. General
Anesth? Post
resuscitation pulmonary
edema. Hypocalcemia
due to massive
transfusion. Invasive
monitoring indications.
Pharmacology of
uterotonic drugs.
Survival in postpartum
hemorrhage requires
aggressive IV
resuscitation: always
consider combining
procedures (start 2nd IV
while drawing blood
sample for transfusion
cross match).
INTERPERSONAL
AND
COMMUNICATION
SKILLS
(What must we say)
Safety is
jeopardized
unless team
members are
fully apprised
of patient’s
condition
(blood loss
following
delivery, vital
signs, plans
for
intervention).
Effectiveness of lifesaving intervention
depends on effective
communication between
team members.
Communications of a
defensive or
argumentative nature
are counter-productive
to efficient and safe
care. The focus should
be patient care, with
analysis of
misunderstandings at a
later time.
PATIENT CARE
(Overall
Assessment)
PROFESSIONALISM
(How must we act)
Orders (blood cross
match) must be
prioritized and fully
implemented in a
timely fashion.
Professional duty to
accompany critically ill
patient to the OR, to
ensure safety, and to
expedite therapy.
Vanderbilt University Medical Center
NO
Resources (blood
products, staff time)
were not utilized in
an efficient manner.
Must communicate patient’s
condition and intended
interventions (blood
transfusion, emergency
hysterectomy), and in a way
that is understandable and
useful to the patient,
respecting patient autonomy.
Patient’s ethnic,
socio-economic,
“service patient”
status should have
no effect on quality
of care.
Professional duty to attempt
to preserve patient autonomy
(make sure patient
understands situation and
interventions)
SYSTEMBASED
PRACTICE
(On whom do
we depend and
who depends
on us)
System must
ensure that
appropriate
consultants are
notified when
needed to ensure
safety in lifethreatening
medical condition.
During postpartum
bleeding, type & cross
match must be drawn,
sent, and verified
promptly. Failure to do
so threatens life.
Standard of care should
not vary due to
differences in staffing that
result from time of day /
night (availability of lab
medicine physician, timely
transport of blood
samples, adequate
number & expertise of
obstetrics,
anesthesiology, & nursing
staff)
Failures to draw,
send, and verify
cross match blood
sample jeopardizes
effectiveness of lifesaving therapy.
Improvement
PRACTICEBASED
LEARNING
AND
IMPROVEMEN
T
(How must we
improve)
Policy and
Procedures
changed for
Mother/Baby in
trouble
Revise the criteria for
and system of
communicating urgent
/ emergent request for
Anesthesiology
consultation
Departmental
Teaching
Conference on
management of
parturient with
D.I.C.
Procedure
outlined for
fastest prep
for OR
© Bingham, Quinn Vanderbilt University (Used with permission from Anesth. Dept)
Vanderbilt University Medical Center
Increased awareness
of need to consider
patient centeredness
even in emergent or
crisis situations.
Communication with
father / family
members when
appropriate and
possible.
Patient with
Coronary Artery Disease
(Internal Medicine Residents
Ambulatory Rotation)
Vanderbilt University Medical Center
Care of Patient with Chest Pain
Internal Medicine-Ambulatory Rotation
IOM
ACGME
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENT-CENTERED
No
No
(Socio-economic
issues)
No
(Socio-economic
issues)
Yes from VUMC
Yes from VUMC
Assessment of Care
I.
PATIENT CARE
(Overall Assessment)
yes/no
No
(Socioeconomic
issues)
Yes from VUMC
Many comorbidities (CA,
diabetes, GERD,
II. a
Hypertension,
MEDICAL KNOWLEDGE
Etc.)
(What must I know)
Should we
communicate
all the neg
II. b
INTERPERSONAL AND effects of
COMMUNICATION SKILLS uncontrolled
(What must I say)
diabetes?
PROFESSIONALISM
(How must I act)
When should
MD be BLUNT
with noncompliant pt ?
II. d
Needs other
II. c
resources to
SYSTEM-BASED
manage her
PRACTICE
(On whom do I depend diseases.
and who depends on me)
Yes
No
She can be seen
when she wants
What is organ and
disease progression
for a 70+ yr old?
Unstable Angina,
Diabetes, previous visit
for reflux 3 weeks
before hospitalization.
Make sure heart pts Frustrating to have
understand the
many problems to
signs of angina and address and not
not wait 2 weeks.
enough time.
Past medical records
were not available.
The care of this
patient requires more
time from PCP. Focus
of visit might need to
be decisions she
needs to make given
her situation.
Are there culture
When it is appropriate
barriers preventing her to “fire” a patient in
from being compliant? order to have more
time for others?
Schools do not
teach children and
especially
adolescents about
health practices.
Does she really want
to change her
lifestyle? How do you
know?
Cannot afford her
meds therefore
she cannot be
“compliant”
What are her goals for
her disease? Feels
she has already outlived most of her older
family members.
Shared decisionmaking important
because of her
lifestyle.
Attended DIP program Intermittent
Different life-style No case manager
but HbA1c still not well appointments for
of Af-American
involved to help find
controlled. Relies on chronic disease does whose husband is resources for this pt.
samples for her meds. not work well.
musician and
works late hours.
Improvement
III.
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(How must I improve)
Create card
with “signs of
trouble” for all
elderly pts.
Could visiting
Create an agenda at
nurses be involved? the beginning of the
visit so that all
important issues are
addressed.
Use Church as Ctr for
education and care.
Vanderbilt University Medical Center
Social worker or case What comes in
mgmt would be very generic form of
helpful.
drugs?
Know how sample
pharmacy works.
Clarify goals that
patients want before
frustrating both pt and
provider. Could we
get a “contract” with
this patient about her
care?
Panel of Patients with
Coronary Artery Disease
Vanderbilt University Medical Center
Panel Management of CAD Patients:
(AHA Guidelines)
• Medications:
– Aspirin
– Beta Blocker,
– Statin if LDL > 100
•
•
•
•
Blood Pressure Control
ACE-Inhibitor/ARB
Smoking Cessation
Diabetes Screen / HgA1c
Vanderbilt University Medical Center
Internal Medicine Residents
Ambulatory Rotation
Medications by Resident Group
100.0%
90.0%
80.0%
Percentage
70.0%
60.0%
Aspirin
50.0%
BetaBlocker
Ace Inhibitor
40.0%
30.0%
20.0%
10.0%
0.0%
1
2
3
4
5
Resident Group
Vanderbilt University Medical Center
6
7
8
9
Practice-based learning and
Improvement
(based on care of patients
with CAD)
Vanderbilt University Medical Center
Vanderbilt University Medical Center
Patient with CAD
Internal Medicine Residents
February, 04
April, 04 (class 3)
May, 04 (class 4)
Physician in room with
Patient
2
New
Patient.
?
Page 3
Follow-up
on CAD
Patient
N
Get updated
history including
all risk factors
Patient Education
(or other
preventive health
issues)
Physical Exam
Y
Seen at VUMC
before
?
N
Get pt.
Information
from
StarPanel
Other
complaints to be
addressed
?
N
Review:
VS
Medication list
Problem list
N
Y
Acute visit
?
N
Review of
systems
approach
-Meds
-EBM
-etc
Information shared
with patient
Does MD have
time to address
all issues
?
Y
N
Formulate Plan
(confer with
Attending as
needed)
N
Get as much
information
as possible
Synthesize
Information
Address only acute
complaint and
reschedule for other
issues if needed
Need
Hospitalization
?
Focused/
Directed
H&P
Y
Different Process
All patients may
have long list of
complaints. MD
has to see pt in 15
minutes
Previous info not
available. Can we
have pt fill in info
in waiting room?
Problem list should
include what has
been tried and
failed (with meds)
Explain computer
issues with pt (esp
problem list) so
they don’t feel
ignored
Vanderbilt University Medical Center
Location of
computer and not
being able to look
at patient
Could we have time
for visit match what
needs to be done?
Especially for pts with
Chronic diseases
Wait time for tests
results
Location of
patients while they
wait
3
DOCUMENTATION
OF NEW PTS.
PATIENT
VISIT ISSUES
Documentation hold-up of
encounters, particularly
new pts
NURSING &
TECH INFO
STAR PANEL
Communicating w/
referring physician/pt: type
letter or call
StarPanel
note organization
Typing new pt
notes too slow
Not using pt waiting time
to capture info
MEDICINE
RESIDENT CLASS
04/01/04
5/21/04
Obtaining outside records
Time lost: time spent w/
tech in room should not
exceed 2 - 3 min.
Window popup w/ age, genderspecific standard of care
guidelines for ICD-9 code or dx
Check-in takes too long
Parking for patients
No-show patients
Having to type notes
on new pts
Nurse write down meds
or put on problem list
when doing intake
assessment
StarPanel tutorials to show
the ins & outs of new tools
in StarPanel
Proper followup: interventions,
referrals, tests, teaching
Documentation: typing
new pt note
PRE-VISIT INFORMATION
FROM PATIENTS
If no available problem
list, a hard copy of last
Star note in chart or door
to review last times visit
StarPanel too slow, always
pops up w/ wrong pt
Benefits of each medicine
by class; “your Dr has started
you on a B Blocker because…"
“this medicine will help with…"
6th grade level educational
materials for Dx (i.e. high
cholesterol: diet/nutrition, quit
smoking, etc)
OPOC too slow, takes too
much time to get pt out of
room (the only room we have!)
Test from OSH (Imaging,
Labs, Vaccinations, etc.
Redundant info (tech gets cc)
we redo this
Pt needs to bring meds or
list of meds to confirm
Vital signs are optional
Search engine for Meds!
No definition for pt appointment
time (check-in, vitals, to room, to
see Dr?)
List of formulary meds for
that pt’s ins. Available in a
popup/menu, also timeliness
Previous info
not available
Confusion about who does what
in clinic (tech/nurse/secretary)
Log into system - slow!!
Paper charts were designed by?
- not easily useful to physicians
Delays in Patient Care
Pt scheduled for f/u appt
with another appt previously
Wait time for test
scheduled, ends up as no
results too long
show for one
All residents in clinic have pts
Too many forms
scheduled at same time
to fill out for tests
Except for new pts & female
physical, all appts are same
length of time (20 mins)
Location of computer not being able to see pt
Explain computer
issues to pt (i.e.
problem list) so they
don’t feel ignored
Staff: Decision chart
regarding what to do
with late arrivals
Resident workrooms are
poorly configured and
poorly furnished
Current Med list/
Previous Med list
Problem list should include
what has been tried &
failed (meds)
Appointment template is
never right!
Scheduler will not allow for
alternate ways to schedule
pts
Too few rooms for 4
residents
Location of pts while they wait
No pt in room when ready to see pt
Insufficient room space
Allergies (true)
TESTS
Room for pt to wait while
MD sees next pt
Most important problem/
issue today (SMIP - single
most important problem!)
Start Labs (MP, CBC w/ diff,
Lipid profile, HgAIC, EKG)
Residents all waiting
for preceptor at same
time, major holdup in
schedule
SCHEDULING
Variation in whether or
not vitals are even done
Variation in time it takes each
nurse to check in a pt
Meds I don’t like - why?
Malfunctioning diagnostic
equipment
Multiple pts scheduled at
same time for physician
Room turnover is an issue.
Other rooms are not ready to
go or there are pts in waiting rm
w/ no tech to bring them back
LATE
ARRIVALS
ROOM
ENVIRONMENT
Vanderbilt University Medical Center
PROBLEM LIST
& MEDS
One location for labs to be drawn & vitals
taken by nurse for all pts, creates roadblock
ROOM
UTILIZATION
Improvements From Medicine Residents:
Pat Covington RN, Manager
 EMR: We can now text message across departments.
 Use of pt waiting time: Have Kiosk in exam room to fill in
review of systems. Questionnaires being sent to pts ahead of
time. Those with email get questionnaire and can return via
email.
 Availability of techs: Modified schedule of techs to improve
service. Residents’ schedules were also changed to better
utilize staff.
 Patient visit survey and phone calls will now be done after
visit.
 Patient Letter revised: “Bring old records, come 15 minutes
before appt.”
Vanderbilt University Medical Center
Transforming M&M Conferences
into
Practice-based Learning and
Improvement
Vanderbilt University Medical Center
Care of Child with Hyperleukocytosis
M&M 3/25/04 (Peds Hem/Onc)
IOM
SAFE
ACGME
1
TIMELY
2
EFFECTIVE
3
EFFICIENT
4
EQUITABLE
5
PATIENT -CENTERED
Assessment
I.
PATIENT CARE
II. A
MEDICAL
KNOWLEDGE
7
8
(What must I know)
II. B
PROFESSIONALIS
M
(How must I act)
II. C
INTERPERSONAL AND
COMMUNICATION
10
SKILLS
9
Mostly yes
(Toxicity of chemo
needed better
monitoring)
Yes
-Hypercalcemia led
to hypotension.
-Respiratory
di stress secondary
to fluid overload
and atelectasis
required intubation
Complications of
Leukopheresis was
discussed.
PCP referred child
to ED for evaluation
very quickly (from
community 40 miles
away).
Full dose
Chemotherapy
started quickly
Feedback to PCP
was done as soon as
a concern was
voiced.
Yes (but variation
exists)
WBC dropped from
324K to 37K by
midnight
Management of
Hyperleukocytosis: was
major discussion for
M&M conference.
Yes
Discussed lack of
benefit and increase
cost of cranial
irradiation
Some physician
variation noted at VU for
treatment. Can we
standardize with
pathway?
Experienced
physicians and
researchers
communicated well.
Yes
Yes
Family told of
possible Dx within 2
hours of ED visit.
How to tell family bad
news (lecture at VU).
Pediatrics Oncologists
have a lot of experience
and are very family
centered. Family was
well informed of likely
dx and plan of action.
Able to talk to family
and PCP in
professional and
evidenced -based
manner.
Hand -offs were smooth
and well executed.
Pare nts felt
comfortable providing
inform consent by 7
PM the same day.
Lab results were done
quickly from ED.
Team worked well to
have treatment begin
quickly with good
results within 10 hours
ED good
communication with
House Officer.
Social worker met with
family to explain what
was happening.
(What must I say)
II. D
SYSTEM -BASED
11
PRACTICE
(On whom do I depend
and who depends on me)
III.
PRACTICE -BASED
LEARNING AND
12
IMPROVEMENT
(How can I improve)
Toxicity was an
issue and the
team
needed to do a
better job of
recording what was
happening.
Be s ure everyone
knows the toxicity
and complications
and document.
Quick response by
VCH to PCP.
hyperleukocytosis
5 hours to Dx
8 hours to start of Tx
Discussed issue of
dialysis for treatment.
Consulted nephrology
and PICU. Dialysis
nurse notified early and
circuit primed.
Improvement
Create pathway for
hyperleukocytosis to
decrease variation
Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
6
Care of Patient With Ewing’s Sarcoma (pain mgmt)
(Anesthesia Case Conference/M&M)
ACGME
IOM
SAFE
a
b
TIMELY
EFFECTIVE
c
EFFICIENT
d
EQUITABLE
e
PATIENT-CENTERED
f
Assessment
Yes ?
g
PATIENT CARE
(What I must do)
No
Knowledge of pain
meds and how to
MEDICAL
keep pt
h
KNOWLEDGE
comfortable was
(What I must know) not known. Fear of
overdosing lead to
under dosing.
Discussions with
surgeons re:
i
PROFESSIONALISM procedures are
appropriate for this
((How I must act)
pt. Hand-offs not
well managed
Patient knows
medications and
INTERPERSONAL
routine so that he
AND
can help monitor
COMMUNICATION
his care. All team
j
SKILLS
members need to
(What I must say)
know his med
regime.
SYSTEM-BASED
k
PRACTICE
(On whom do I
depend and who
depends on me)
TEAM did not
always know what
was going on.
Hand-offs were not
well managed.
No
No
Care and pain mgmt There were no
were not anticipated guidelines for proper
to prevent delays. care of young patient
dying of cancer that
included medications,
especially drug
tolerances.
Be prepared to turn What was evidence
patient over to other for procedure and
clinician when
outcomes?
others can do better
job.
Response by
nurses and
physicians were not
timely because lack
of common
knowledge
All care team
members were not
included in discussion
of post-op care and
pain mgmt of this
patient.
All steps of the
process of care
were not known
(including who was
key in each step)
and therefore
delays occurred.
Plan of care should
have been s shared
with all (pharmacy,
surgeons, residents,
support services) to
make system work for
patient rather than
hinder care.
Vanderbilt University Medical Center
Not sure this was a
problem
No
Cancer patient on
high dose of
opioids.
Pain mgmt for
Physiology of pain
post-op CANCER and Knowledge of
pt is different from opioid tolerance so
routine post-op
that pt can be kept
pt.
comfortable. Patient
knowledge of web
use.
Include appropriate
Discussion with pt
professionals early in
and family about
the care (psychiatry,
quality of life issues.
family support,
church, etc. )
Communication
with a YOUNG
person dying of
cancer is different
from an older
person.
Needless variation
among clinicians is a
problem and causes
inefficiency of care.
Inclusion of patient
and family in plan of
care, especially pain
mgmt.
Team should
advocates for patient
in a complex system..
Care was not always
coordinated and
integrated.
Expectations and
comfort of patient
were not known and
addressed.
System Based
Practice
(What is the
process? On
whom do I
depend? Who
depends on
me?)
The Team did
not always
know what was
going on.
Hand-offs were
not well
managed
All steps of the
process of care
were not known
(including who was
key in each step)
therefore delays
occurred.
Plan of care should
have been shared with
all (Pharmacy,
surgeons, residents,
support services to
make system work for
pt rahter than hinder
care.
Needless
variation
among
clinicians is a
problem and
caused
inefficiency of
care.
Team should
advocate for pt in a
complex system. Care
was not coordinated
and integrated.
Expectations and
comfort of pt were not
known and
addressed.
Improvement
PRACTICEBASED
LEARNING
AND
IMPROVEMENT
(How must we
improve)
Residents need
to know
principles of
flowcharting
and RCA to
address these
issues.
Anesthesia
residents should
take the lead in
getting the team to
discuss pain mgmt
and changes
needed while pt still
in our system.
Team could share talk
of lit review for this
complex pt. Run chart
of pain scale could be
one metric to
determine results of
care.
Information Technology
© Bingham, Quinn Vanderbilt University
(Used with permission from Anesth. Dept)
Vanderbilt University Medical Center
Patient and family
should be included in
improvement and
monitoring of his own
care. Feedback to be
sought and used for
further improvement.
Healthcare Matrix: Care of Patient with postpartum respiratory arrest
OB M&M April 29, 2005
AIMS
Competencies
SAFE
TIMELY
EFFECTIVE
EFFICIENT
PATIENTCENTERED
EQUITABLE
Assessment of Care
PATIENT CARE
(Overall Assessment)
Yes/No
No
Resp arrest
during awake
intubation.
Yes
Yes: had proper tx.
No: Tx could have
been better.
Yes
MEDICAL KNOWLEDGE
and SKILLS
(What must we know?)
DDX eval and
Tx for ooCO
abd
SOB:PE/MI/CHF
/ flashpulm
edema/
pneumonia
Pt evaluation and
work-up organized
and timely.
Appropriate tx given
the DDx and evolving
clinical picture (CxR #1
read as c/w pneumonia
w no edema. Lasix Tx.
Anesthesia initially
used CPAP/OUOAO
to manage low O2
sats. Unfamiliar
modality in this
clinical setting.
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say?)
Awake
intubation
choice by
anesthesia 2/2
airway edema.
Order given and
executed promptly.
Emotional
reaction to
stressful
situation took the
staff by surprise.
Nurses on 4E assessed situation and
contacted MDs promptly. Timely
anesthesia consult and response.
Did busy service delay
Tx? (don’t think so)
Monitor malfunction
might have shown
arrest when she
wasn’t.
?
Pt did not fill Rx for
BP meds. despite
d/c instructions
given.
PROFESSIONALISM
(How must we behave?)
SYSTEM-BASED
PRACTICE
(On whom do we
depend and who
depends on us?)
Yes until arrest
occurred.
The team worked
very well together.
Managing the
family’s hysteria
during code
situation was very
challenging.
Good procedure of
nurses reviewing
meds and discharge
instructions. Getting
meds filled after reg
hours a problem.
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned?
What will we improve?)
Could we have
prevented the
resp arrest? C.
Osmotic
pressures need
to be done.
Could have
transferred to L&D
faster.
Reviewed lit on noncardiogenic Pulm
Edema.
Need to be more
aggressive with Lasix.
Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
All rights reserved.
Be mindful of
cultures that tend
to react more
physically and
emotionally to
stressful events.
Can anything be
done about getting a
few doses of meds
for pts being
discharged at odd
times?
Care of Patient with Femoral Vein Cannulation
Nephrology M&M 4/2/04
AIMS
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
Competencies
PATIENTCENTERED
Assessment
NO
PATIENT CARE
(What must I do)
MEDICAL
KNOWLEDGE
(What must I
know)
INTERPERSONAL
AND
COMMUNICA-TION
SKILLS
(What must I say)
Yes
Yes
No
Pt not always
safe as evidence
by several
adverse events
Need to find/learn best method.
Evidence of Ultrasound for dialysis line
placement.
Need additional
anatomy lessons
for performing
this procedure.
Need to know
what to do with
arterial
punctures. What
to do when
patient cannot be
still?
No guidelines in
literature for Fem.
Cannulation.
HCT not efficient way
to monitor bleeding
Nurses need to
know when
cannula has been
pulled in order to
have more
observation
Communicating use of
Niagra cath that other
areas have found less
favorable.
Use of patches used
on other specialties
for punctures not well
known.
Vanderbilt University Medical Center
Not Sure
How informed is
patient/family? No
post procedure
instructions.
Better instructions for
patient and family.
(Femoral Cannulation Cont’d)
PROFESSIONALISM
(How must I act)
SYSTEM-BASED
PRACTICE
(On whom do I
depend and who
depends on me)
Sharing
complications
and near misses
among all
specialties will
increase
learning.
Sharing expertise from
colleagues in surgery,
radiology and cardiac cath for
most effective and efficient
way to do cannulation.
No nursing
orders for postprocedure care.
Change of shift
dangerous time
for patients.
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(How can I
improve)
Keep QA log on
all procedures
to detect
trends. Need
to monitor
near misses
and
complications
to learn.
Multidisciplinary Team to decide on orders,
policy and procedures for Team
venous cannulation.
Multidisciplinary
to
decide on orders, policy and
procedures for venous
cannulation
© Bingham, Quinn Vanderbilt Univ. (Used with Permission from Nephrology Dept.)
Vanderbilt University Medical Center
ACTION PLAN
Improvement:
Item
#
ACTION
By Whom?

NOTES:
Vanderbilt University Medical Center
By When?
Comments
Date
Completed
Medical Students
(Neurology Clerkship)
Vanderbilt University Medical Center
Healthcare Matrix: Care of Patient with stroke - occlusion of the ICA of unknown origin.
AIMS
SAFE
Competencies
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment of Care
Yes
No
Yes
I.
PATIENT CARE
(Overall Assessment)
Yes/No
Yes, from VUMC,
Yes from VUMC
No for
placement.
No
b/c of insurance
issues
Yes – patient
was informed
and
incorporated
in decision
making
process
II. A
MEDICAL
KNOWLEDGE
(What must we know)
Yes. Everyone on the
stroke service was on
top of the latest in
knowledge.
Yes.
Yes.
Yes.
II. B
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
Yes. Communication
between neuro and
surgery was clear.
Attendings and
residents were in
contact
Yes –
phone calls and
meetings were used
when things couldn’t
wait for note in chart
Yes and no –
comm. Between
medical teams was
great. Ins issues led
to placement
problems though
Yes
yes
Yes – always
kept in mind
patients
perspective
Yes There was no
breakdown in safety
due to pro problems
Yes – there were
never any delays in
doing anything for the
pt in terms of pro
Yes
Yes
Yes and no – pt was
on service for a
while,– but not really
treated much better
than others
Yes –
Yes – patient was
monitored and kept in
system
Yes and no
– no delays in
providing emergent
care, but getting
rehab was hard.
Yes
No– consultants
used appropriately.
Problem was not in
Vanderbilt system,
but in insurance
system
Yes
Yes – all
resources were
used according
to pts own
goals for rehab
A lot of energy
and time was
used ineffectively
trying to place
him
Everyone worked
hard for him
because he was
there so long and
trying hard to
rehab. not more
than everyone else
Pt was very
involved in his
own care and
course and his
wishes were
always
respected.
II. C
PROFESSIONALISM
(How must we act)
II. D
SYSTEM-BASED
PRACTICE
(On whom do we
depend and who
depends on us)
Yes.
Improvement
III.
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned
and what do we
improve)
Patient safety was
maintained at all
times. We still don’t
know what caused
stroke after surgery
though.
Rehab placement
took too long –
everyone worked
hard, but maybe
could have worked
harder
Vanderbilt University Medical Center
Care was
administered
effectively within
limits – not much
treatment for
strokes like this yet
Vanderbilt University Medical Center
Practice-based Learning
and Improvement
Tools and Methods
Vanderbilt University Medical Center
IMPROVEMENT MODEL
Whatare
arewe
wetrying
tryingto
toaccomplish?
accomplish?
What
AIM---AIM
Howwill
willwe
weknow
knowthat
thataachange
changeisisan
animprovement?
improvement?
How
DataOver
OverTime
Time––
- -Data
(Tools: Run
RunCharts,
Charts,Control
ControlCharts)
Charts)
(Tools:
Whatchanges
changescan
canwe
wemake
makethat
thatwill
willresult
resultininan
animprovement?
improvement?
What
ProcessAnalysis
Analysis––
--Process
(Tools:Flowchart,
Flowchart,Cause
Cause&&Effect
EffectDiagram,
Diagram,Pareto
ParetoChart,
Chart,etc.)
etc.)
(Tools:
P
Act
Plan
Act to keep change
or Abandon and try
another change
A
the
Improvement
Study
Do
the
Results
the
Improvement
Vanderbilt University Medical Center
D
PDSA Cycle—Small rapid cycles of change
S
Operating Room Team
AIM:
Reduce “Start Time” Delays in O.R.
Vanderbilt University Medical Center
©VUMC2001
Run Chart of Delays
OR Delays in Start Time
120
105
90
Time
75
60
45
30
15
0
1
3
5
7
9
11
13
15
17
19
21
23
25
Patients
Vanderbilt University Medical Center
©VUMC2001
Process Flowchart
Nursing
evaluation
done?
No
Perform
nursing
evaluation
weight
Yes
Surgery
H&P done?
No
Perform H&P
Yes
Surgical
consent
signed?
Yes
Anesthesia
evaluation
done?
Risk &
medicolegal
issues
addressed?
No
No
Obtain signed
consent
Yes
Perform evaluation:
H&P
Indicated tests:
labs
ECG
CXR
No
Cancel
Surgery
Yes
Need
pre-op
lines in
holding?
No
Place indicated
lines
Yes
OR
ready?
No
Wait
Vanderbilt University Medical Center
©VUMC2001
Cause and Effect Diagram
PEOPLE
PROCEDURES
Surgeon Late
Anesthesia late
Patient
complications
Consult notes
not in chart
Nursing evaluation not done
Meds not
given
Consultation
not done
Double
booked
H&P not done
No pre-op
education
Anesthesia evaluation
not done
Tests not
done
Not available
Medical record missing
Instruments
not ready
Test results
not in chart
OR Start
Time
Delays
No patient
consent
No
authorization
Registration
not complete
No pre-op check list
Instruments not
available
EQUIPMENT
POLICY
Vanderbilt University Medical Center
©VUMC2001
Pareto Chart
PARETO CHART
59.00
100
94.92
89.83
47.20
83.05
72.88
35.40
59.32
42.37
23.60
11.80
0.00
0.00
A
B
C
D
E
F
G
# of errors
Cum Freq
Vanderbilt University Medical Center
©VUMC2001
New Aim
(Based on Data)
To reduce the number of preoperative
tests performed so that only those
which are important to the medical
mgmt of adult surgical pt during preop period are ordered.
Vanderbilt University Medical Center
©VUMC2001
How Will We Know a Change Is
an Improvement?
Measurement:
Percentage Excess Tests Per Specialty
Based Upon Agreed Upon Guidelines
Vanderbilt University Medical Center
©VUMC2001
What Changes Can We Make?
Develop disease and surgical procedural
testing guidelines for:
-laboratory testing,
-electrocardiography
-chest radiography
in adult surgical patients
Vanderbilt University Medical Center
©VUMC2001
Reduction in Unnecessary Preoperative Tests
2000
1.8
1800
1.6
1600
1.4
1400
# Patients
1200
1.0
1000
0.8
800
Tests per patient
1.2
0.6
600
0.4
400
200
0.2
0
0.0
1
2
3
4
5
Quarter
Vanderbilt University Medical Center
©VUMC2001
Preoperative Testing Variation Rates by Service
900
800
67
700
600
500
66
63
62
61
59
55
# Patients
80%
% Excess Tests
70%
60%
55
54
50%
464
400
40
330
310
40%
39
32
30%
300
200
100
108
38
25
7
53
28
94
9
51
51
19
20%
157
120
12
10%
Urology
Plastics
Vascular
CT Surg
Hepatobil/Tx
Gynecology
Neuro
Oto
Gyn-Onc
Renal/Tx
Trauma
General
Oral/Maxil
0%
Ortho
0
Additional Testing Rate (%)
90%
86
Oncology
Number of Patients
1000
Surgical Service
Vanderbilt University Medical Center
©VUMC2001
System-Based Practice
at the
Organization Level
Vanderbilt University Medical Center
When organizations are not
“Systems”
Quality of
Patient Care
R
Average Time to Make
Clinical Decisions
Quality
Erosion
+
+
Average
Length of Stay
Average Lab
Turnaround Time
R
-
Death Spiral
-
Phlebotomists
+
Hiring
Vanderbilt University Medical Center
+
Hospital +
Profit
Quality of
Patient Care
-
Residents
R
Average Time to Make
Clinical Decisions
Quality
Erosion
+
+
Average
Length of Stay
Average Lab
Turnaround Time
R
-
Death Spiral
-
Phlebotomists
+
Hiring
Lab Manager
Vanderbilt University Medical Center
+
Hospital
Profit
+
Hospital
CEO
Using the Matrix






History
Physical Exam
Labs
Diagnosis
Tests
Consults
Etc.
Vanderbilt University Medical Center
Care of
Patient
(Matrix)
“Closing the Loop”
• Start with diagnosis as basis for
assessment
• Identify issues of care related to Aims
and Competencies
• Identify lessons learned and
improvement needed
• Complete action plan for improvements
with accountabilities and timeline
Vanderbilt University Medical Center
Upcoming Matrix
Enhancements
Vanderbilt University Medical Center
Healthcare Matrix: Care of Patient(s) with Stroke
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
An Oracle Database is being
built that will collect data from
each cell and allow analysis
and reports to be generated
by:
INTERPERSONAL AND
COMMUNICATION
SKILLS
Institution
Department
Diagnosis
IOM Aim
Competency
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
Excel Spreadsheet for Matrix Analysis
Student ID
3
19
4
18
Aims
Competencies
Content
Diagnosis
Primary Code
(positive, negative,
^improvement)
Secondary Code
Safe
Professionalism
Decisions were made based
on accepted algorithms and
consensus within the team.
Timely
Interpersonal
Communication
skills
Delays in communication
increased the time it took to
get an initial head CT and
begin treatment.
Pregnancy
Intracerebral
Hemorrhage
negative
Teamwork
Practice-Based
Learning &
Improvement
We could have taken the time
to do a better initial H&P to
better discern what his
condition was like at initial
presentation to compare it to
discharge condition
Stroke
^improvement
Care Plan
System-based
Repeated imaging and brain
biopsies were unnecessary.
Reduce switching of primary
neurologists to avoid repeat
testing.
Celiac Sprue
negative
EBM
Interpersonal
Communication
skills
This patient spoke Spanish.
Skilled interpreters were not
available. Medical students
and family were used often as
interpreters which was not
ideal.
Hydrocephalus
negative
Translators
Medical Knowledge
Team took the time to know
the patient and her desire for
treatment.
Lung Cancer with
Brain Mets
positive
Effective
Efficient
12
Equitable
2
PatientCentered
Vanderbilt University Medical Center
Stroke
positive
EBM
Matrix as “Front Door”
to Data and Education
Vanderbilt University Medical Center
Healthcare Matrix: Care of Patient(s) with Stroke
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Cost per
discharge
Outcomes
by race,
gender, SES
Pt and family
satisfaction
data
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
FMEA
Events
Time
Studies
MEDICAL KNOWLEDGE
(What must we know)
Outcomes
data
Evidence
based
Order sets
Data linked
directly to cells in
the Matrix
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Process
Flowcharts
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
Healthcare Matrix: Care of Patient(s) with Stroke
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Cost per
discharge
Outcomes
by race,
gender, SES
Pt and family
satisfaction
data
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
FMEA
Events
Time
Studies
MEDICAL KNOWLEDGE
(What must we know)
Outcomes
data
Evidence
based
Order sets
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Process
Flowcharts*
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
Link to Web
based
Education
How to Flowchart a Process
• On-line web site for Improvement
education
http://mot.vuse.vanderbilt.edu/mt322
(Dr. Quinn’s current course being redesigned for
managers and physicians)
Vanderbilt University Medical Center
On Transformation:
“And one should bear in mind that there is
nothing more difficult to execute, nor more
dubious of success, nor more dangerous
to administer than to introduce a new
system of things; for he who introduces it
has all those who profit from the old
system as his enemies, and he has only
lukewarm allies in all those who might
profit from the new system.”
Machiavelli
Vanderbilt University Medical Center
Healthcare Matrix
Summary Points:
•
Is a framework for integrating competencies into
existing educational activities
•
Provides a new mental model for Clinicians analyzing
patient care
•
Facilitates use of “resident performance data as the
basis for improvement”
•
Encourages use of “external quality measures to verify
resident and program performance levels”
Vanderbilt University Medical Center
Thank You!
Vanderbilt University Medical Center
Implementation of
Healthcare Matrix
Vanderbilt University Medical Center
Internal Review Questionnaire
Core Competencies
1. How does your program provide education that
develops patient care practice that is
compassionate, appropriate and effective?
How effective is that training?
1
Not
effective
2
Somewhat
effective
Vanderbilt University Medical Center
3
Moderately
Effective
4
Effective
5
Very
effective
Implementation
Internal Review Process:
– Analyze responses to competency
questionnaire and discuss with program
director; suggest improvements if needed
– Provide information on competencies and
use of Matrix
– Offer to assist in the integration of
competencies in M&M and case
conferences, etc.
Vanderbilt University Medical Center
Implementation
• Introduction to Matrix: Program Director or
Dept. Chairs invite us to do lecture or Grand
Rounds to introduce competencies and Matrix.
• Using the Matrix:
– Attend M&M or case conferences as observers
– Note the discussion on a blank Matrix
showing which cells/competencies were
discussed and which were omitted
– Send Matrix to program director and discuss
next steps
Vanderbilt University Medical Center
Implementation
• Residents and the Matrix:
– Residents fill in Matrix on their own
– Best to let them struggle a little with the competencies
as they think about care of their patient
– Get someone (coach) to review Matrix with them
– If the situation/case is difficult, Dept Chair, Program
Director and mentors may assist with filling out Matrix
and presentation
• Helpful hint:
– Find a “coach” to help residents. At the outset, we work
with the residents and faculty. Then Chief residents or
interested faculty take the lead. Sometimes nurses can
be coaches such as in Psychiatry at VU.
Vanderbilt University Medical Center
7/2001
6/2002 7/2002
Phase I
• Define specific
objectives for
residents to
demonstrate
learning of the
competencies.
• Begin integrating
the teaching and
learning of
competencies into
residents’ didactic
and clinical
experiences.
6/2006
Phase II
7/2006
6/2011
Phase III
• Improve the
evaluation
processes for all
six of the
Competencies.
• Use resident
performance
data as the
basis for
improvement.
• Provide
aggregated
resident
performance
data for Internal
Review Process.
• Begin to use
external quality
measures to
verify resident
and program
performance
levels.
Vanderbilt University Medical Center
7/2011
Beyond
Phase IV
• Identify
benchmark
programs.
• Involve
community in
building
knowledge
about good
GME.
Research Agenda to Validate Matrix
(Based on Kirkpatrick, Evaluation of Training, 1994)
• Does the Matrix provide a useful framework
for teaching and evaluating the performance
of clinicians around the competencies?
• Phase I of ACGME :
– Define objectives for learning
– Begin integrating the teaching and learning of
competencies into didactic and clinical
educational experiences
Vanderbilt University Medical Center
Research Agenda to Validate Matrix
• What are we learning about the care
(columns) and education (rows) from
completed matrices?
• Phase II of ACGME:
– Improve the evaluation processes for all six of
the Competencies
– Provide aggregated resident performance data
for Internal Review Process
Vanderbilt University Medical Center
Research Agenda to Validate Matrix
• Are the behaviors of clinicians changing
based on their completion of practicebased learning and improvement?
• Phase III of ACGME:
– Use resident performance data as the basis
for improvement
– Begin to use external quality measures to verify
resident and program performance levels
Vanderbilt University Medical Center
Research Agenda to Validate Matrix
• Are the processes and outcomes of care
improving?
• Phase III of ACGME:
– Begin to link clinical quality indicators and
patient surveys with education
• Phase IV of ACGME:
– Adapt and adopt generalizable information
about emerging models of excellence.
Involve community building knowledge
about good GME.
Vanderbilt University Medical Center
Learning Core Competencies
Evaluation of
Evaluation of
Residents (2006) Tools (2011)
Care of Patient with ……
AIMS
Safe
Timely
Effective
Efficient
Suggested
Tools based
on Matrix
data
Equitable
Competencies
PatientCentered
Assessment
Patient Care
Medical
Knowledge
Interpersonal
Communication
Skills
Based on matrices for a
dept or diagnosis, which
evaluation tools best fit
the need?
Professionalism
System-based
Practice
Improvement
Practice-based
learning and
Improvement
Information Technology
Vanderbilt University(Dr.
Medical
Center provided the idea for this graph)
Paul Batalden
Appropriate
tools?
Learning Core Competencies
Evaluation of
Evaluation of
Residents (2006) Tools (2011)
Care of Patient with ……
AIMS
Safe
Timely
Effective
Efficient
Suggested
Tools based
on Matrix
data
Equitable
Competencies
Appropriate
tools?
PatientCentered
Assessment
Patient Care
Medical
Knowledge
Interpersonal
Communication
Skills
Are the evaluation tools
appropriate and
providing useful data?
Professionalism
System-based
Practice
Improvement
Practice-based
learning and
Improvement
Information Technology
Vanderbilt University(Dr.
Medical
Center provided the idea for this graph)
Paul Batalden