Transcript (SBP) and Practice Based Learning and Improvement (PBLI)

CHAMP
Teaching on Today’s Wards
Session 3 – Systems Based Practice and
Practice Based Learning and Improvement
Chad Whelan, MD
Julie Johnson, PhD
Paula Podrazik, MD
Learning Objectives
• Describe the importance of teaching systems
based practice (SBP) and practice based learning
and improvement (PBLI)
• Improve comfort and skills in teaching and
evaluating SBP and PBLI
– Define systems-based practice
• Demonstrate how solutions to problems affect the system
– Define practice-based learning and improvement
• Demonstrate teaching and evaluation of this ACGME
competency
Learning Objectives
• Develop strategies for teaching these core
competencies in clinical settings
– Practice identifying triggers for teaching
systems based practice
– Learn about one model for improvement
– Choose an improvement topic
Agenda
10:00 – 10:25
10:25 – 10:50
10:50 – 11:00
11:00 – 11:25
11:25 – 11:45
11:45 – 11:55
11:55 – 12:00
Introduction to systems based practice and practice
based learning and improvement
Small group exercise – identifying teaching triggers
Debriefing
Introduction to practice based learning and
improvement and the PDSA Improvement Model
Group exercise – Selecting a topic for improvement
Debriefing
Final Comments and Take Home Points
ACGME/ABMS Core Competencies
• Patient Care
• Medical Knowledge
• Interpersonal & Communication Skills
• Professionalism
• Practice-based Learning & Improvement
• Systems-based Practice
What comes to mind
when I say “system”?
• Name a system that you are part of now,
or one you’ve been part of in the past
• What word comes to mind when you
think of that system?
System: A Definition
• A set of interacting, interrelated, or
independent elements that work together
in a particular environment to perform the
functions that are required to achieve a
specific aim
Bertalanffy, 1968
ACGME Elements
Systems-Based Practice
• Understand inter-relatedness of system
components
• Know how types of medical practice &
delivery systems differ regarding costs
& resource allocation
• Practice cost-effective health care
• Advocate for quality patient care
• Work with others to improve patient
care
ACGME Elements
Practice Based Learning and Improvement
• Analyze practice and perform improvement
activities
• Find and assimilate evidence related to patient
needs
• Use information about own patients to design
improvements for a population of patients
• Use information technology to manage
information
• Facilitate the learning of students and other
health care professionals
How are SBP and PBLI different?
• Systems-based practice
– Analytic tool, way of viewing the world that makes our caregiving and change efforts more successful
– Focus is understanding the interdependencies of a system or
series of systems
– Changes can be made and measured on the system
• Practice-based learning and improvement
– Focus is on reflection and change at the level of the provider or
group of providers and what they do in caring for their patients
– Goal is measurement as an aid to learning about and improving
practice
– Some changes can be made by provider, others require systemlevel intervention
How are SBP and PBLI different?
• SBP is like a village
– “A physician must work together with a
community of providers to deliver optimal
patient care”
• PBLI is like a mirror
– “Holding up a mirror to ourselves to
document, assess, and improve our practice”
Source: Ziegelstein & Fiebach, Acad. Med. 2004;79:83.
Sometimes it’s hard to separate the two
• How can I improve care for my patients or
my team’s patients?
– e.g., do a daily census audit of foley catheters
to reduce the inappropriate use
• How can I improve the system?
– e.g., build in a reminder so that all foley
catheters are automatically discontinued after
2 days, unless specific criteria are met
We Can Focus on the System at
Different Levels
Community,
Market, Social
Policy System
Self-care
System
Individual
care-giver &
patient System
Macroorganization
System
Microsystem
Method of Teaching SBP and PBLI Needs to
Address the Level of the Learner
• Dreyfus Model
Novice
Advanced
Beginner
Competent
Proficient
Expert
• Method of teaching has to be relevant to
the learner and grounded in the daily
work of caring for patients
Recognizing the Opportunity to Teach
Systems-based Practice in Residency
Training
• There are multiple opportunities to tease out the
system issues and talk about them, once we
recognize them
• This can be a Pandora’s Box – we need to assure
that the organization can support the
improvement work that will be required
– Organizational support
– Feedback on what is being done to address the issues
• Faculty are looking for methods, teaching tools,
etc. to make this easier
How Can We Identify Opportunities for
Teaching SBP?
• What are the triggers for teaching?
– Topics
– Transitions
– Failures
• Where do the triggers occur?
– Everywhere!!!
Triggers for Teaching about Systems
Location
Topic
Transition
Failures
Example
• Imagine this scenario
– Your team is post call, in conference room
getting a run-down on patients:
– 67 year-old male with chronic renal
insufficiency secondary to poorly controlled
hypertension admitted to initiate dialysis and
to get placed with a dialysis center
Triggers for Teaching about Systems
Location
Conference
Room
Topic
Cost,
burden of
hypertension
Transition
Process of
initiating
dialysis
Failures
Cost, burden of
uncontrolled
hypertension
Patient With ESRD (cont.)
• Bedside Presentation:
– Patient is admitted from ER for initiation of dialysis
– Although he has known he will need dialysis soon
(he already has access), he did not always show up
for his renal clinic appointments
– His blood pressure has been poorly controlled and he
does not always take his medications
– His social history is notable for his current IVDA. His
nephrologist was surprised at how quickly he
progressed over the past 6 months to the point where
he requires dialysis, although not emergently
– The patient was essentially admitted electively to
facilitate initiation of dialysis
Triggers for Teaching for Systems
Location
Conference
Room
Bedside
Topic
Cost, burden of
hypertension
Cost, burden of
drug rehab
Transition
Process of
initiating
dialysis
Compliance,
patient
preference in
initiating
dialysis
Failures
Cost, burden of
uncontrolled
hypertension
Admission process
through ER as a
“workaround” to
getting a dialysis
chair
Patient with ESRD (cont.)
• Post-Bedside Discussion:
– You agree with the team that there were no urgent
indications for dialysis
– Your team tells you that his nephrologist had a
difficult time getting the patient a chair as an
outpatient as he is poorly compliant and uses IV
drugs
– The nephrologist told the patient it would be
easier to go to the ER to get admitted to start
dialysis,
– At this point your team is obviously frustrated by
the events that got this patient admitted through
the ER to an acute hospital bed for something that
medically could have been done as an outpatient
Triggers for Teaching for Systems
Location
Conference
Room
Topic
Cost, burden of
hypertension
Bedside
Cost, burden of
drug rehab
Post-bedside
Contraindications for
dialysis
Transition
Process of
initiating
dialysis
Compliance,
patient
preference in
initiating
dialysis
PCP
communication
Failures
Cost, burden of
uncontrolled
hypertension
Admission process
through ER as a
“workaround” to
getting a dialysis
chair
Cost, burden of
dialysis
Small Group Exercise #1
• What are the triggers for teaching about
systems based practice in the case?
– Work in small groups
– Complete the Triggers for Teaching Matrix
Small Group Exercise #1
• Debriefing
• See handout on teaching systems based
practice
Take Home Points
• Systems issues are prevalent
• We tend to create elaborate processes to
“work around” the most problematic
system issues
• There are multiple opportunities to tease
out the system issues and talk about them,
once we recognize them
Take Home Points
• This can be a Pandora’s Box – we need to
assure that the organization can support
the improvement work that will be
required
• Faculty are looking for methods, teaching
tools, etc. to make this easier
• Observation is important -- what are the
system issues you have seen?
Practice Based Learning and
Improvement
• A more indepth look . . .
What Do We Need to Improve Care?
Professional Knowledge
Improvement Knowledge
• Subject
• System
• Discipline
• Variation
• Values
• Psychology
• Theory of Knowledge
+
Traditional
Improvement
of Health Care
Continual
Improvement
of Health Care
If you want to teach people a new way
of thinking, don’t bother trying to teach
them.
Instead give them a tool,
the use of which will lead to new ways
of thinking
- Buckminster Fuller
Plan, Do, Study, Act Cycle
A Model for Improvement
• The plan, do, study, act or PDSA cycle links
ideas to action and then makes the connection to
continuous learning
– It can be done at the individual level (e.g., changes
you want to make to your teaching process)
– It can be done at the team level (e.g., small
improvement pilots that you can guide your team
through in a 2-4 week timeframe)
Plan, Do, Study, Act Cycle
A Model for Improvement
• The PDSA cycle provides framework for
efficient trial-and-error learning
methodology
– Small changes can have a big impact (thing
about the effect on the system)
– Choose carefully
– Pilot test
Plan, Do, Study, Act Cycle
A Model for Improvement
Act
What changes
to make, spread,
& next cycle
Plan
Aim,who, what,
when & data
collection plan
Study
Do
Analyze, compare
to prediction, ID
lessons learned
Execute, collect &
analyze data, note
unexpecteds
Plan, Do, Study, Act Cycle
A Model for Improvement
• Plan
–
–
–
–
Describe objective and specific change
Specify where it fits into the process flow
Who, does what, when, with what tools and training
Data collection plan: who measures what and
displays how and where
• Do
– Carry out the change
Plan, Do, Study, Act Cycle
A Model for Improvement
• Study
– Make sure that you leave time for reflection about
your test
– Use the data and the experience of those carrying out
the test to
– Discuss what happened
– Did you get the results you expected? If not, why not?
– Did anything unexpected happen during the test?
Plan, Do, Study, Act Cycle
A Model for Improvement
• Act
– Given what you learned during the test, what
will your next test be? Will you make
refinements to the change? Abandon it? Keep
the change and try it on a larger scale?
PDSA Worksheet
• This worksheet for tracking PDSA cycles
that has been developed by the Institute
for Healthcare Improvement (IHI)
• See handout
Group Exercise
• Selecting a topic for improvement
– The work before the work . . .
Draft an initial list of priority
improvements
• Consider these questions:
• The clinical areas that really need
to be improved are __________________________
• The reason things don’t work
right around here is _________________________
• There’s one thing that we do all the time that accomplishes
very little and that’s _______________
– How would different people answer those questions?
(e.g., nurses, physicians, patients/family,
pharmacists, secretaries, etc.)
Draft an initial list of priority
improvements (cont.)
• Prioritize your list
– in order of descending achievable benefit not
yet achieved (ABNA) (1=highest ABNA)
– least cost to change (1=least costly)
– shortest time to get started (1=can get started
with a small test next week)
– greatest importance to inpatient medicine
wards (1=most important)
Finally, consider the
“ramp of complexity”
P
A
D
C
P
A
D
Complexity
C
P
A
D
C
Time
Based on the exercise, what are the
priorities?
• Improvement Priorities:
–
–
–
–
–
–
–
Homework
• Think about the topic(s) identified
– How would you assess the magnitude of the
problem?
– What data will you need?