Patient Safety & Quality Improvement in
Graduate Medical Education
Ariane Marie-Mitchell, MD, PhD, MPHPreventive Medicine & Pediatrics
October 24, 2013
OUTLINE
I. What do all residents need to know about PSQI
II. What resources are available to learn about PSQI
III. How can residency programs integrate training in PSQI
Training physicians to participate in Quality Improvement is a positive trend in health care.
A. Strongly AgreeB. AgreeC. Somewhat AgreeD. NeutralE. Somewhat DisagreeF. DisagreeG. Strongly Disagree Stro
ngly Agree
Agree
Somewhat Agre
e
Neutral
Somewhat Disa
gree
Disagree
Strongly
Disagree
77%
23%
0% 0%0%0%0%
THECOMMONWEALTH
FUND
0.6 0.6 0.6
0.5
0.4
0.3
0.1
0.00.0
0.1
0.2
0.3
0.4
0.5
0.6
France* Germany UnitedStates*
UnitedKingdom*
Canada** OECDMedian
Netherlands NewZealand**
Deaths Due to Surgical or Medical Mishaps per 100,000 Population, 2006
Source: OECD Health Data 2008, “June 2008.”
* 2005**2004
THE COMMONWEALTH
FUND
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
AUS CAN GER NETH NZ UK US
OVERALL RANKING (2010) 3 6 4 1 5 2 7
Quality Care 4 7 5 2 1 3 6
Effective Care 2 7 6 3 5 1 4
Safe Care 6 5 3 1 4 2 7
Coordinated Care 4 5 7 2 1 3 6
Patient-Centered Care 2 5 3 6 1 7 4
Access 6.5 5 3 1 4 2 6.5
Cost-Related Problem 6 3.5 3.5 2 5 1 7
Timeliness of Care 6 7 2 1 3 4 5
Efficiency 2 6 5 3 4 1 7
Equity 4 5 3 1 6 2 7
Long, Healthy, Productive Lives 1 2 3 4 5 6 7
Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
Exhibit ES-1. Overall Ranking
PSQI IS ABOUT HOW TO PRACTICE MEDICINE
LLUMC Physician LoungePSQI
www.lluphysicianlounge.com/psqi/• Overview• Faculty• Introduction to PSQI• Advanced Practice of PSQI• Models for Integrating PSQI into GME• Selected References
Introduction to PSQICore Competencies
Practice Based Learning and Improvement (how good is my practice?)• Use QI methods to analyze practice and implement changes
Systems Based Practice (how good is the health care system?)• Advocate for quality patient care and optimal patient care
systems• Work in inter-professional teams to enhance patient safety and
improve quality• Participate in identifying system errors • Use QI methods to implement system solutions
Introduction to PSQILearning Objectives
Patient Safety• Know the scope of medical errors and main types • Distinguish between error and harm • Use voluntary reporting systems to report errors and
near-misses • List key methods for reducing errors • Use key communication skills including SBAR (Situation,
Background, Assessment, Recommendation), briefings, read-backs, and CUS (Concerned, Uncomfortable, Safety)
• Describe a root cause analysis • Structure an effective apology
Introduction to PSQILearning Objectives
Quality Improvement• List six dimensions of quality health care• Describe how U.S. health care system compares to others • Create a specific aim statement • Select outcome, process and balancing measures • Select appropriate measures of change • Use PDSA (Plan, Do, Study, Act) cycles • List key differences between QI and research • Understand basics of sampling methods for QI • Create and use key QI tools • Understand the basics of spread and diffusion
Does your program require residents to complete any IHI Open School Modules during training?
A. YesB. NoC. ConsideringD. Don’t know
Yes No
Considerin
g
Don’t know
50%
17%17%17%
Does your program require residents to participate in an Improvement Project using QI methods?
A. YesB. NoC. ConsideringD. Don’t know
Yes No
Considerin
g
Don’t know
73%
0%
18%9%
My program has enough faculty to mentor residents on an Improvement Project using QI methods.
A. Strongly AgreeB. AgreeC. Somewhat AgreeD. NeutralE. Somewhat DisagreeF. DisagreeG. Strongly Disagree Stro
ngly Agree
Agree
Somewhat Agre
e
Neutral
Somewhat Disa
gree
Disagree
Strongly
Disagree
21%
29%
21%
14%
7%
0%
7%
Introduction to PSQIOnline Learning
IHI Open School (Institute for Healthcare Improvement) • Patient Safety – 101-105 meet objectives or ~6 hours (2 required pre-intern)• Quality Improvement- 101-104 meet objectives or ~4 hours
Alternatives• Mayo Clinic Quality Academy• AMA Introduction to Practice of Medicine
Introduction to PSQIDidactics
See “Selected References- PSQI Education” • WHO Patient Safety Curriculum• University of Chicago Medical Center Internal
Medicine Quality Curriculum
Introduction to PSQIPractice-Based Learning Project
Key Steps• #1 Identify a Faculty Mentor• #2 Describe your Professional Opportunity• #3 State your Aim • #4 Diagram a Cause-Effect Analysis• #5 Define your Measures• #6 Conduct an Evidence Review• #7 Collect Baseline Data• #8 Test a Change (repeat tests until outcome achieved)
Improvement Projects
Practice-Based Learning• Data source = your patient
encounters• Change focuses on your
practice behaviors
Systems-Based Practice• Data source = your clinical
microsystem• Change requires team effort
Describe Cause-Effect AnalysisUse Evidence
Collect and Study DataTest Changes
PBL Project Example
• Professional Opportunity: Underuse of influenza vaccination in my adult patients
• Aim Statement: “I will increase my influenza vaccinations rate to 80% in my eligible adult patients age 18-64 by December 30, 2013”
• Evidence Review: ACIP Vaccine Recommendations for 2013
PBL Project Example: Cause-Effect Diagram
Materials
PhysicianPatients
Vaccine availability
I know the guidelines
Vaccine Record_
Processes
InfluenzaVaccination
Rate Vaccination rate
I remember to order_Contraindicated
Nurse Schedule
Declined
Insurance coverage I effectively counsel
PBL Project Example (cont’d)• Outcome measure =
# patients age 18-64 who received influenza vaccination /total # eligible patients age 18-64 seen during time period
• Process measures = – Proportion missed opportunities to order– Proportion orders declined
• Balancing measures =– Proportion patient complaints re: billing
PBL Worksheet
LET’S PRACTICE:1. Obtain a PBL Worksheet at your table2. Draft items #2-53. Discuss with others at your table
TIME ~ 10 minutes
How many total hours are dedicated in your current curriculum to learning PSQI?
A. None (any PSQI is outside regular work hours)
B. Less than 1 hour per month (<12 hours per year)
C. More than 1 hour per month but <1 hour per week
D. About 1 hour or more per week None (a
ny PSQ
I is outsi
d...
Less
than 1 hour per m
on..
More than 1 hour p
er m...
About 1 hour o
r more p..
25%
13%
38%
25%
Models for Integrating PSQI into GME
Pre-Residency Model• Complete IHI Open School Certification
Intern Model• Complete IHI Open School Certification OR monthly
didactics• Improvement Project, conducted by small groups,
mentored by faculty from clinic during monthly meetings• Improvement Project final presentations at Grand Rounds
Models for Integrating PSQI into GMEOne Block ModelPGY1/PGY2• Complete IHI Open School Certification OR monthly didactics
PGY3• One month long rotation including ~24 hours of scheduled time
– Didactic sessions related to PSQI– Review and presentation of patient cases at quality assurance or
mortality review committee meetings– Serve as auditors in bi-weekly hospital wide Joint Commission
Accreditation mock surveys– Improvement Project, identified and completed by individual
residents, presented at end of month OR year
Models for Integrating PSQI into GME
Two Block ModelPGY2 e.g. during 2 months of ambulatory care• Weekly meetings for didactics or development of
Improvement Project- first PDSA cycle
PGY3 e.g. during 2 months of ambulatory care• Weekly meetings for didactics or continuation of
Improvement Project- second PDSA cycle
Models for Integrating PSQI into GMELongitudinal Model PGY1: • IHI Patient Safety modules and Readings• PBL Project, conducted over 6 months, mentored by faculty, presented
by individual residents at noon conferencePGY2:• IHI Quality Improvement modules and Readings• SBP Project, join existing team and conduct over 12 months, mentored
by faculty, presented by group at Grand Rounds at end of the yearPGY3:• IHI Quality Improvement/Leadership modules and Readings• SBP Project, lead QI team over 12 months, mentored by faculty,
presented by group at Grand Rounds at end of the year
SUMMARY• See our PSQI website
www.lluphysicianlounge.com/psqi/– Learning Objectives– Online Resources– Project Guidance– Models for Integrating PSQI into GME
• Encourage senior residents to participate in the Advanced Practice of PSQI Concentration
Physician participation in Patient Safety and Quality Improvement initiatives…
is Good Medicine
The one thing to teach about PSQI
