pbrns - learning communities

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  • 1. Can Family Medicine Become a Learning Community? James W. Mold, M.D., M.P.H. Department of Family and Preventive Medicine University of Oklahoma Health Sciences Center - OKC

2. Objectives

  • Introduce the idea of a learning community and explain why Family Medicine is well-positioned to become one
  • Propose a sliding scale for evidence
  • Discuss the role of practice-based research networks
  • Point out some challenges and unanswered questions

3. Four Stories and a Joke

  • Mark Gregory, Okarche, Oklahoma
  • The Great Harvest Bread Company
  • Cystic fibrosis
  • Cooperative extension
  • The man with the frog on his head
  • If youve heard this story before, dont stop me. Id like to hear it again.Groucho Marx

4. A 1960s Perspective

  • Just because weve always done it that way doesnt mean its the best way to do it.
  • Were all in this together.
  • We can make the world a better place.
  • Each of us can have an impact.
  • If we work together, we can achieve anything.
  • Dont trust anyone over 30

5. In a Small Town (the first story)

  • Okarche, Oklahoma1998
  • It doesnt help when the QIO comes in, audits my charts, and tells me what a lousy job I am doing.If they would tell me who is doing a good job, maybe I could talk with them and find out how to do it better.
  • Mark Gregory, M.D.

6. Whats the best way to

  • Manage laboratory test results?
  • Deliver preventive services?
  • Improve my care for patients with diabetes?
  • Handle prescription refills?
  • Help patients remember to bring their medications with them to appointments?
  • Help overweight patients lose weight and keep it off?
  • How would you approach these questions?

7. What Mark Didnt Say

  • If they would just tell me:
  • What the literature says I should do.
  • What the specialists say I should do.
  • What the guidelines say I should do.
  • What my academic colleagues say I should do.
  • What CME resources are available.

8. Performance Distributions

  • Virtually always present
  • Wider than you would expect
  • Within practices and between practices
  • High performers are oftennotthe usual suspects
  • Highest performers in one area arent necessarily the highest performers in other areas
    • Some true exemplars (quest for excellence)

9. 10. 11. 12. 13. 14. What Exemplars Know

  • Principles
  • Techniques
  • Scripts
  • Often dont realize what they are doing differently or even that they are exemplars.

15. Diabetes

  • Exemplar Principles
  • Diabetes visits every 3 months
  • Label charts
  • Use teamwork, protocols
  • Use a registry
  • Choose one eye specialist
  • Flow sheet (?)

16. DM Pilot Study

  • 30 (non-exemplar) clinicians
    • Taught exemplar principles
    • Provided with:
    • Practice facilitator
    • PDA-based registry
  • High rate of acceptance of principles. No disagreements.
    • Mean of 4/6 principles implemented

17. Quality of Care Indicators

  • A1c:87%96%p=0.0003
  • UA protein:53%64%p=0.05
  • Lipid Panel:69%80%p=0.02
  • Foot Exam:71%82%p=0.004
  • Retinal Exam:48%59%p=0.04
  • Pneumo:42%61%p=0.0006
  • ACEI for BP:72%86%p=0.03
  • ACEI for prot:53%64%p=0.05
  • Paired t-tests; physician as unit of analysis

18. Best Practices Research

  • Whats the best way to do x ?
  • Identify the steps or components of x
  • Define best
  • Find exemplars for each component
  • Figure out what they do
    • Principles
    • Techniques
    • Scripts
  • Put pieces back together and test them
  • Mold JW and Gregory ME.Best practices research.Family Medicine 2003; 35(2): 131-134.

19. Lab Test Management

  • Track results to be sure they come back to chart
  • Notify patients of results
  • Document patient notification
  • Assure that patients with abnormal results get follow-up they need

20. Lab Test Management

  • Wide range of methods used for each step
  • 92% of clinicians within the same practice used different methods to notify their patients
  • Half of clinicians who said they were very satisfied with their systems were exemplars.(Half were not.)
  • Combined best method works extremely well
  • Cost: $5.19 per patient
  • Mold JW et al. Management of Laboratory Test Results in Family PracticeJFP (2000)49(8):709-715

21. Where Are You Little Star?

  • Identifying exemplars:
  • Show of hands
    • Simple, cheap
    • Lots of false positives and false negatives
  • Audit everyone (external)
    • Time consuming
    • Accurate
  • Self-assessment (internal)
    • Possible middle ground?

22. Bread and Butter

  • The Great Harvest Bread Company
  • Freedom franchisees must:
  • Use the grain chosen by the company
  • Grind the grain in the bakery
  • Give away samples of bread
  • Share their successful innovations and discoveries with other franchisees
  • Bread and Butter: What a bunch of bakers taught me about business and happiness by Tom McMakinSt. Martins Press, New York, NY

23. Cystic Fibrosis

  • For 45 years, the Cystic Fibrosis Foundation has kept track of the outcomes of every cystic fibrosis child cared for in the 117 cystic fibrosis centers around the U.S.By agreement with the centers, the data is kept confidential.
  • In 2003, average life expectancy of people with cystic fibrosis was 33.In the top performing center it was 47.
  • At the median CF center, the average FEV1 was 75% of normal.At the top center it was 100% of normal.
  • Qawande, A. The bell curve.New Yorker, Dec 2004

24. Come a Little Bit Closer

  • Exemplar methods:
  • Very high expectations (e.g. normal FEV1)
  • Patient involvement (e.g. anticipatory chest PT)
  • Creative solutions to treatment challenges (e.g. electronic chest PT machine)
  • Aggressive medical management

25. Beans in Their Ears

  • Reactions of non-exemplary (academic) centers:
  • There must be something different about the patient populations
  • There must be something different about the environment (air quality/pollution)
  • No randomized controlled trials

26. Here in the Real World 27. The Times They are Changing

  • Interdependency
  • Interdiscipinary
  • Teams/Teamwork
  • Networks
  • Collaboratives
  • Centers/Institutes
  • Think tanks
  • Multi-national
  • World economy
  • Internet
  • E-mail
  • Google
  • Amazon
  • eBay
  • Blogs
  • YouTube
  • My Space
  • Idol

28. Bits and Pieces

  • IHI Learning Collaboratives
  • Contact, Help, Advice, and Information Networks (CHAINs)
    • http://chain.ulcc.ac.uk/chain/about.html
  • The Leapfrog Group
  • VA best practices QI Initiatives
  • Regional Health Information Organizations
  • IOM Report:The Learning Healthcare System
  • NC Community Care

29. Communities of Practice

  • Cultivating Communities of Practiceby Wenger, McDermott, and Snyder; Harvard Business School Press, 2002
  • Requirements:
  • Domain (topic area or areas) - Creates common ground and sense of common identity
  • Community Creates the social fabric of learning (relationships based on respect and trust)
  • Practice (collective knowledge set) Set of frameworks, tools, styles, language, stories

30. Communities of Practice

  • Principles:
  • Design for evolu