teaching for quality (te4q) january 12, 2014 university of california, san francisco
TRANSCRIPT
Teaching for Quality (Te4Q)
January 12, 2014
University of California, San Francisco
Introduction & Background: why Te4Q?
Faculty
Dave Davis, MD
Senior Director, Continuing Education and Improvement, Association of American Medical Colleges, Washington, DC
Jennifer S. Myers, MD FACP FHM
Associate Professor of Medicine Director of Quality & Safety Education; Associate DIO for Quality, GME Perelman School of Medicine, University of Pennsylvania Philadelphia, PA
Participants & Projects: what’s brought you here?
Getting the ideaDeveloping an educational innovation in Quality
Improvement/Patient Safety
Participant & Project introductions..
Name Faculty Role Project Aim/Goal Learners
the patient’s perspective
The clinical care gap
The National view:Dartmouth Atlas 2010 - HbA1c data
The TeQ Report: Why Teachingfor Quality?
The Te4Q Vision:Quality
Improvement is core to what it means to be a
physician
aamc.org/te4q
Te4Q Recommendation
“Every academic health center will have a critical mass of faculty ready, able and willing to engage in, role model, and teach about patient safety and the improvement of health care”
AAMC’s response:The Te4Q Faculty Development Program
Moving ‘QI/PS savvy’ clinicians to expert QI educators
Clinical faculty as: Teachers Curriculum developers Evaluators, competency assessors Educational Quality Improvers Change Agents Leaders Role Models Mentors/peer advisers
The Te4Q Faculty Development Certificate Program
Pre-Requisite: some knowledge of QI/PS Self- & Organizational-Readiness Assessments Pre-reading Skill Building Workshop QI Educational Project w/presentation in 3 mo. Community of Practice Dissemination of Work—Presentation or
Publication Certificate
Te4Q Workshop Objectives
Address an identified gap in the education of students, residents, and/or practicing clinicians regarding quality improvement and patient safety
Design an educational innovation to fill that gap Effectively implement the initiative Assess the impact of the innovation on learners and
the larger community Enable and lead educational and organizational change
Workshop Agenda
Introductions
Adult Learning and Educational Principles
Identify Gaps
Learner Levels/Competencies
Educational Program Goals and Objectives
Interprofessional Education
Educational Design: effective formats for learning
Reflection & Feedback
Developing QI/PS Content (JM)
Frameworks for Teaching Quality
What to Teach
Teaching & Learning in the Clinical Environment
Workshop Agenda, cont’d Assessing the Impact I
Learner Assessment Formative vs Summative Feedback
Assessing the Impact II Program Evaluation
Reflection & Feedback
Making the Case & Leading Change Culture & the Hidden Curriculum Creating a Strategy for producing change Developing and implementation strategy
Dissemination and Next steps
16
Thank You
Section I:Adult Learners:
setting goals, achieving competency in QI/PS
Knowing Your Learner: Who are they? What are the core and supportive competencies in QI/PS?
Assessing your own learning needs
In time…developing effective educational goals and learning objectives based on your learners needs
SOI Knowledge
Subject Matter
Knowledge – Clinical
Medicine
Subject Matter Knowledge: Knowledge basic to the things we do. Professional knowledge: our clinical, educational, and/or research expertise
Knowledge
of Education
Knowledge of education: Knowledge of adult learning principles, curriculum development, learner assessment, etc.
We Have a Lot of These People
We Have Some of These People
Knowledge of Education
Subject Matter Knowledge – Clinical Medicine
Great
Teach
ers
Knowledge of Education
We Have a Lot of These People
Subject Matter Knowledge – Clinical Medicine
SOI Knowledge
Science of Improvement: Knowledge of the theories of systems, variation, measurement, and psychology.
We Don’t Have a Lot of These People
SOI Knowledge
Subject Matter Knowledge
Improvement occurs when we combine subject matter knowledge and the science of improvement in creative ways to
develop effective ideas for change and then execute them using proven quality improvement methods.
Impro
vem
e
nt
We Have a Precious Few Number of These People
Creating Quality & Safety Educators
Subject Matter Knowledge – Clinical Medicine
Knowledge of Education
SOI Knowledge
Quality & Safety
EducatorsWe Do Not Have Enough of These
People
What Type of Faculty Are Interested in Teaching Quality & Safety?
Education Role QI/PS Role No Formal Role0
10
20
30
40
50
60
70
80
2012
2013
2014
* Quality and Safety Educators Academy – Attendee Roles
Concepts of Competence: what do we want our learners
to do? To ‘look like’?
Competency is defined as the observable behavior that combines knowledge, skills, values, and attitudes related to a
specific activity
Meet Dr Zadowski
Emily Z is a 3rd year Internal Medicine resident.
She meets you in Emerg to discuss Jim Halton, a 72 yr old male with congestive heart failure. He needs re-admission, has increasing symptoms of CHF (weight gain, increasing SOBOE, orthopnea) - the result of inadequate care in his last admission.
You and she review the notes from his admission and discharge last week – including nursing and other professional notes. You use the chart to stimulate her observations about quality this case and others like it.
Is she competent in Quality? What questions would you think to ask?
Medical Knowledge Patient Care Interpersonal Communication Professionalism Systems-based Practice Practice-based Learning and Improvement
Common competencies:the ACGME/ABMS Framework
In the Beginning…
The Mirror:Practice Based Learning & Improvement
The Village:Systems-Based Practice
What Kind of Doctor Does our Health System Need?
Frank, et al. Lancet. 2010. 376: 1923-57.
Old Model
New Model
Teamwork & Professionalism
Knowledge
Skills
Attitudes
Quality Safety
QI methods, Measurement,& Tools
Safety Tools: RCA, FMEA
Safety Principles Error Types Human Factors
Leadership & Change Management
Safety Culture
Error Reporting
Evidence-Based MedicineHealth Information Technology
IOM
SafeTimelyEfficientEffectivePt centeredEquitable
Stewardship
Value
Myers, Tess, et al. Am J Med Qual. 2013
The checklist: Te4Q QI/PS “Proficient” Competencies
Critically evaluate and apply current healthcare information and scientific evidence for patient care
Systematically analyze practice using quality improvement methods and demonstrate improvements in practice
Working effectively in health care delivery settings, including identifying system issues and improving them
Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care
Participate in identifying system errors and implementing potential system solutions (patient safety)
Work in interprofessional teams to enhance patient safety and improve patient care quality
Dreyfus Model: Novice Expert Dreyfus and Dreyfus, 1982
Developmental Stages in QI/PS
Level Training Level Example
Novice Pre-Clinical medical student
• Introductory lectures, web exercises• Group work on case studies in QI/PS
Advanced Beginner
Clerkship Student or Sub-Intern
• Students apply concepts (e.g., RCA) in a “project” at the academic health center•Teacher is model and “coach”
Competent Residency & Fellowship
• Apply concepts to his or her own panel of patients in interprofessional team
Proficient Fellowship & Early practice
• Regularly review and improve care for patients
Expert Advanced practice/faculty
• Develop novel ways to understand and improve systems of care
Two Types of Faculty Development
*All Faculty are clinical teachers and role models for the residents
Quality and
Safety Educat
ors
Formal
Curriculum
Type 1: Expert Type 2: Proficient
Leading Experiential Activities or
Immersion Activities
Our Trainees Need Both
All Faculty*
Informal Curriculum
Faculty Learners: Skills We’d Like to Build
Proficient (Type 1) Expert (Type 2) MasterCore knowledge of QI/PS
Common language
Doing basic improvement in practice
Modeling QI/PS principles with learners
Prepared as a good improvement team member
Participating in MOC Part IV
Other attributes…..
Proficient, plus…
Increased experience in QI/PS projects (eg. lead)
Leader in education and curricular implementation
Able to create experiential and didactic learning activities for students, residents, others
Able to understand and measure learner progress
Expert, plus…
Curricular reform and/or clinical leadership roles related to QI/PS
Scholarship in QI/PS
Career focus in QI/PS
Te4Q
A Look at Your Self Assessments
• What is YOUR stage of development in QI/PS?• What are your strengths• Which skills need development?
Knowing the TeacherSelf-Reflection Exercise:
Proficient Expert MasterCore knowledge of QI/PS
Common language
Doing basic improvement in practice
Modeling w/learners
Prepared as good improvement team member
Participating in MOC Part IV
Proficient, plus…
Increased experience in QI/PS projects (eg. lead)
Leader in education and curricular implementation
Able to create experiential and didactic learning activities for students, residents, others
Able to understand and create metrics to assess learner progress
Expert, plus…
Curricular reform and/or clinical leadership roles related to QI/PS
Scholarship in QI/PS
Career focus in QI/PS
Think About Your Project
Your Primary Learner(Who Is Teaching? )
Your Secondary Learner(Who Is Learning?)
KnowledgeType
Subject Matter
Science of Improve-
ment
EducationalPrinciples
Subject Matter
Science of Improvement
UMEProficient
-> Expert
? ? Novice Novice
GME Proficient -> Expert
? ?Advanced Beginner -> Competent
Novice -> Advanced Beginner
CPD Proficient -> Expert ? ?
Proficient -> Expert ?
Knowing your LearnersTeam Think - Share• Who are your faculty learners?
• What is their stage(s) of learning in the science of improvement? in educational principles?
• Based on the above, what are their educational needs?
1. GOAL/AIM: What is the gap or problem you want to address through your educational program? What are the Quality Improvement/Patient Safety competencies you want your learners to exemplify at the completion of your educational program? 2. OBJECTIVES: What are the learning objectives? Use the term ‘performance expectation’ to guide you here. What do you want learners to do after the activity?
Think SMART: specific, measurable, actionable, relevant and time bound 3. EDUCATIONAL DESIGN: What learning methods/formats will you use? Develop 2-3 bullet points to outline your educational idea, project or innovation and what QI/PS content you want to include. 4. LEARNER ASSESSMENT: How will you assess your learners? What methods will you use to assess what your learners have accomplished? 5. PROGRAM EVALUATION: How will you evaluate your initiative? How will you know its impact and how it might be improved? 6. IMPLEMENTATION: How will you implement your project/innovation? Who will be your partners? What resources will you need? From whom will you need ‘buy-in”? How confident are you that you will be able to complete your project?
7. DISSEMINATIONDissemination Plan: How will you report your project to a larger audience? eg. Poster, presentation, publication.
BREAKand evaluations
Adult learning Section II:
Creating effective educational program and innovations
the program planning cycle goals/objectives
effective educational interventions
Quality Cycle
Kern: Curriculum Development for Medical Education 2009
1. Problem Identification
& Needs Assessment
1. Problem Identification
& Needs Assessment
2. Goals & Objectives2. Goals & Objectives
3. Educational Strategies
4. Implementation
5. Evaluation & Feedback
Educational Planning Cycle
Comparing Educational Planning with Quality Improvement
Adapting problem and aim statement from QI/PS: Developing Goals & ObjectivesWe’ve identified our problem and level of learner, and now….
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| 43
Creating a Problem Statement• Commonly used in both
Academic and Quality / Performance Improvement methodologies.
• Should meet the following criteria:
• Focused only on one problem• Only one or two sentences long• Should not suggest a solution• Unambiguous and devoid of
assumptions
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Taking Aim
| 44
• Aim statements are very specific declarations of what a team will be focusing on as they strive to improve a process or a system.
• They should include a few elements:
• The system to be improved and the population
• A numerical goal (preferably an ambitious “stretch” goal)
• A timeframe
Your need/problem/goal
Goals/Objectives: Make them SMART
1. First, a stem…• After completing the seminar, residents will be able to…. • After this unit, the medical student will have . . .• By completing the Year 3 curriculum, the health professional
student will….. • At the conclusion of the course/unit/study the learner will . .
2. Next, add an action verb• Use verbs from Bloom’s taxonomy list • Determine the actual product, process, or outcome….
Creating Educational Objectives
http://www.educationoasis.com/curriculum/LP/LP_resources/lesson_objectives.htm
Interface of Learning Objectives and Teaching Strategiescase studies
projectsexercises
projects critiquesproblems simulations
case studies appraisalscreative exercises
problems develop plans EVALUATIONexercises constructs appraise
case studies simulations assessexercises critical incidents choosepractice discussion SYNTHESIS estimate
demonstrations questions arrange evaluatequestions projects test collect judgediscussion sketches compose measure
review simulations ANALYSIS construct ratetest role play analyze create revise
assessment microteach calculate design scorereports compare formulate select
lecture learner APPLICATION contrast organize valuevisuals presentations apply criticize managevideo writing demonstrate debate planaudio dramatize diagram prepare
examples COMPREHENSION employ differentiate proposeillustrations describe illustrate distinguish set upanalogies discuss interpret experiment
Cognitive Processing Dimension
explain operate inspect→ KNOWLEDGE express practice inventory define Identify perform question
list recognize schedule relate record restate shop test
Learning Objectives
repeat translate sketch use
Adapted from: Bloom, B.S. (Ed.), Engelhart, M.D., Furst, E.J., Hill, W.H., & Krathwohl, D.R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook 1: Cognitive domain. New York: David McKay.
Ellen F. Goldman, EdD 11-1-2010
Bloom’s Taxonomy
Goal/Aim: After the full QI/PS course, 25% of all Internal Medicine and Medicine-Pediatric residents will complete a longitudinal QI project with general internal medicine faculty
AVOID CHOOSE• Vague verbs
“Know how to …” Explain, describe, discuss• General terms Be as specific as possible
Example of Program/Activity Objective
Examples of Learner Objective
Not so good: At the end of this session, the resident will understand quality improvement methodologies….
Suggestions for Improvement:
Better…
After completion of this course, learners in that course will be able to:
define Root Cause Analysis* (RCA); recognize which clinical situations require RCA; explain why RCA is important; demonstrate mutual respect on interprofessional
teams; and have performed an interprofessional mock RCA.
**a determination of the factors, processes and problems leading to an error or care gap
Your Te4Q Educational InitiativeTeam Think – Share:• Define/refine your learning objectives for your QI/PS
Initiative.• Share one of your objectives with us, your “consultants”
Interface of Learning Objectives and Teaching Strategiescase studies
projectsexercises
projects critiquesproblems simulations
case studies appraisalscreative exercises
problems develop plans EVALUATIONexercises constructs appraise
case studies simulations assessexercises critical incidents choosepractice discussion SYNTHESIS estimate
demonstrations questions arrange evaluatequestions projects test collect judgediscussion sketches compose measure
review simulations ANALYSIS construct ratetest role play analyze create revise
assessment microteach calculate design scorereports compare formulate select
lecture learner APPLICATION contrast organize valuevisuals presentations apply criticize managevideo writing demonstrate debate planaudio dramatize diagram prepare
examples COMPREHENSION employ differentiate proposeillustrations describe illustrate distinguish set upanalogies discuss interpret experiment
Cognitive Processing Dimension
explain operate inspect→ KNOWLEDGE express practice inventory define Identify perform question
list recognize schedule relate record restate shop test
Learning Objectives
repeat translate sketch use
Adapted from: Bloom, B.S. (Ed.), Engelhart, M.D., Furst, E.J., Hill, W.H., & Krathwohl, D.R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook 1: Cognitive domain. New York: David McKay.
Ellen F. Goldman, EdD 11-1-2010
Bloom’s Taxonomy
Developing Educational Strategies & Methods
Principles and Methods
What the theory of adult learning tells us..
Comfort/respect
Experience: (Kolb) build on learner’s
experience
Relevance: to current status, roles
Engagement: role play, simulations
Reflection: (Schon) on past
experience, errors,
prevention
What the research tells us
Physicians and others not self-aware: objective needs assessment, performance feedback important
Knowledge necessary but not sufficient for change; didactics lousy at changing performance
What works? Interactivity; sequencing; predisposing, enabling and reinforcing strategies
‘CPD’ > conferences; = practice-based tools (reminders, audit-feedback, protocols & training)
Docs pass through stages of learning: awareness, agreement, adoption to adherence
…Cochrane reviews, AHRQ/EB reviews, others
Large Group: Interactive Lecturing
Active participation: e.g.,
think-pair-share Lecturer=facilitator, docent,
group leader Widespread use of case, problems, vignettes NOITE: the Flipped classroom: reading and learning
before the session with application of knowledge at the session.
Generally 7-10 learners Uses case-based materials to stimulate discussion
• A patient safety issue, e.g., wrong site surgery and a subsequent RCA or fishbone exercise
• A communication error in a team• Other…your own
Requires clear learning objectives, expectations of full participation
May use a tutor (expert or non-expert), or be self-led
Very useful for team development
Small Group Problem-Based Learning
Experiential LearningReal-world experience
- Handoffs- M&M conferences- Rounds- Bedside/Clinic
Simulations- Role play- Standardized
patients- Simulation labs- Cases- Computerized/
games
LEAN thinking
TeamSTEPS Microsystem planning
Process mapping
Fishbone diagrams
The five why’s
Using an Tool BoxQuality Improvement Tools
Root cause analysis
Educational
http://patientsafetyed.duhs.duke.edu/module_b/module_overview.html
Other Siteshttps://depts.washington.edu/toolbox/errors
www.aamc.org/initiatives/cei/te4Q
Methods useful in Staging Learning – e.g., changing the culture of quality in the workpace Examples using the Pathman/PRECEED model
Stage/Method Awareness Agreement Adoption Adherence
Predisposing LectureNewsletterGrand roundsMeetings
Enabling ChampionsSmall group discussionLeadership buy-inPeer buy-in
WorkshopsTraining sessionsSimulationMentorship, coachingQuality projects
Reinforcing Role-playFeedback in practiceMentorship
RemindersAudit/FeedbackCelebration of achievements
Teach Dr Zadowski
Emily Z is a 3rd year IM resident.
She meets you in Emerg to discuss Jim Halton, a 72 yr old male with congestive heart failure. He needs re-admission. You and she review the notes from his admission and discharge last week – including nursing and other professional notes. You use the chart to stimulate her observations about QI/PS this case and others like it.
How would you prepare her and her classmates for practices which focus on quality improvement and patient safety? What educational programs, experiences and other education can you create?
Core Entrustable Professional Activities for Entering Residency (CEPARs)
• EPA 13: Identify system failures and contribute to a culture of safety and improvement
• EPA 8: Give or receive a patient handover to transition care responsibility
• EPA 9: Collaborate as a member of an interprofessional team
1. GOAL/AIM: What is the gap or problem you want to address through your educational program? What are the Quality Improvement/Patient Safety competencies you want your learners to exemplify at the completion of your educational program? 2. OBJECTIVES: What are the learning objectives? Use the term ‘performance expectation’ to guide you here. What do you want learners to do after the activity?
Think SMART: specific, measurable, actionable, relevant and time bound 3. EDUCATIONAL DESIGN: What learning methods/formats will you use? Develop 2-3 bullet points to outline your educational idea, project or innovation and what QI/PS content you want to include. 4. LEARNER ASSESSMENT: How will you assess your learners? What methods will you use to assess what your learners have accomplished? 5. PROGRAM EVALUATION: How will you evaluate your initiative? How will you know its impact and how it might be improved? 6. IMPLEMENTATION: How will you implement your project/innovation? Who will be your partners? What resources will you need? From whom will you need ‘buy-in”? How confident are you that you will be able to complete your project?
7. DISSEMINATIONDissemination Plan: How will you report your project to a larger audience? eg. Poster, presentation, publication.
Section III:
Applying the Content of QI/PS to educational program and innovations
Teaching Quality Can Feel Like This
What to teach ?
Will the Residents “buy-in”?…
With what time ?
Who will teach ?
Will the Faculty “buy-in”? even “show up”?
How to teach ?
Where is the Curriculum Guide?
Outline
How Can This Content be Organized?• Educational Frameworks
What to Teach? • Quality & Safety Content
How to Teach?• Strategies for Effective Teaching of Quality & Safety
Our Reality: The “Middle Place”
Undergraduate & Graduate Medical
Education in quality and safety is still highly variable
Patien
t Saf
ety
Qua
lity Im
prov
emen
t
Inpa
tient
Han
doffs
Discha
rge
Trans
itions
High V
alue
Cost C
onsc
ious C
are
0
20
40
60
80
100
QSEA 2012 QSEA 2013 QSEA 2014 Penn Fall 2013
Progress Has Been Slow
Medical Knowledge Patient Care Interpersonal Communication Professionalism Systems-based Practice Practice-based Learning and Improvement
Common competencies:the ACGME/ABMS Framework
Some Content Outlines
http://www.aacn.nche.edu/education-resources/ipecreport.pdfhttp://qsen.org/http://www.ihi.org/education/ihiopenschool/Pages/default.aspxhttp://www.who.int/patientsafety/education/curriculum/EN_PSP_Education_Medical_Curriculum/en/
Quality & Safety in the ACGME Milestones
Good News:
…they mostly all say the same thing
Bad News:
…each specialty chose their own language to describe their target competencies in:
• Systems-Based Practice• Practice-Based Learning & Improvement• Interpersonal & Communication Skills • Professionalism
Example: Surgery Systems-Based Practice Milestone
This resident makes suggestions for changes in the healthcare system that may improve patient care.
This resident reports problems that could produce medical errors.
This resident participates in groups or PI teams designed to reduce errors & improve health outcomes
SBP Milestones for a Graduating ResidentMedicine Surgery Emergency Med
Efficiently coordinates activities of team members to optimize care
Coordinates activities of health care professional team to provide optimal care at time of discharge…
Coordinates system resources to optimize patient care for complicated medical situations.
Identifies and advocates for safe care and optimal systems
Makes suggestions for health system improvement
Leads team reflections such as de-briefings, RCAs, or M&M to improve team performance
Activates formal system resources to investigate or mitigate error
Reports problems with technology or processes that could result in medical error
Identifies situations when breakdowns in teamwork or communication could lead to medical error
Participates in PI teams designed to reduce errors and/or improve care outcomes
Participates in an institutional PI project to optimize ED practice
Advocates for cost-conscious utilization of resources & incorporates these principles
Understands appropriate use of standardized approaches to care & contributes to them
Practices cost effective care
The Milestones are mostly all at the “Does” Level
Miller’s Pyramid for Learner Assessment
Outline
How Can This Content be Organized?• Educational Frameworks
What to Teach? • Quality & Safety Content
How to Teach?• Strategies for Effective Teaching of Quality & Safety
Teamwork & Professionalism
Knowledge
Skills
Attitudes
Quality Safety
QI methods,Measurement,& Tools
Safety Tools: RCA, FMEA
Safety Principles Error Types Human Factors
Leadership & Change Management
Safety Culture
Error Reporting
Evidence-Based MedicineHealth Information Technology
IOM
SafeTimelyEfficientEffectivePt centeredEquitable
Stewardship
Value
Myers, Tess, et al. Am J Med. 2013
Teach Dr Zadowski
Emily Z is a 3rd year IM resident.
She meets you in Emerg to discuss Jim Halton, a 72 yr old male with congestive heart failure. He needs re-admission. You and she review the notes from his admission and discharge last week – including nursing and other professional notes. You use the chart to stimulate her observations about QI/PS this case and others like it.
How would you prepare her and her classmates for practices which focus on quality improvement and patient safety? What educational programs, experiences and other education can you create?
Safety & Quality Are Connected
Safety event
Quality Improvement Opportunity
Afferent Arm
Efferent Arm
One Safety Event or Quality Problem:Two Pathways For Teaching & Learning
Preventable Adverse Event, Near Miss, Quality Problem
Patient Safety
Methods
QI Methods
Retrospective Analysis Prospective Improvement
What Should We Review?Both? Neither?
Patient Safety Methods Model for human error Hierarchy of Improvement Plans Cause-Effect Diagramming Event Reporting/Safety Culture
QI Methods Framing & scoping the
problem FOCUS-PDSA Process Mapping &
Observation Root Cause Tools Aim statements Measuring for Quality
Only Two Strategies to Eliminate Errors
• Find and fix systems problems
• Plug up the “holes” in the swiss cheese
• Mitigate and absorb the natural human error rate
• Promote safety behaviors and culture
How Do Errors Happen?
EVENT ofHARM
Reason, Managing the Risks of Organizational Accidents, 1997
Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”)
BLUNT END
LATENT ERRORSAre inherent properties of the system that allow or “set up” the individual to fail
SHARP END
ACTIVE ERRORS are made by individuals
Blunt vs SharpActive vs Latent
Fishbone (Cause & Effect) Diagram
Why has roomturnover
time increased?
People Place
Policies Processes
EFFECT
CAUSES
• Structured team brainstorming
• Represents relationship between some effect and all of the possible causes influencing it
Five WhysEnvironmental Services Taking Longer to Clean rooms1st Why? New specialized room sterilization 2nd Why? High rates of resistant organisms3rd Why? Some staff less familiar with the process4th Why? No standardized training process for part-
time, temporary staff
Weak Actions: Signs
Intermediate Actions: Beeping
Strong Actions: Swipe card only
How do you prevent customers from leaving their ATM cards behind?
Hierarchy of Improvement Plans
Ranking the Effectiveness of Error-Reduction Strategies
Most Effective (Strong)
– Forcing functions and constraints– Automation and computerization– Standardization and protocols– Checklists and double-check systems– Rules and policies– Education and information– Exhortation: “Be more careful. Be vigilant.”
Least Effective (Weak)
Gosbee JW, Gosbee LL, eds. Human Factors Engineering to Improve Patient Safety.
Oakbrook IL: Joint Commission Resources 2005
One Safety Event or Quality Problem:Two Pathways For Teaching & Learning
Preventable Adverse Event, Near Miss, Quality Problem
Patient Safety
Methods
QI Methods
Retrospective Analysis Prospective Improvement
How I Used to Do Quality Improvement
Different Quality Improvement Methodologies: Similar Principles…All Foreign to Healthcare
A3 Diagram
FOCUS Before You Begin PDSA CyclesD E F I N E
F I N D
Problem Statement (from patient’s/customer’s viewpoint): (10 points)
Concise. Customer- focused. Addresses the business case. Shows why a change is needed. Background Provides background for the problem statement (1-3 paragraphs with a minimum of 3
references using APA reference format. Why is this problem important? Who is interested in it (nationally and/or locally) and why? Is there evidence behind this being a problem in healthcare? If so, provide a summary of that evidence. [note: this item will be handed in typewritten, attached to your paper A3]
Target Condition: (10 points)
Your target condition will move you towards delivering exactly what the customer wants, closer to IDEAL. You identify at least one process, outcome, and balancing measure for your proposed project. You have a clear aim statement, and your process and outcome metrics are expressed as S.M.A.R.T. goals.
P L A N A N D
D O
I M P R O V E
Propose and Test Countermeasures: (10 points)
Each countermeasure is clearly related to a root cause in the previous section. For each countermeasure, state how you will DO the tests - What, When and by Whom.
M E A S U R E
O R G A N I Z E
C L A R I F Y
Current Condition: (20 points)
There is evidence that you did your “Go and See”. The section is rich with data. Data is presented graphically – bar charts, run charts, or SPC charts are
preferred. You have at least one process map (Value-stream, flow chart, spaghetti diagram). The metric(s) you are trying to move are clearly identified. Baseline/pre-test metrics are presented here.
Must consider at least one potential process, outcome, and balancing metric You have completed a stakeholder analysis and attached it to your paper A3.
Metrics/Results: (10 points)
If a test of change has been implemented, the S.M.A.R.T. goals are restated and results presented as data. Data should be in a run chart or a statistical process control chart (note: this is not required for successful completion of the project for class; some students may not have this item completed yet; see next bullet)
If a test of change has not been implemented, describe which countermeasure you have chosen to test first and why.
Reflect on What You Have Done and Learned so Far in Improvement work: (10 points) Write a 1-3 paragraph reflection on what you learned by going through this process. What was most challenging and why? What surprised you most and why? What do you think is your biggest challenge going forward? [note: this will be handed in typewritten attached to your A3]
CH E CK
or
S T U D Y
C O N T R O L
A N A L Y Z E
U N D E R S T A N D
S E L E C T
Root Cause Analysis: (20 points)
You use a relevant root cause tool. (5 Whys, Fishbone, Pareto). Must use at least one tool, though you may need more than one for a deep analysis.
Your choice of which root cause(s) to tackle is supported by the data in the Current Condition section – i.e. the data validates that you have identified the true root cause(s) and have chosen the right one(s) to work on first.
Make it Standard Work (Implement Successful Countermeasures): While this step is not required for this class, be aware that failing to execute this step is extremely common in healthcare. Skipping this step is usually the root cause for failing to sustain improvements after attention has moved on to the next project. You should think about how you might implement a successful countermeasure and sustain any improvements.
A C T
Executive Sponsor Initial Approval (signature and date): Not required for this class – but never do a real project without this!
Executive Sponsor Final Approval (signature and date): Not required for this class – but never do a real project without this!
FOCUS Find – Problem StatementOrganize – Current ConditionClarify – Current ConditionUnderstand – Root Cause ToolsSelect - Root Cause Tools…beginning to select and think of countermeasures that match the root cause(s)
Propose and Test Countermeasures
PDSAPlan – Plan your 1st Test of ChangeDo – “Do” the ChangeStudy – Track your results (metrics) and
compare them to your predictionsAct – Reflect on the test and decide what to
do next…i.e. second test of change, 3rd, test of change, eventually implement
Outline
How Can This Content be Organized?• Educational Frameworks
What to Teach? • Quality & Safety Content
How to Teach?• Strategies for Effective Teaching of Quality &
Safety
Building Bridges: Linking Educational Activities With Health
System Improvement Efforts
Sound Familiar? “Our hospital is struggling with the over-utilization of labs and we have had 2 RCAs on medication errors at discharge. We just found out that the GME office is starting QI education at the program level and neither of these topics was prioritized. Why doesn’t anyone talk to each other around here?” - Chief Quality & Safety Officer
“We have an incident reporting system, but I am pretty sure the nurses are the only ones who use it. The
residents don’t know who reads them so are scared to report. We also don’t see the faculty reporting so why
would we bother? We are busy enough.”
- Resident
“We cannot get a departmental QI project off the ground because we can’t get the baseline data, let alone set up a process for ongoing measurement and evaluation.”.
-Associate Program Director
Aligning Our Missions
Residents as Common End Point
Operational Quality/Safety Goals:Trainees as Front line providers
Educational goals: Trainees as learners
Residents as Common End Point
Operational Quality/Safety Goals:Trainees as Front line providers
Educational goals: Trainees as learners
Barriers to Alignment and Capability are Deeply Entrenched
More Barriers
• Discontinuous trainee involvement
- Impedes the concept of ongoing system improvement
• Difficulties in scheduling and implementing essential team-based interprofessional learning and improvement
‒ Simulation the default
• Failure to rush provide real-time data for improvement to the front-line
• Lack of faculty trained in point-of-care experiential, inter-professional learning techniques and improvement science methods
• Tortuous and painful promotional pathway and reward structure for such faculty
Slide adapted with permission from Don Goldmann MD, IHI
Will Require Shared Responsibility:New Relationships, Roles, and Work
Trainees
Infrastructure, Shared Work Plan
OversightCentralized resources
Curriculum development,Teaching,Mentorship
Daily supervision, role modeling, & practice enforces local quality/safety culture
Core QI/PS
Faculty
Frontline Faculty & All
Staff
Tess, Vidyarthi, Yang, Myers [In Press]
“Top 5 List” for Healthcare Organizations That Wish to Achieve Excellence in Teaching for Quality
#1. Select Educational Content that aligns with health care system needs
“ Top-Down” vs “Bottom-Up” Approach to Project Selection
106
ENGAGEMENT Involve faculty and staff as partners with patients and families to achieve goals of care.
Penn Medicine will improve the health of our patients and assure safe care.
CONTINUITY Deliver seamlessly coordinated care across all settings and service lines.
VALUE Provide high quality, efficient care and the best outcomes for all patients.
Resident Project Selection Aligns with a Clinical Microsystem QI Need
Resident Unit QI Topic Career Path
I.L. Gen Med Discharge Med Rec Endocrine & CHIPS* fellow
M.P. MICU Post-Intubation Checklist RWJ Scholar
I.W. CCU FMEA Door to Balloon Time Cardiology Fellow
M.A. L & D Safety Culture and Team Debriefings Urogyn Fellow
H.G. Emerg Dept Communication: Neurology & ED Academic Emerg Med
S.G. Medicine Clinic Screening Colonoscopy Rates Primary Care
Patel, Brennan, Myers, et al. Acad Med. 2014
*Center for Healthcare Improvement & Patient Safety, UPenn
#2: The Education Must Be “Hands-On”
• Real cases for quality improvement & patient safety learning– Dissect a near miss or preventable adverse event using root cause tools– Use a current quality problem to:
• Define and scope the problem• Write a specific aim statement• Identify process, outcome, and balancing measures• Identify root causes and select countermeasures
• Real data for QI review– What type of data?
• Healthcare associated infections• Patient satisfaction scores• Readmission rates• Test utilization • Other?
Data Matters
You Need to Consider:How will I get these cases?
How/where will I get this data?
For this hands-on education, need to determine the relative value of these goals -- to improve care right now, to teach someone to improve care, or both?
Examples of Each from Penn
• Improve care right now:– On the general medicine teaching services, we have committed
to including the nurse in bedside rounds
• Teach someone to improve care– 3rd year Penn Medical, Nursing, and Pharmacy students reflect
upon and dissect a preventable adverse event together using root cause analysis tools
• Do Both– 2nd year Penn internal medicine residents each review one of
their own 30-day readmissions looking for opportunities for improvement to feed back to the Dept of Medicine Readmission task force
– Role Modeling
#3. The Educators Must…. Make Connections for the Trainees
One success factor for trainee QI projects is faculty mentors who have local system knowledge and deep
connections within the organization*
Ogrinc G, et al. Academic Medicine, 2014
What are we connecting the trainees to?
Residents & FellowsInfrastructure
Data
People in our Organization
Creating Quality & Safety Educators
Subject Matter Knowledge – Clinical Medicine
Knowledge of Education
SOI KnowledgeConnections
within their health system
Quality & Safety Educators
Assume trainees know nothing (and I mean nothing)
about managing a project longitudinally and running meetings
#4 Use a Common Language
• Make the “jargon” UCSF-branded jargon• Takes awhile, but begins to catch on• Helpful for teaching across the continuum and
sharing of educational materials
#5 Look for Every Opportunity to Make Teaching & Learning Interprofessional
• Teaching about Health care delivery and improvement is a natural IPE topics
• IP Quality & Safety Grand Rounds• By definition, QI projects are interprofessional
Break: Apply the 5 Tips to Your Project
Select Educational Content That Aligns With Organizational Health Care Needs
“Hands-On” EducationEducators Making Connections For TraineesUse a Common LanguageMake it Interprofessional Whenever Possible
1. GOAL/AIM: What is the gap or problem you want to address through your educational program? What are the Quality Improvement/Patient Safety competencies you want your learners to exemplify at the completion of your educational program? 2. OBJECTIVES: What are the learning objectives? Use the term ‘performance expectation’ to guide you here. What do you want learners to do after the activity?
Think SMART: specific, measurable, actionable, relevant and time bound 3. EDUCATIONAL DESIGN: What learning methods/formats will you use? Develop 2-3 bullet points to outline your educational idea, project or innovation and what QI/PS content you want to include. 4. LEARNER ASSESSMENT: How will you assess your learners? What methods will you use to assess what your learners have accomplished? 5. PROGRAM EVALUATION: How will you evaluate your initiative? How will you know its impact and how it might be improved? 6. IMPLEMENTATION: How will you implement your project/innovation? Who will be your partners? What resources will you need? From whom will you need ‘buy-in”? How confident are you that you will be able to complete your project?
7. DISSEMINATIONDissemination Plan: How will you report your project to a larger audience? eg. Poster, presentation, publication.
#6: Remember that all formal curriculum has a parallel “hidden” curriculum…
…more on this tomorrow!
“QI”