Teaching QI at University of Chicago


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Presented at Association of American Medical Colleges Integrating QI meeting in Chicago, IL June 2010. Chronicles journey incorporating QI education for students, residents, faculty, and allied health professions.

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  • 5:20 VA 15:00 JO 21:30 LV 27:09 VA
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  • Good afternoon, I am Dr. Lisa Vinci and I will be presenting the results of a curriculum that we use to teach internal medicine residents quality improvement at the University of Chicago. The title of my presentation is the Effect of a Quality Assessment and Improvement Curriculum on Resident Knowledge and Skill in Improvement
  • The residents complete 2 one month blocks over a year. The course meets weekly for 90 min session. Brainstorm ideas kind of vague and confusing – brainstorm ideas for potential improvement areas…
  • To compete the practice improvement module – 5 charge for compliance with recommended preventive care measures, survey 5 of their pts about the quality of care they receive in the clinic, and complete a systems review of clinic structure and organization …..the residents review the data and chooses an area for improvement Using the PDSA cycle the design, implement and measure the effect of a small QI project.
  • Animate in slides, simplify language Block 3 as one group --
  • Account for the effect of accumulation experience
  • These are the results of the self assessment of QI skill. We report the percent of residents who rated themselves as very to extremely comfortable with various QI tasks. As you can see the post curriculum PGY2 residents rated their skills as markedly higher in all tasks. Consider showing a graph – so not as busy P-values - * for <.01, ** for <.001 Change % to in the column with pgy2 pre etc.
  • As you can see there were statistically significant differences in the QI knowledge scores between the pre and post PGY2 group and between the post curriculum PGY2 group and the PGY3 controls. Color problem
  • We faced several challenges in designing the curriculum. To address time constraints we held the sessions during the ambulatory block. Each of the 4 faculty were able to run any given session, many sessions were team taught. We lacked a practice assessment tool. Fortuntely the ABIM PIMs were adapted for use in GME around the this time. We are fortunately to have Vinny Arora who has a lot of experience in evaluation of educational interventions, and Julie Johnson who has an extensive background in QI. We tried to engage the residents by allowing them to pick their own projects. We sought to optimize feasibility by working on 3 projects in groups
  • Teaching QI at University of Chicago

    1. 1. Techniques and Tools for Integrating Quality and Patient Safety Education across the Continuum: The University of Chicago Journey Vineet Arora, MD, MAPP, Julie Oyler, MD, Lisa Vinci, MD Association of American Medical Colleges Integrating Quality: Linking Clinical and Educational Excellence Meeting June 3-4, 2010 (Chicago, IL)
    2. 2. Outline of Our Journey <ul><li>Early Beginnings & Guiding Principles </li></ul><ul><li>Teaching Quality to Residents : Quality Assessment & Improvement Curriculum (QAIC) </li></ul><ul><li>Spreading to Faculty & Other Clinical Departments: Quality Scholars Program </li></ul><ul><li>Creating Student Leaders & Lessons Learned </li></ul>2004- 2006- 2008- 2009-
    3. 3. Teaching QI at University of Chicago <ul><li>STRENGTHS </li></ul><ul><li>Structure of UME and GME under one roof </li></ul><ul><li>Located on an undergraduate campus with graduate programs in health administration </li></ul><ul><li>Culture of scholarship in medical education </li></ul><ul><ul><li>Funding for innovation </li></ul></ul><ul><li>Small institution </li></ul><ul><li>CHALLENGES </li></ul><ul><li>Limited faculty expertise </li></ul><ul><li>Lack of allied health professional schools (i.e. pharmacy, nursing, etc.) </li></ul><ul><li>Small faculty </li></ul><ul><li>Focus on biological sciences </li></ul><ul><li>Clinical quality infrastructure developing </li></ul>
    4. 4. Early Beginnings 2004-2006 <ul><li>IHI Health Professions Collaborative </li></ul><ul><li>Networked with other faculty who teach QI / safety </li></ul><ul><li>Attended IHI meetings </li></ul><ul><ul><li>Learned basics of QI/Safety </li></ul></ul><ul><ul><li>Learned of the importance of interprofessional learning </li></ul></ul>Linda Headrik, U Missouri Greg Ogrinc, Dartmouth Julie Johnson, U New South Wales Vineet Arora, MD MAPP Caitlin Schaninger, MS4 Mary Johnson, MSW at the IHI Forum
    5. 5. Principles in Teaching QI <ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    6. 6. Principles in Teaching QI <ul><li>Core Components </li></ul><ul><li>Developing Aim Statement </li></ul><ul><li>Choosing measures </li></ul><ul><li>Process mapping </li></ul><ul><li>Plan-Do-Study Act </li></ul><ul><li>Sustainability & Spread </li></ul>SMART AIMS S - Specific M - Measurable A - Attainable R - Relevant T - Timely <ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    7. 7. Principles in Teaching QI <ul><li>Core Components </li></ul><ul><li>Developing Aim Statement </li></ul><ul><li>Choosing measures </li></ul><ul><li>Process mapping </li></ul><ul><li>Plan-Do-Study Act </li></ul><ul><li>Sustainability & Spread </li></ul><ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    8. 8. Principles in Teaching QI <ul><li>Core Components </li></ul><ul><li>Developing Aim Statement </li></ul><ul><li>Choosing measures </li></ul><ul><li>Process mapping </li></ul><ul><li>Plan-Do-Study Act </li></ul><ul><li>Sustainability & Spread </li></ul><ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    9. 9. Principles in Teaching QI <ul><li>Core Components </li></ul><ul><li>Developing Aim Statement </li></ul><ul><li>Choosing measures </li></ul><ul><li>Process mapping </li></ul><ul><li>Plan-Do-Study Act </li></ul><ul><li>Sustainability & Spread </li></ul><ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    10. 10. Principles in Teaching QI <ul><li>Core Components </li></ul><ul><li>Developing Aim Statement </li></ul><ul><li>Choosing measures </li></ul><ul><li>Process mapping </li></ul><ul><li>Plan-Do-Study Act </li></ul><ul><li>Sustainability & Spread </li></ul><ul><li>Team-based projects that are driven by learners with faculty guidance </li></ul>
    11. 11. Teaching Residents Quality Improvement Lessons Learned from the Quality Assessment & Improvement Curriculum (QAIC) 2006- present
    12. 12. Curricular Development <ul><li>Review of ACGME PBLI & SBP requirements </li></ul><ul><li>Identified suitable time in residency training </li></ul><ul><ul><li>PGY2 and 3 ambulatory blocks </li></ul></ul><ul><li>Creation of Lectures for Core QI Principles </li></ul><ul><li>Developed Evaluation Plan </li></ul><ul><ul><li>QIKAT </li></ul></ul><ul><li>Without EHR, mechanism to collect data for practice assessment needed </li></ul><ul><ul><li>Contacted ABIM to adapt PIM to residency program </li></ul></ul><ul><li>Obtained funding through internal competition for medical education grants </li></ul><ul><ul><li>Graduate Medical Education Funding </li></ul></ul>
    13. 13. Quality Curriculum Overview * Each block consists of four 90 minutes lecture/time slots Block 2 QI Project Develop and implement a small QI project with group of 10 residents Block 1 Quality Assessment Complete data collection for ABIM PIM PGY-2 Block 4 Quality Summary Pay for Performance and Hospital Quality Measures Block 3 Sustainability and Spread Measure project sustainability, complete PIM PGY-3 Ambulatory Block Winter/Spring (1 month*) Ambulatory Block Summer/Fall (1 month*) Residency Year
    14. 14. Blocks 1 and 2: Practice Improvement Modules Block 1 - Collect Data Review Report Block 2 - Plan to Improve Aim Statement Process Mapping Stakeholder interviews Test Change
    15. 15. Residents Return in Small Groups during PGY3 Ambulatory Block to Sustain Project Block 2 – Jan 2007 10 residents review baseline data, implement QI project & collect early post data e.g. documentation of smoking counseling Block 3 – August 2007 3 of 10 residents review early post data & develop a plan for sustainability e.g. developed referral process to smoking clinic Block 3 – October 2007 3 of 10 residents revise plan for sustainability & collect late post data e.g. revised referral process, educated staff Block 3 – December 2007 4 of 10 residents develop summary/poster of QI project and finalize project e.g. project presented at Hospital Quality Fair Block 1 – July 2006 10 residents complete CPS PIM and review data
    16. 16. PIMs at University of Chicago <ul><ul><li>July 2006 to May 2010 </li></ul></ul><ul><ul><li>94 IM Residents completed the 2 year curriculum </li></ul></ul><ul><ul><li>30 IM Residents currently participating </li></ul></ul><ul><ul><li>9 group QI projects completed to date; 3 projects in process </li></ul></ul><ul><ul><li>Clinical Preventive Services and Preventive Cardiology PIM’s used </li></ul></ul>Oyler, JL et al. JGIM, 2008 Vinci LM et al. QSHC-In press Got BMI?
    17. 17. Evaluation for QAIC: Pre-Post & PGY3 Historical Controls Using historical controls allows us to explore possibility that increased QI knowledge is the result of accumulation of resident experience (and not QAIC ) Pre - test Post - test PGY2 Historical Control PGY3 QAIC PGY2 pre vs. post PGY2 post vs. PGY3 control
    18. 18. Self-Assessment of QI Tasks: Pre-Post and Post vs. Historical Controls (PGY3) 93 89 89 93 86 82 96 89 96 89 96 96 pgy2 post- n=26 54 21 13 42 58 22 54 25 58 54 67 71 pgy3 control n=24 p values 0.001 0.001 26 Build next improvement 0.001 0.001 18 Identify how data is linked to processes 0.001 0.001 9 Use PDSA cycle 0.001 0.001 18 Implement structured plan to test a change 0.03 0.001 44 Identify best practice/ compare local practice 0.001 0.001 11 Use small cycles of change 0.001 0.001 32 Identify if a change leads to improvement 0.001 0.001 24 Make changes in a system 0.001 0.001 21 Study the process 0.001 0.001 41 Use measurement to improve 0.01 0.001 53 Apply the best professional knowledge 0.01 0.01 71 Write a clear aim pgy2 post vs pgy3 control pgy2 Pre- post pgy2 pre- n=26 % Residents reporting comfortable with QI task
    19. 19. Results- QIKAT P<0.001 P<0.001 Vinci, QSHC, in press Ogrinc, JGIM, 2004
    20. 20. Curriculum Feedback <ul><li>“ I gained skills to make me feel less frustrated and helpless within the system I work” </li></ul><ul><li>“ It is important to have an objective way to evaluate if a change is made” </li></ul><ul><li>“… .the ability to focus an aim and design and implement quality improvement projects in a measurable fashion” </li></ul>
    21. 21. University of Chicago Successes <ul><li>9 resident posters presented at national, regional, and local meetings </li></ul><ul><li>2 faculty publications on curriculum </li></ul><ul><li>1 resident publication submitted as a result of ABIM PIM curriculum </li></ul><ul><li>APDIM Educational Innovations Award 2008 </li></ul><ul><li>Midwest SGIM Innovation </li></ul><ul><li>Award 2009 </li></ul><ul><li>SGIM Clinical Innovations </li></ul><ul><li>Award 2009 </li></ul>
    22. 22. Teaching Quality Improvement Obtained funding through internal competition for medical education grants Funding Used historical control group Evaluation plan Solutions Challenges Choose their own projects for their clinic Resident engagement 3 team projects per year Feasibility of individual resident QI project Partner with faculty experienced in QI & evaluation Faculty expertise Use pre-existing tool- ABIM Practice Improvement Module Lack of practice assessment tools Ambulatory block Team of 4 faculty Time constraints for residents and faculty
    23. 23. Teaching the Teachers: Spreading to Faculty & Other Clinical Departments The Quality Scholars Faculty Development Course 2008-present
    24. 24. Quality Scholars: Curriculum <ul><li>Internal grant: </li></ul><ul><ul><li>Excellence in Clinical Care and Education Award </li></ul></ul><ul><li>Curriculum based on QAIC </li></ul><ul><ul><li>Aims </li></ul></ul><ul><ul><li>Process mapping </li></ul></ul><ul><ul><li>Choosing measure </li></ul></ul><ul><ul><li>PDSA cycles </li></ul></ul><ul><li>Course Structure </li></ul><ul><ul><li>6 faculty and 1 RN </li></ul></ul><ul><ul><li>Twice weekly for 1 month </li></ul></ul><ul><ul><li>Faculty brought projects to the group </li></ul></ul><ul><ul><li>Lunch! </li></ul></ul>
    25. 25. Quality Scholars: Faculty Projects <ul><li>Screening for delirium in geriatric inpatients </li></ul><ul><li>Increase pneumonia vaccination rates on the inpatient medicine service </li></ul><ul><li>QI curriculum for endocrinology fellows </li></ul>
    26. 26. Quality Scholars: Successes <ul><li>Endocrinology faculty taught improvement skills to Endocrinology fellows and faculty </li></ul><ul><ul><li>Designed and implemented a diabetes specific progress note </li></ul></ul><ul><li>Pediatrics faculty taught improvement skills to pediatrics residents and faculty </li></ul><ul><ul><li>Improved clinic process for completing age appropriate screening </li></ul></ul>
    27. 27. Quality Scholars: Challenges and Solutions Solutions Challenges Align people and projects with institutional goals Institution chosen vs faculty chosen projects Spread course over 6 months Intensity of course (8 sessions in 1 month) Spread course over 6 months/focus on educational value Need to produce scholarly work Obtain letter of support from chairmen Protecting faculty time
    28. 28. Quality Scholars: Pharmacists <ul><li>5 sessions with 5 inpatient pharmacists </li></ul><ul><ul><li>Recent pharm graduates have training in QI </li></ul></ul><ul><li>Project: </li></ul><ul><ul><li>Medication reconciliation at admission </li></ul></ul><ul><li>Challenging to work </li></ul><ul><li>outside own area </li></ul><ul><li>Highlights the need for </li></ul><ul><li>and challenge of interdisciplinary QI </li></ul>
    29. 29. Faculty QI Education Evolving <ul><li>Including faculty in resident QAIC </li></ul><ul><ul><li>Complete an ABIM PIM </li></ul></ul><ul><ul><ul><li>Learn basic QI skills </li></ul></ul></ul><ul><ul><ul><li>Meet ABIM Maintenance of Certification requirements </li></ul></ul></ul><ul><ul><li>Faculty bring clinical expertise </li></ul></ul><ul><ul><li>Aligns with departmental needs </li></ul></ul><ul><ul><li>Flexible and accessible (3 courses/year) </li></ul></ul><ul><ul><li>Efficient use of faculty time </li></ul></ul>
    30. 30. Expansion to Medical School Initially largely through student groups IHI Open School Chapter Improvehealth.org
    31. 31. Pritzker Initiative: Our Big Break <ul><li>Launched 2005 </li></ul><ul><ul><li>Created an opportunity for innovation via “blue sky” approach </li></ul></ul><ul><ul><li>Implemented Aug 2009 </li></ul></ul><ul><li>Scholarship & Discovery </li></ul><ul><ul><li>Research </li></ul></ul><ul><ul><ul><li>Basic, Clinical, Social Sciences </li></ul></ul></ul><ul><ul><li>Global Health </li></ul></ul><ul><ul><li>Community Health </li></ul></ul><ul><ul><li>Medical Education </li></ul></ul><ul><ul><li>AND…Quality & Safety Track </li></ul></ul>“ For medical education to flourish from one generation to the next, it has to reconfigure itself in response to changing scientific, social, and economic circumstances.” -Abraham Flexner Jordan Cohen, MD, former President, AAMC at launch of Pritzker Initiative
    32. 32. Components of QST (started Aug 2009) <ul><li>10 week Elective in QI Methods & Safety for first years </li></ul><ul><ul><li>Practical experience learning </li></ul></ul><ul><li>IHI Open School </li></ul><ul><ul><li>Online courses written by world-renowned faculty </li></ul></ul><ul><ul><li>Case studies, podcasts, videos, featured articles </li></ul></ul><ul><li>Clinical Training </li></ul><ul><ul><li>Department specific M&M/patient safety conferences  </li></ul></ul><ul><li>Mentored Projects </li></ul><ul><ul><li>Mentors with QI/safety interests identified </li></ul></ul><ul><ul><li>Students encouraged to seek them out </li></ul></ul><ul><ul><li>Start a mentored QI project during their 1 st year & finish prior to graduation </li></ul></ul><ul><ul><li>Funding for summer work </li></ul></ul><ul><ul><li>Dissemination at a local, regional or national conference </li></ul></ul>
    33. 33. Learn more about QST… <ul><li>From one of our medical students </li></ul><ul><li>Panel on Student and Resident-Led QI Initiatives </li></ul><ul><li>Marcus Dahlstrom </li></ul><ul><ul><li>Friday session </li></ul></ul><ul><ul><li>8:00-9:30am </li></ul></ul>
    34. 34. Lessons Learned <ul><li>Curricular change takes time </li></ul><ul><li>Persistence needed </li></ul><ul><li>Start small for an early win </li></ul><ul><li>Use that early win to get noticed </li></ul><ul><li>Scale up when ready </li></ul><ul><li>Support from leadership critical </li></ul><ul><ul><li>Moral & financial </li></ul></ul>
    35. 35. The Importance of a Good Team
    36. 36. Acknowledgements <ul><li>Marcus Dahlstrom, MSII, Co-Chapter Leader </li></ul><ul><li>Caitlin Schaninger, MSIV, Co-Chapter Leader </li></ul><ul><li>Megan Moore, GPHAP Student </li></ul><ul><li>Laura Botwinick, Director, Graduate Program Health Administration & Policy (GPHAP) </li></ul><ul><li>Gregg Kauffman, MSI, Soon-to-be Co-Chapter Leader </li></ul><ul><li>Holly Humphrey, MD, Dean of Medical Education </li></ul><ul><li>Jim Woodruff, MD, Internal Medicine Residency Director </li></ul><ul><li>Halina Brukner, MD, Associate Dean of Medical Education </li></ul><ul><li>Mike Simon, MD, Dean for Graduate Medical Education </li></ul><ul><li>Sandy Smith, PhD, Senior Learning Specialist </li></ul><ul><li>Lou Portugal, MD, Director of Quality for Department of Surgery </li></ul><ul><li>Andrew Davis, MD, Director of Quality for Department of Medicine </li></ul><ul><li>U of C RIME attendees </li></ul>
    37. 37. Questions or Copies of Materials… <ul><li>University of Chicago Quality Website for curriculum materials & articles </li></ul><ul><ul><li>http:// www.tinyurl.com / UChicagoQAIC </li></ul></ul><ul><li>For Quality Assessment and Improvement Curriculum Toolkit </li></ul><ul><ul><li>Email [email_address] . uchicago.edu </li></ul></ul>