Teaching QI at University of Chicago

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)

Outline of Our Journey
Early Beginnings & Guiding Principles
Teaching Quality to Residents : Quality Assessment & Improvement Curriculum (QAIC)
Spreading to Faculty & Other Clinical Departments: Quality Scholars Program
Creating Student Leaders & Lessons Learned
2004- 2006- 2008- 2009-

Teaching QI at University of Chicago
STRENGTHS
Structure of UME and GME under one roof
Located on an undergraduate campus with graduate programs in health administration
Culture of scholarship in medical education
Funding for innovation
Small institution
CHALLENGES
Limited faculty expertise
Lack of allied health professional schools (i.e. pharmacy, nursing, etc.)
Small faculty
Focus on biological sciences
Clinical quality infrastructure developing

Early Beginnings 2004-2006
IHI Health Professions Collaborative
Networked with other faculty who teach QI / safety
Attended IHI meetings
Learned basics of QI/Safety
Learned of the importance of interprofessional learning
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

Principles in Teaching QI
Team-based projects that are driven by learners with faculty guidance

Core Components
Developing Aim Statement
Choosing measures
Process mapping
Plan-Do-Study Act
Sustainability & Spread
SMART AIMS S - Specific M - Measurable A - Attainable R - Relevant T - Timely

Core Components
Developing Aim Statement
Choosing measures
Process mapping
Plan-Do-Study Act
Sustainability & Spread

Teaching Residents Quality Improvement Lessons Learned from the Quality Assessment & Improvement Curriculum (QAIC) 2006- present

Curricular Development
Review of ACGME PBLI & SBP requirements
Identified suitable time in residency training
PGY2 and 3 ambulatory blocks
Creation of Lectures for Core QI Principles
Developed Evaluation Plan
QIKAT
Without EHR, mechanism to collect data for practice assessment needed
Contacted ABIM to adapt PIM to residency program
Obtained funding through internal competition for medical education grants
Graduate Medical Education Funding

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

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

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

PIMs at University of Chicago
July 2006 to May 2010
94 IM Residents completed the 2 year curriculum
30 IM Residents currently participating
9 group QI projects completed to date; 3 projects in process
Clinical Preventive Services and Preventive Cardiology PIM’s used
Oyler, JL et al. JGIM, 2008 Vinci LM et al. QSHC-In press Got BMI?

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

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

Results- QIKAT P<0.001 P<0.001 Vinci, QSHC, in press Ogrinc, JGIM, 2004

Curriculum Feedback
“ I gained skills to make me feel less frustrated and helpless within the system I work”
“ It is important to have an objective way to evaluate if a change is made”
“… .the ability to focus an aim and design and implement quality improvement projects in a measurable fashion”

University of Chicago Successes
9 resident posters presented at national, regional, and local meetings
2 faculty publications on curriculum
1 resident publication submitted as a result of ABIM PIM curriculum
APDIM Educational Innovations Award 2008
Midwest SGIM Innovation
Award 2009
SGIM Clinical Innovations
Award 2009

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

Teaching the Teachers: Spreading to Faculty & Other Clinical Departments The Quality Scholars Faculty Development Course 2008-present

Quality Scholars: Curriculum
Internal grant:
Excellence in Clinical Care and Education Award
Curriculum based on QAIC
Aims
Process mapping
Choosing measure
PDSA cycles
Course Structure
6 faculty and 1 RN
Twice weekly for 1 month
Faculty brought projects to the group
Lunch!

Quality Scholars: Faculty Projects
Screening for delirium in geriatric inpatients
Increase pneumonia vaccination rates on the inpatient medicine service
QI curriculum for endocrinology fellows

Quality Scholars: Successes
Endocrinology faculty taught improvement skills to Endocrinology fellows and faculty
Designed and implemented a diabetes specific progress note
Pediatrics faculty taught improvement skills to pediatrics residents and faculty
Improved clinic process for completing age appropriate screening

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

Quality Scholars: Pharmacists
5 sessions with 5 inpatient pharmacists
Recent pharm graduates have training in QI
Project:
Medication reconciliation at admission
Challenging to work
outside own area
Highlights the need for
and challenge of interdisciplinary QI

Faculty QI Education Evolving
Including faculty in resident QAIC
Complete an ABIM PIM
Learn basic QI skills
Meet ABIM Maintenance of Certification requirements
Faculty bring clinical expertise
Aligns with departmental needs
Flexible and accessible (3 courses/year)
Efficient use of faculty time

Expansion to Medical School Initially largely through student groups IHI Open School Chapter Improvehealth.org

Pritzker Initiative: Our Big Break
Launched 2005
Created an opportunity for innovation via “blue sky” approach
Implemented Aug 2009
Scholarship & Discovery
Research
Basic, Clinical, Social Sciences
Global Health
Community Health
Medical Education
AND…Quality & Safety Track
“ 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

Components of QST (started Aug 2009)
10 week Elective in QI Methods & Safety for first years
Practical experience learning
IHI Open School
Online courses written by world-renowned faculty
Case studies, podcasts, videos, featured articles
Clinical Training
Department specific M&M/patient safety conferences
Mentored Projects
Mentors with QI/safety interests identified
Students encouraged to seek them out
Start a mentored QI project during their 1 st year & finish prior to graduation
Funding for summer work
Dissemination at a local, regional or national conference

Learn more about QST…
From one of our medical students
Panel on Student and Resident-Led QI Initiatives
Marcus Dahlstrom
Friday session
8:00-9:30am

Lessons Learned
Curricular change takes time
Persistence needed
Start small for an early win
Use that early win to get noticed
Scale up when ready
Support from leadership critical
Moral & financial

The Importance of a Good Team

Acknowledgements
Marcus Dahlstrom, MSII, Co-Chapter Leader
Caitlin Schaninger, MSIV, Co-Chapter Leader
Megan Moore, GPHAP Student
Laura Botwinick, Director, Graduate Program Health Administration & Policy (GPHAP)
Gregg Kauffman, MSI, Soon-to-be Co-Chapter Leader
Holly Humphrey, MD, Dean of Medical Education
Jim Woodruff, MD, Internal Medicine Residency Director
Halina Brukner, MD, Associate Dean of Medical Education
Mike Simon, MD, Dean for Graduate Medical Education
Sandy Smith, PhD, Senior Learning Specialist
Lou Portugal, MD, Director of Quality for Department of Surgery
Andrew Davis, MD, Director of Quality for Department of Medicine
U of C RIME attendees

Questions or Copies of Materials…
University of Chicago Quality Website for curriculum materials & articles
http:// www.tinyurl.com / UChicagoQAIC
For Quality Assessment and Improvement Curriculum Toolkit
Email [email_address] . uchicago.edu

Teaching QI at University of Chicago

by Vineet Arora

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