CHAMP Teaching on Today’s Wards Session 3 – Systems Based Practice and  Practice Based Learning and Improvement Chad Whela...
Learning Objectives <ul><li>Describe the importance of teaching systems based practice (SBP) and practice based learning a...
Learning Objectives <ul><li>Develop strategies for teaching these core competencies in clinical settings </li></ul><ul><ul...
Agenda <ul><li>10:00 – 10:25 Introduction to systems based practice and practice based learning and improvement </li></ul>...
ACGME/ABMS Core Competencies <ul><li>Patient Care </li></ul><ul><li>Medical Knowledge </li></ul><ul><li>Interpersonal & Co...
What comes to mind  when I say “system”?  <ul><li>Name a system that you are part of now, or one you’ve been part of in th...
System: A Definition <ul><li>A set of interacting, interrelated, or independent elements that work together in a particula...
ACGME Elements   Systems-Based Practice <ul><li>Understand inter-relatedness of system components </li></ul><ul><li>Know h...
ACGME Elements   Practice Based Learning and Improvement <ul><li>Analyze practice and perform improvement activities </li>...
How are SBP and PBLI different? <ul><li>Systems-based practice </li></ul><ul><ul><li>Analytic tool, way of viewing the wor...
How are SBP and PBLI different? <ul><li>SBP is like a village </li></ul><ul><ul><li>“A physician must work together with a...
Sometimes it’s hard to separate the two <ul><li>How can I improve care for my patients or my team’s patients? </li></ul><u...
We Can Focus on the System at Different Levels Community, Market, Social Policy System Macro-organization System Microsyst...
Method of Teaching SBP and PBLI Needs to Address the Level of the Learner <ul><li>Dreyfus Model </li></ul><ul><li>Method o...
Recognizing the Opportunity to Teach
Systems-based Practice in Residency Training <ul><li>There are multiple opportunities to tease out the system issues and t...
How Can We Identify Opportunities for Teaching SBP? <ul><li>What are the triggers for teaching? </li></ul><ul><ul><li>Topi...
Failures Transition Topic Location Triggers for Teaching about Systems
Example <ul><li>Imagine this scenario </li></ul><ul><ul><li>Your team is post call, in conference room getting a run-down ...
Process of initiating dialysis Cost, burden of uncontrolled hypertension Cost,  burden of hypertension Conference Room Fai...
Patient With ESRD (cont.) <ul><li>Bedside Presentation: </li></ul><ul><ul><li>Patient is admitted from ER for initiation o...
Cost, burden of drug rehab Compliance, patient preference in initiating dialysis Process of initiating dialysis Admission ...
Patient with ESRD (cont.) <ul><li>Post-Bedside Discussion:  </li></ul><ul><ul><li>You agree with the team that there were ...
Cost, burden of drug rehab Contra-indications for dialysis PCP  communication Compliance, patient preference in initiating...
Small Group Exercise #1 <ul><li>What are the triggers for teaching about systems based practice in the case?  </li></ul><u...
Small Group Exercise #1 <ul><li>Debriefing </li></ul><ul><li>See handout on teaching systems based practice  </li></ul>
Take Home Points <ul><li>Systems issues are prevalent </li></ul><ul><li>We tend to create elaborate processes to “work aro...
Take Home Points <ul><li>This can be a Pandora’s Box – we need to assure that the organization can support the improvement...
Practice Based Learning and Improvement <ul><li>A more indepth look . . . </li></ul>
What Do We Need to Improve Care? Improvement Knowledge <ul><li>System </li></ul><ul><li>Variation </li></ul><ul><li>Psycho...
If you want to teach people a new way of thinking, don’t bother trying to teach them.  Instead give them a tool,  the use ...
Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>The plan, do, study, act or PDSA cycle links ideas to action an...
Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>The PDSA cycle provides framework for efficient trial-and-error...
Plan, Do, Study, Act Cycle A Model for Improvement Aim,who, what, when & data collection plan Execute, collect & analyze d...
Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Plan </li></ul><ul><ul><li>Describe objective and specific chan...
Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Study </li></ul><ul><ul><li>Make sure that you leave time for r...
Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Act </li></ul><ul><ul><li>Given what you learned during the tes...
PDSA Worksheet <ul><li>This worksheet for tracking PDSA cycles that has been developed by the Institute for Healthcare Imp...
 
Group Exercise <ul><li>Selecting a topic for improvement </li></ul><ul><ul><li>The work before the work . . . </li></ul></ul>
Draft an initial list of priority improvements <ul><li>Consider these questions: </li></ul><ul><ul><ul><li>The clinical ar...
Draft an initial list of priority improvements (cont.) <ul><li>Prioritize your list </li></ul><ul><ul><li>in order of desc...
Finally, consider the  “ramp of complexity” Time Complexity P D C A P D C A P D C A
Based on the exercise, what are the priorities? <ul><li>Improvement Priorities: </li></ul>
Homework <ul><li>Think about the topic(s) identified </li></ul><ul><ul><li>How would you assess the magnitude of the probl...
Upcoming SlideShare
Loading in...5
×

CHAMP Teaching on Today's Wards

447

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
447
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • ACGME and ABMS have identified 6 core competencies necessary for a physician to deliver high quality care. Of these, PBLI and SBP are the most challenging to define, incorporate into training and practice, and evaluate. Although SBP and PBLI are closely wedded, today’s focus is on SBP
  • Bertanlanffy -- The Founder of the scientific, mathematical Theory of Systems
  • In essence these are the key elements of the ACGME’s definition for SBP To demonstrate competence in systems-based competence, residents must
  • Practice-Based – Actions taken with others (micro-system) for the benefit of patients (D. Duffy) “ Competence in Practice-Based Learning and Improvement is the integrating competence that leads to life-long learning, quality health care, and joy in practice. Developing Competence in PBLI begins with acquiring evidence-based knowledge of one’s patient needs, processes and outcomes of care PBLI incorporates leadership and collaboration skills needed to change the microsystem that provides health care.” See Duffy slides from ACGME-IHI workshop Dec. 2003: sTraining &amp; THCIACGMEACGME-IHI 2003Duffy[1].ppt PBLI for practitioners: Patient needs – Process of care – outcomes, all within the practice microsystem.
  • Efforts at each of the different levels of the health care system and the interactions between them can influence the ability to achieve patient safety and quality
  • Examples of work arounds --- ordering all labs stat, Pandora’s Box – who can advocate for the issues? In our system it is the Program Director and the hospitalists.
  • Examples of work arounds --- ordering all labs stat, Pandora’s Box – who can advocate for the issues? In our system it is the Program Director and the hospitalists.
  • CHAMP Teaching on Today's Wards

    1. 1. CHAMP Teaching on Today’s Wards Session 3 – Systems Based Practice and Practice Based Learning and Improvement Chad Whelan, MD Julie Johnson, PhD Paula Podrazik, MD
    2. 2. Learning Objectives <ul><li>Describe the importance of teaching systems based practice (SBP) and practice based learning and improvement (PBLI) </li></ul><ul><li>Improve comfort and skills in teaching and evaluating SBP and PBLI </li></ul><ul><ul><li>Define systems-based practice </li></ul></ul><ul><ul><ul><li>Demonstrate how solutions to problems affect the system </li></ul></ul></ul><ul><ul><li>Define practice-based learning and improvement </li></ul></ul><ul><ul><ul><li>Demonstrate teaching and evaluation of this ACGME competency </li></ul></ul></ul>
    3. 3. Learning Objectives <ul><li>Develop strategies for teaching these core competencies in clinical settings </li></ul><ul><ul><li>Practice identifying triggers for teaching systems based practice </li></ul></ul><ul><ul><li>Learn about one model for improvement </li></ul></ul><ul><ul><li>Choose an improvement topic </li></ul></ul>
    4. 4. Agenda <ul><li>10:00 – 10:25 Introduction to systems based practice and practice based learning and improvement </li></ul><ul><li>10:25 – 10:50 Small group exercise – identifying teaching triggers </li></ul><ul><li>10:50 – 11:00 Debriefing </li></ul><ul><li>11:00 – 11:25 Introduction to practice based learning and improvement and the PDSA Improvement Model </li></ul><ul><li>11:25 – 11:45 Group exercise – Selecting a topic for improvement </li></ul><ul><li>11:45 – 11:55 Debriefing </li></ul><ul><li>11:55 – 12:00 Final Comments and Take Home Points </li></ul>
    5. 5. ACGME/ABMS Core Competencies <ul><li>Patient Care </li></ul><ul><li>Medical Knowledge </li></ul><ul><li>Interpersonal & Communication Skills </li></ul><ul><li>Professionalism </li></ul><ul><li>Practice-based Learning & Improvement </li></ul><ul><li>Systems-based Practice </li></ul>
    6. 6. What comes to mind when I say “system”? <ul><li>Name a system that you are part of now, or one you’ve been part of in the past </li></ul><ul><li>What word comes to mind when you think of that system? </li></ul>
    7. 7. System: A Definition <ul><li>A set of interacting, interrelated, or independent elements that work together in a particular environment to perform the functions that are required to achieve a specific aim </li></ul>Bertalanffy, 1968
    8. 8. ACGME Elements Systems-Based Practice <ul><li>Understand inter-relatedness of system components </li></ul><ul><li>Know how types of medical practice & delivery systems differ regarding costs & resource allocation </li></ul><ul><li>Practice cost-effective health care </li></ul><ul><li>Advocate for quality patient care </li></ul><ul><li>Work with others to improve patient care </li></ul>
    9. 9. ACGME Elements Practice Based Learning and Improvement <ul><li>Analyze practice and perform improvement activities </li></ul><ul><li>Find and assimilate evidence related to patient needs </li></ul><ul><li>Use information about own patients to design improvements for a population of patients </li></ul><ul><li>Use information technology to manage information </li></ul><ul><li>Facilitate the learning of students and other health care professionals </li></ul>
    10. 10. How are SBP and PBLI different? <ul><li>Systems-based practice </li></ul><ul><ul><li>Analytic tool, way of viewing the world that makes our care-giving and change efforts more successful </li></ul></ul><ul><ul><li>Focus is understanding the interdependencies of a system or series of systems </li></ul></ul><ul><ul><li>Changes can be made and measured on the system </li></ul></ul><ul><li>Practice-based learning and improvement </li></ul><ul><ul><li>Focus is on reflection and change at the level of the provider or group of providers and what they do in caring for their patients </li></ul></ul><ul><ul><li>Goal is measurement as an aid to learning about and improving practice </li></ul></ul><ul><ul><li>Some changes can be made by provider, others require system-level intervention </li></ul></ul>
    11. 11. How are SBP and PBLI different? <ul><li>SBP is like a village </li></ul><ul><ul><li>“A physician must work together with a community of providers to deliver optimal patient care” </li></ul></ul><ul><li>PBLI is like a mirror </li></ul><ul><ul><li>“Holding up a mirror to ourselves to document, assess, and improve our practice” </li></ul></ul><ul><ul><li>Source: Ziegelstein & Fiebach, Acad. Med. 2004;79:83. </li></ul></ul>
    12. 12. Sometimes it’s hard to separate the two <ul><li>How can I improve care for my patients or my team’s patients? </li></ul><ul><ul><li>e.g., do a daily census audit of foley catheters to reduce the inappropriate use </li></ul></ul><ul><li>How can I improve the system? </li></ul><ul><ul><li>e.g., build in a reminder so that all foley catheters are automatically discontinued after 2 days, unless specific criteria are met </li></ul></ul>
    13. 13. We Can Focus on the System at Different Levels Community, Market, Social Policy System Macro-organization System Microsystem Individual care-giver & patient System Self-care System
    14. 14. Method of Teaching SBP and PBLI Needs to Address the Level of the Learner <ul><li>Dreyfus Model </li></ul><ul><li>Method of teaching has to be relevant to the learner and grounded in the daily work of caring for patients </li></ul>Novice Advanced Beginner Competent Proficient Expert
    15. 15. Recognizing the Opportunity to Teach
    16. 16. Systems-based Practice in Residency Training <ul><li>There are multiple opportunities to tease out the system issues and talk about them, once we recognize them </li></ul><ul><li>This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required </li></ul><ul><ul><li>Organizational support </li></ul></ul><ul><ul><li>Feedback on what is being done to address the issues </li></ul></ul><ul><li>Faculty are looking for methods, teaching tools, etc. to make this easier </li></ul>
    17. 17. How Can We Identify Opportunities for Teaching SBP? <ul><li>What are the triggers for teaching? </li></ul><ul><ul><li>Topics </li></ul></ul><ul><ul><li>Transitions </li></ul></ul><ul><ul><li>Failures </li></ul></ul><ul><li>Where do the triggers occur? </li></ul><ul><ul><li>Everywhere!!! </li></ul></ul>
    18. 18. Failures Transition Topic Location Triggers for Teaching about Systems
    19. 19. Example <ul><li>Imagine this scenario </li></ul><ul><ul><li>Your team is post call, in conference room getting a run-down on patients: </li></ul></ul><ul><ul><li>67 year-old male with chronic renal insufficiency secondary to poorly controlled hypertension admitted to initiate dialysis and to get placed with a dialysis center </li></ul></ul>
    20. 20. Process of initiating dialysis Cost, burden of uncontrolled hypertension Cost, burden of hypertension Conference Room Failures Transition Topic Location Triggers for Teaching about Systems
    21. 21. Patient With ESRD (cont.) <ul><li>Bedside Presentation: </li></ul><ul><ul><li>Patient is admitted from ER for initiation of dialysis </li></ul></ul><ul><ul><li>Although he has known he will need dialysis soon (he already has access), he did not always show up for his renal clinic appointments </li></ul></ul><ul><ul><li>His blood pressure has been poorly controlled and he does not always take his medications </li></ul></ul><ul><ul><li>His social history is notable for his current IVDA. His nephrologist was surprised at how quickly he progressed over the past 6 months to the point where he requires dialysis, although not emergently </li></ul></ul><ul><ul><li>The patient was essentially admitted electively to facilitate initiation of dialysis </li></ul></ul>
    22. 22. Cost, burden of drug rehab Compliance, patient preference in initiating dialysis Process of initiating dialysis Admission process through ER as a “workaround” to getting a dialysis chair Cost, burden of hypertension Bedside Cost, burden of uncontrolled hypertension Conference Room Failures Transition Topic Location Triggers for Teaching for Systems
    23. 23. Patient with ESRD (cont.) <ul><li>Post-Bedside Discussion: </li></ul><ul><ul><li>You agree with the team that there were no urgent indications for dialysis </li></ul></ul><ul><ul><li>Your team tells you that his nephrologist had a difficult time getting the patient a chair as an outpatient as he is poorly compliant and uses IV drugs </li></ul></ul><ul><ul><li>The nephrologist told the patient it would be easier to go to the ER to get admitted to start dialysis, </li></ul></ul><ul><ul><li>At this point your team is obviously frustrated by the events that got this patient admitted through the ER to an acute hospital bed for something that medically could have been done as an outpatient </li></ul></ul>
    24. 24. Cost, burden of drug rehab Contra-indications for dialysis PCP communication Compliance, patient preference in initiating dialysis Process of initiating dialysis Cost, burden of uncontrolled hypertension Admission process through ER as a “workaround” to getting a dialysis chair Cost, burden of dialysis Cost, burden of hypertension Post-bedside Bedside Conference Room Failures Transition Topic Location Triggers for Teaching for Systems
    25. 25. Small Group Exercise #1 <ul><li>What are the triggers for teaching about systems based practice in the case? </li></ul><ul><ul><li>Work in small groups </li></ul></ul><ul><ul><li>Complete the Triggers for Teaching Matrix </li></ul></ul>
    26. 26. Small Group Exercise #1 <ul><li>Debriefing </li></ul><ul><li>See handout on teaching systems based practice </li></ul>
    27. 27. Take Home Points <ul><li>Systems issues are prevalent </li></ul><ul><li>We tend to create elaborate processes to “work around” the most problematic system issues </li></ul><ul><li>There are multiple opportunities to tease out the system issues and talk about them, once we recognize them </li></ul>
    28. 28. Take Home Points <ul><li>This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required </li></ul><ul><li>Faculty are looking for methods, teaching tools, etc. to make this easier </li></ul><ul><li>Observation is important -- what are the system issues you have seen? </li></ul>
    29. 29. Practice Based Learning and Improvement <ul><li>A more indepth look . . . </li></ul>
    30. 30. What Do We Need to Improve Care? Improvement Knowledge <ul><li>System </li></ul><ul><li>Variation </li></ul><ul><li>Psychology </li></ul><ul><li>Theory of Knowledge </li></ul>Traditional Improvement of Health Care Continual Improvement of Health Care + Professional Knowledge <ul><li>Subject </li></ul><ul><li>Discipline </li></ul><ul><li>Values </li></ul>
    31. 31. If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead give them a tool, the use of which will lead to new ways of thinking - Buckminster Fuller
    32. 32. Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>The plan, do, study, act or PDSA cycle links ideas to action and then makes the connection to continuous learning </li></ul><ul><ul><li>It can be done at the individual level (e.g., changes you want to make to your teaching process) </li></ul></ul><ul><ul><li>It can be done at the team level (e.g., small improvement pilots that you can guide your team through in a 2-4 week timeframe) </li></ul></ul>
    33. 33. Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>The PDSA cycle provides framework for efficient trial-and-error learning methodology </li></ul><ul><ul><li>Small changes can have a big impact (thing about the effect on the system) </li></ul></ul><ul><ul><li>Choose carefully </li></ul></ul><ul><ul><li>Pilot test </li></ul></ul>
    34. 34. Plan, Do, Study, Act Cycle A Model for Improvement Aim,who, what, when & data collection plan Execute, collect & analyze data, note unexpecteds Analyze, compare to prediction, ID lessons learned Plan Do Study Act What changes to make, spread, & next cycle
    35. 35. Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Plan </li></ul><ul><ul><li>Describe objective and specific change </li></ul></ul><ul><ul><li>Specify where it fits into the process flow </li></ul></ul><ul><ul><li>Who, does what, when, with what tools and training </li></ul></ul><ul><ul><li>Data collection plan: who measures what and displays how and where </li></ul></ul><ul><li>Do </li></ul><ul><ul><li>Carry out the change </li></ul></ul>
    36. 36. Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Study </li></ul><ul><ul><li>Make sure that you leave time for reflection about your test </li></ul></ul><ul><ul><li>Use the data and the experience of those carrying out the test to </li></ul></ul><ul><ul><li>Discuss what happened </li></ul></ul><ul><ul><li>Did you get the results you expected? If not, why not? </li></ul></ul><ul><ul><li>Did anything unexpected happen during the test? </li></ul></ul>
    37. 37. Plan, Do, Study, Act Cycle A Model for Improvement <ul><li>Act </li></ul><ul><ul><li>Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale? </li></ul></ul>
    38. 38. PDSA Worksheet <ul><li>This worksheet for tracking PDSA cycles that has been developed by the Institute for Healthcare Improvement (IHI) </li></ul><ul><li>See handout </li></ul>
    39. 40. Group Exercise <ul><li>Selecting a topic for improvement </li></ul><ul><ul><li>The work before the work . . . </li></ul></ul>
    40. 41. Draft an initial list of priority improvements <ul><li>Consider these questions: </li></ul><ul><ul><ul><li>The clinical areas that really need to be improved are __________________________ </li></ul></ul></ul><ul><ul><ul><li>The reason things don’t work right around here is _________________________ </li></ul></ul></ul><ul><ul><ul><li>There’s one thing that we do all the time that accomplishes very little and that’s _______________ </li></ul></ul></ul><ul><ul><li>How would different people answer those questions? (e.g., nurses, physicians, patients/family, pharmacists, secretaries, etc.) </li></ul></ul>
    41. 42. Draft an initial list of priority improvements (cont.) <ul><li>Prioritize your list </li></ul><ul><ul><li>in order of descending achievable benefit not yet achieved (ABNA) (1=highest ABNA) </li></ul></ul><ul><ul><li>least cost to change (1=least costly) </li></ul></ul><ul><ul><li>shortest time to get started (1=can get started with a small test next week) </li></ul></ul><ul><ul><li>greatest importance to inpatient medicine wards (1=most important) </li></ul></ul>
    42. 43. Finally, consider the “ramp of complexity” Time Complexity P D C A P D C A P D C A
    43. 44. Based on the exercise, what are the priorities? <ul><li>Improvement Priorities: </li></ul>
    44. 45. Homework <ul><li>Think about the topic(s) identified </li></ul><ul><ul><li>How would you assess the magnitude of the problem? </li></ul></ul><ul><ul><li>What data will you need? </li></ul></ul>
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×