The Ambulatory Long Block: A University of Cincinnati Educational Innovations Project<br />Eric J. Warm M.D., Brian Revis ...
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The Ambulatory Long Block


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The Ambulatory Long Block

  1. 1. The Ambulatory Long Block: A University of Cincinnati Educational Innovations Project<br />Eric J. Warm M.D., Brian Revis M.D., Sara McCune M.D., Jennifer Ernst, M.D., Yvette Neirouz, M.D., Tiffiny Diers M.D., Bradley Mathis M.D., Gregory Rouan M.D.<br />PATIENT SATISFACTION<br />CLINICAL QUALITY RESULTS<br />LONG BLOCK MICROSYSTEM<br />ABSTRACT<br />BACKGROUND: Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting<br /> <br />OBJECTIVE: Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients<br /> <br />METHODS: We created the ambulatory long-block as part of the ACGME’s Educational Innovation Project. The long-block occurs from the 17th to the 29th month of residency, and isayear-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. Long-block residents follow approximately 120-150 patients, have office hours 3 half-days per week, and are responsive to patient needs (by answering messages, refilling medications, etc.) daily. Otherwise, long-block residents rotate on electives and research experiences with minimal overnight call. Residents receive extensive instruction in chronic illness care, quality improvement, and inter-professional teams<br /> <br />RESULTS: The long-block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. There has also been a trend towards decreased emergency department visit rates and no show rates. Additionally, the long-block resulted in a robust multi-source evaluation that identified high, intermediate, and low performing residents, and suggested specific formative feedback for each<br /> <br />CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation <br /> <br />NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement<br /><ul><li> Patient Satisfaction is at an all time high (at left)
  2. 2. Resident scores have improved the most
  3. 3. Satisfaction dips immediately after a long-block ends but then rebounds (above)
  4. 4. This may represent breaking and reforming of therapeutic relationships
  5. 5. The large team is broken up into mini-teams
  6. 6. Each mini-team consists of a nurse leader, and a group of residents, supported by many ancillary staff</li></ul>EDUCATIONAL RESULTS<br /><ul><li> The entire team, including residents, nurses, and support staff learn improvement skills, motivational interviewing and shared decision making at a yearly retreat
  7. 7. In 2007, the nursing staff transitioned from a mostly medical assistants to all RN and LPN level staff to provide case management
  8. 8. A nurse practitioner was also added</li></ul>BACKGROUND<br /><ul><li> Most internal medicine graduate medical education is inpatient-based
  9. 9. This historical bias towards the inpatient setting has led to dysfunctional ambulatory training settings
  10. 10. Many residents receive little support for ambulatory chronic illness management, improvement science, or interdisciplinary teamwork
  11. 11. The end result of these combined deficiencies has been characterized as the “training/practice gap” – few internal medicine graduates leave residency with the skills needed to function effectively in the ambulatory setting
  12. 12. The practice uses an electronic medical record (Centricity) and a disease registry (MQIC)
  13. 13. Residents receive extensive EMR training
  14. 14. Residents and nurses then have a pre-clinic “huddle” to review the patients that will be seen , and decide on an efficient plan for the day
  15. 15. Prior to each clinic session, residents review the EMR, prepare a progress note, and make a list of things that must be done during the session
  16. 16. The Learner’s Perception Survey demonstrated significant improvement after the long-block intervention</li></ul>CONTEXT<br /><ul><li>Residents participate in long-block board review course
  17. 17. Each long- block class has shown significant increases in in-training exam scores from PGY-2 to PGY-3
  18. 18. Our residency is in the upper quartile for passing the ABIM certification examination
  19. 19. The University of Cincinnati internal medicine residency program consists of 108 residents (69 categorical) based in a large academic health center
  20. 20. The categorical resident ambulatory practice is an urban safety-net practice located next to the main teaching hospital
  21. 21. Residents are responsible for approximately 19,000 ambulatory visits per year
  22. 22. 58% of the patients have hypertension and 32% have diabetes; only 1% have private insurance
  23. 23. Residents rated their ambulatory clinic experience low during exits interviews, reported little time for learning in the ambulatory setting due to difficulty balancing ward and ambulatory duties, and reported a lack of personal reward the ambulatory setting
  24. 24. The practice also had poor patient-doctor continuity, poor clinical quality markers, poor patient satisfaction, and poor staff satisfaction
  25. 25. The initial data from the first long-block showed significant improvement for many process measures and intermediate outcome measures of care
  26. 26. The initial improvements have held, and the resident practice now has many measures of care that are better than the larger health system</li></ul>EVALUATION<br /><ul><li> Data includes quality data (above), financial performance data, patient satisfaction data, visit volume data, and the results of ongoing Plan-Do-Study-Act cycles
  27. 27. The entire team meets weekly to review data and solve problems; an open agenda is set by all team members
  28. 28. Every meeting starts with a patient story
  29. 29. Residents receive individual reports monthly
  30. 30. Each report includes a ranking on each measure compared with peers
  31. 31. Data is used as part of competency evaluation </li></ul>HYPOTHESIS<br />PATIENT-CENTERED MEDICAL HOME<br /><ul><li> Improving resident physician continuity within a highly functional clinical micro-system would improve care and education
  32. 32. The resident ambulatory practice now meets many of the criteria for the National Committee for Quality Assurance’s Patient-Centered Medical Home</li></ul>INTERVENTION<br /><ul><li> Creation of an Ambulatory Long Block (now into the fourth year)
  33. 33. Part of the RRC-IM/ACGME Educational Innovations Project (EIP)</li></ul>NEW RESIDENCY STRUCTURE<br /><ul><li> PGY-1-2: Months 1-16 </li></ul>– traditional residency, mainly inpatient based, with fixed half-day in the ambulatory practice<br />– small patient panels (15-30)<br />– each PGY-1 is paired with a long-block resident who serves as cross cover and mentor<br />– when the PGY-1 rises to the long-block, he/she inherits long-block partner’s patients<br /><ul><li>PGY 2-3: Months 17-28 – The Long Block </li></ul>– 1 year of electives, paired with ambulatory care; minimal inpatient call service time<br />– patient panels expand (120-150)<br />– residents have ambulatory office hours three half-days per week on average <br />– residents are responsive to patient needs (by answering messages, refilling medications, EMR) daily<br />– a portion of one morning is reserved for an ambulatory education curriculum (AME, figure below))<br />– balance of time is spent on electives (ambulatory, inpatient, research)<br /><ul><li>PGY 3: Months 29-36</li></ul>– residents return to primarily inpatient care<br />– no ambulatory continuity practice<br />– selected residents may elect to continue a portion of their practice one half-day per week <br /><ul><li> Long Block residents receive comprehensive multisource feedback (MSF) that includes self, peer, staff, attending and patient evaluations, as well as concomitant clinical quality data and knowledge-based testing scores
  34. 34. Residents are given a rank for each data point compared to peers in the class, and this data is reviewed with the chief resident and program director over the course of the long-block
  35. 35. The table above shows that in a long-block class the MSF demonstrates residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%)
  36. 36. Each high, intermediate and low performing resident had a least one aspect of the MSF significantly lower than the other, and this serves as the basis of formative feedback during long-block
  37. 37. Residents receive radar graphs (figures A-C, below) as part of their evaluation
  38. 38. Focus is given to lower scored measures (furthest from the center of the radar graph)
  39. 39. Figure A represents the top three residents, Figure B represents 3 residents in the middle of the class, Figure C represents the bottom three residents</li></ul>A<br />C<br />B<br />CONCLUSIONS:An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation <br /> <br />NEXT STEPS:Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement<br /><ul><li> No show rates during the first long-block improved, and have maintained this level over 4 years</li>