Practice-based Learning &
Improvement: How to Incorporate
Trainees in QI/Patient Safety
Activities as Part of GME
Joseph C...
Objectives
Understand the definition and scope of QI and patient
safety
Become familiar with the epidemiology of adverse e...
Goal
Create a curriculum and/or teaching
techniques that can be incorporated into
your clinical practice
Practice Based Learning and
Improvement
Residents must be able to investigate and evaluate their
practices, appraise and a...
PBLI Steps
Monitor practiceMonitor practice
Reflect on or analyze practice to identifyReflect on or analyze practice to id...
IHI Learning Domains
Learning DomainsLearning Domains
Health care as aHealth care as a
process, systemprocess, system
Vari...
Institute of Medicine Report Elevated
Patient Safety Agenda
Top 10 Causes of DeathTop 10 Causes of Death
#1 Heart Disease#...
The IOM Challenge
Challenged the health care system to reengineerChallenged the health care system to reengineer
itself to...
Definition and Scope of Patient
Safety
Definitions of error, adverse event, andDefinitions of error, adverse event, and
pa...
Patient safety is the identification and control of
hazards that could cause harm to patients
Patient safety is the preven...
Semantics?
What do you call the following?
– Wrong leg is amputated
– Wrong medication is dispensed
– Diagnosis is “too la...
Working definitions of patient safety,
errors, and adverse events
VA: Adverse events are:
– Are untoward incidents, therap...
Patient Safety Epidemiology
How many adverse events?
How many close calls?
Inpatient vs outpatient?
Very dependent on defi...
And consider the
research evidence…
Retrospective studies (Brennan, et al, 1991))Retrospective studies (Brennan, et al, 19...
96 - 98% Reliability in Hospitals?
What wouldWhat would 99.9%99.9% reliabilityreliability mean?mean?
– 1 hour of unsafe dr...
Systems Approach to Patient
Safety
Systems model examples
Systems versus Person-Focused
No accountability?
It’s usually the system!
(from UW-Madison Systems Engineering Initiative in Patient Safety)
What is the difference between focusing
on the person and focusing on the
system?
Person approachPerson approach
– Focus o...
High Reliability
Organizations
Main theoretical construct in safetyMain theoretical construct in safety
literatureliteratu...
Patient Safety Challenges
Medicine Views Errors as Failings WhichMedicine Views Errors as Failings Which
Deserve Blame - F...
A More Productive Approach
People Don’t Come to Work to HurtPeople Don’t Come to Work to Hurt
Someone or Make a MistakeSom...
Awareness and Shame May be Largest
Hurdles
1999 Survey at VA and Private Healthcare1999 Survey at VA and Private Healthcar...
Multi-Causal Theory “Swiss Cheese”
Diagram (Reason, 1991)
“Culture of Safety” and “High
Reliability Organizations”
Safety is always on the “agenda” –Safety is always on the “agenda...
Empirical Evidence that Culture and
Attitudes are Key
Effective system fixes with evidence meetEffective system fixes with...
Close Calls and High Reliability
Organizations
Close calls 10-100 times > adverse eventsClose calls 10-100 times > adverse...
Three Related Concepts
Human error is a symptom of troubleHuman error is a symptom of trouble
deeper in the system (it is ...
Fundamental Skill Sets
Trainees Need to be
Successful
Skill Sets that are Needed
Process Improvement ApproachesProcess Improvement Approaches
and Toolsand Tools
Research Method...
Process Improvement
Approaches and Tools
Demming ModelDemming Model
CQI and the PDSACQI and the PDSA
FADEFADE
Six SigmaSix...
Patient Safety
Safety StandardsSafety Standards
– PracticesPractices
– EquipmentEquipment
Sentential EventSentential Event...
Change Management
All Too Often NeglectedAll Too Often Neglected
– To affect positive change you need to engageTo affect p...
Vehicles
Department SpecificDepartment Specific
– M&MM&M
– Exit Rounds
– Log and learning plan
– Yearly reviewYearly revie...
Vehicles
Example
Exit Rounds
Mortality & Morbidity Conference
Practice-based Small Group Learning Program
Evidence-based M...
Arseneau R. Exit rounds: a reflection exercise. Acad Med 1995;70:684-7.
Exit Rounds
Group session with attendingGroup sess...
Mortality & Morbidity
Conference
Focus on adverse on teaching servicesFocus on adverse on teaching services
Analyzes cause...
Practice-based Small Group
Learning Program
Residents meet to review currentResidents meet to review current
information a...
Evidence-based Medicine
Curriculum
Residents rotate as leaders of group session to discuss applicationResidents rotate as ...
Log and Learning Plan
Working with a mentor, residents keep a log ofWorking with a mentor, residents keep a log of
signifi...
Improvement Project
Residents work with a mentor to identify anResidents work with a mentor to identify an
aspect of their...
At UK
Example Perform in your program (yes/no)
Exit Rounds Ortho-postoperative conference
Surgery
Mortality & Morbidity
Co...
National Peer Review Protection?
Patient Safety and Quality andPatient Safety and Quality and
Improvement ActImprovement A...
Litigation?
Federal Rules of Evidence
– Relevance (similarity and timing)
– Danger of unfair prejudice
Admissibility as ev...
Conclusions
QI/Patient Safety activities should be focused on
the system and not the individual
Patient Safety is proactiv...
Useful Web Sites
http://www.improvementskills.orghttp://www.improvementskills.org (excellent tutorial site –(excellent tut...
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  • Objectives changed to better align with content
  • What are our motivators? Why do we want (need) to do this?
  • Institute for Healthcare Improvement
    The Institute for Healthcare Improvement (IHI), a Boston-based, independent organization working
    to accelerate improvement in healthcare systems, has identified the general learning domains listed
    below as areas which encompass the knowledge and skill-sets needed to make dramatic and
    long-lasting improvements that will enhance clinical outcomes and reduce costs.
  • Why? Other motivators
  • A call to arms? Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others.7
  • Specifically
  • Switch gears
  • The first two bullet points express the NCPS definition of patient safety. The remaining bullet points are other definitions that have been advanced by various interest groups.
    Medical error is problematic because it implies this is about “Doctors making mistakes.” In fact, the AMA rightly defends its members by responding that most “medical errors” are not made by physicians. Also, medical error strongly implies that this is about individuals who are assigned blame for something that happens – a very superficial oversimplification of the true story behind an adverse event.
    Having a safe environment in which to practice should be one of our goals, but the focus of patient safety is making it safer for patients as a first priority. Physicians must realize this is primarily not about them, but rather about their patients.
    The last bullet point is a quote from Don Berwick at the Senate HELP Committee hearing on Patient Safety, May 22, 2001. Quality Assurance in hospitals has traditionally focused on collecting and tracking information (like hospital readmissions and wound infections). But, the focus has been on gathering information and not making any changes to reduce the incidence of these events in the future. Patient safety is about identifying hazards proactively, if possible, and implementing changes in a health system to prevent these events from happening in the future.
    Part of professional responsibility to leverage lessons learned from experience with hazards.
    (Jim B says that the first two are the best definitions.)
    “It’s freedom from inadvertent, unintended (iatrogenic) harm.” – Jim Bagian.
    The last bullet point is a quote from Don Berwick at the Senate HELP Committee hearing on Patient Safety, May 22, 2001.
  • Ask participants what they think about these questions. Each of these scenarios could be identified as “medical malpractice,” but will that designation lead to any action to prevent these events from happening again? The point to be made here is that there are systems issues underlying each of these events. If the system issues are addressed, the probability of these recurring events will be reduced. Punishing the individuals involved in these events may be appropriate in some cases, but that will not likely influence the probability of recurrence for any of these events.
    The reason the incidence and prevalence varies widely is due to the fact that these cases are self reports from medical chart abstractions or hospital QA data. One could argue that the true incidence and prevalence of these events is unknowable. Does the act of counting the number of events improve the safety of care in a hospital?
  • VA definitions
    IOM definitions: failure of implementing the plan of care or failure of decision making to use choose the right plan
    Invite the participants to jump in with their notions about patient safety.
    Spectrum of Human Performance refers to the human performance curves. “To Err is Human.” As Jim Reason would say: “You can’t change the human condition but you can change the conditions human work in.” To improve the human performance curves significantly, you must change the conditions of the working environment – improve work processes, replace equipment with more effective and usable equipment, have a rested staff with adequate support from leadership, etc.
  • “Medical Errors,” or Adverse Events - between the 2nd and 9th leading cause of death for all ages in the US! (depending upon measurement methodology)
    Also be sure to note that the numbers of deaths due to adverse events are ONLY for hospitals (not ambulatory care, not long-term care, etc.) so is probably just the tip of the iceberg.
  • IOM study
    Wu Study
    Other recent stuff focused on that specialty or newer ones
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-6.
    Considered a classic, although retrospective, study of the epidemiology of mishaps that occur in a wide variety of inpatient settings. Some of the analysis and recommendations fall short in the area of applying human factors principles and techniques, but the authors have since become more aware.
    Ely JW, Levinson W, Elder NC, Mainous AG. Perceived causes of family physician’s errors. J Fam Pract. 1995;40(4):337-44.
    Very telling and chilling subjective, retrospective study of how well-intentioned professionals can sometimes (often?) make mistakes that lead to injury or death of a patient.
    Gopher, D., M. Olin, Y. Badhi, et al., 1989. The Nature and Causes of Human Errors in a Medical Intensive Care Unit. In Proceedings of the Human Factors and Ergonomics Society 33rd Annual Meeting. Santa Monica, CA: Human Factors and Ergonomics Society.
    Excellent, but hard to obtain, research paper on a prospective study of adverse events and close calls in an Israeli hospital ICU: direct observation, self report, failure modes analysis.
    Andrews. Annals of Internal Medicine. Still looking
  • At this slide, go back and remind them that Brennan found 2-4% rate of medical errors. Comment that 2-4% may sound trivial, but then have them consider the numbers on this slide, which are for a 0.1% error rate! Then have them consider the math of what they would translate to at 2-4%!
  • This is a good slide for a couple of reasons.
    First, it shows what a work system looks like (left side of model). In a work system there are tools and technologies, organizational structure and culture and rules and policies, tasks that are carried out, and environment in which all of this is executed, and the people doing the work. Include in this discussion that the work system model also suggests that a change in one element will necessarily affect (for better or worse) the other elements.
    Second, the model is presented in a manner some of the students should be familiar with – Donabedian’s Structure, Process, Outcome model of quality improvement.
    Here you can explain that the structure affects the manner in which care is delivered, which subsequently affects patient outcomes, but also provider and organizational outcomes (malpractice, extended stays, cost reduction, etc.)
  • This comparison is made with the assumption of a healthcare context
  • Work, time, or trouble have made people avoid this
    Time and trouble avoided later on
  • Shame is not the same as fear of blame or being sued. Since it is internal, the first place most people have to start is with themselves
  • Pros of Swiss Cheese Model
    Lots of people use the model in their slides
    Depicts complexity well
    Many causes linked together
    Helps (somewhat) broaden discussion beyond blame and train
    Helps Wisconsin dairy farmers
    Cons of Swiss Cheese Model
    All barriers look the same, but aren’t
    Appears like “plugging” each hole is the same, but isn’t
    - Stronger versus weaker
    In practice with 163 VA hospitals, hundreds of RCAs
    - Not useful helping dissect problems
    - Not accurate in developing remedies
    Leaves out important principles to fix messy systems (+/- incentives)
  • Put patient safety orientation first on the schedule for new residents/interns/nurses
    Stories here are worth more than in-depth theory discussions
    Some stories and “flow” of ideas are gained by watching Jim Bagian presentation in the VA’s New Employee Orientation Video
    Weeks WB, Bagian JP Developing a culture of safety in the Veterans Health Administration.Eff Clin Pract. 2000 Nov-Dec;3(6):270-6.
  • Dekker’s Field Guide to Human Error Investigations
    - Great analysis of why most safety ideas and practices fail
    - Tools to help avoid pitfalls of safety analysis
    - Words and phrasing that crystallize many concepts
  • Click here for presentation

    1. 1. Practice-based Learning & Improvement: How to Incorporate Trainees in QI/Patient Safety Activities as Part of GME Joseph Conigliaro, MD, MPH, FACPJoseph Conigliaro, MD, MPH, FACP Center for Enterprise Quality and SafetyCenter for Enterprise Quality and Safety Associate Chief Medical Officer, QualityAssociate Chief Medical Officer, Quality and Patient Safetyand Patient Safety
    2. 2. Objectives Understand the definition and scope of QI and patient safety Become familiar with the epidemiology of adverse events in healthcare Build a good foundation for understanding systems approach to patient safety Learn about high reliability organizations Understand and review quality and process improvement activities Summarize skills needed What about litigation?
    3. 3. Goal Create a curriculum and/or teaching techniques that can be incorporated into your clinical practice
    4. 4. Practice Based Learning and Improvement Residents must be able to investigate and evaluate their practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: 1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology 2. Obtain and use information about their own population of patients and the larger population from which their patients are drawn
    5. 5. PBLI Steps Monitor practiceMonitor practice Reflect on or analyze practice to identifyReflect on or analyze practice to identify learning or improvement needslearning or improvement needs Engage in learning or plan improvementEngage in learning or plan improvement Apply new learning or improvementApply new learning or improvement Monitor impact of learning or improvementMonitor impact of learning or improvement
    6. 6. IHI Learning Domains Learning DomainsLearning Domains Health care as aHealth care as a process, systemprocess, system Variation andVariation and measurementmeasurement Customer/BeneficiaryCustomer/Beneficiary knowledgeknowledge Leading, following andLeading, following and making changes inmaking changes in healthcarehealthcare CollaborationCollaboration Social context andSocial context and accountabilityaccountability Developing new, locallyDeveloping new, locally useful knowledgeuseful knowledge Professional subjectProfessional subject mattermatter
    7. 7. Institute of Medicine Report Elevated Patient Safety Agenda Top 10 Causes of DeathTop 10 Causes of Death #1 Heart Disease#1 Heart Disease #2 Cancer#2 Cancer #3 Cerebrovascular#3 Cerebrovascular #4 Pulmonary#4 Pulmonary #5#5 MEDICAL ERRORSMEDICAL ERRORS #6 Pneumonia/influenza#6 Pneumonia/influenza #7 Diabetes#7 Diabetes #8 Motor Vehicles#8 Motor Vehicles #9 Suicide#9 Suicide #10 Kidney Disease#10 Kidney Disease 30,000-98,000 Medical Errors30,000-98,000 Medical Errors
    8. 8. The IOM Challenge Challenged the health care system to reengineerChallenged the health care system to reengineer itself to ensure better outcomesitself to ensure better outcomes Need a system thatNeed a system that – Integrates careIntegrates care – Emphasizes preventionEmphasizes prevention – Utilize evidence-based medicine and measures ofUtilize evidence-based medicine and measures of service and qualityservice and quality
    9. 9. Definition and Scope of Patient Safety Definitions of error, adverse event, andDefinitions of error, adverse event, and patient safety; and why they matterpatient safety; and why they matter Scope of patient safetyScope of patient safety – What we call itWhat we call it – System focus, not individualSystem focus, not individual – What we measureWhat we measure – What we hope to achieveWhat we hope to achieve VA National Center for Patient Safety
    10. 10. Patient safety is the identification and control of hazards that could cause harm to patients Patient safety is the prevention of harm or injury to patients Is Patient safety a euphemism for medical error? – Not really - medical error is poorly defined and often a euphemism for blaming an individual Patient safety is about providing a safe environment in which to practice How can there be quality healthcare if it isn’t safe? What is patient safety?
    11. 11. Semantics? What do you call the following? – Wrong leg is amputated – Wrong medication is dispensed – Diagnosis is “too late” to save patient with meningitis – You almost go into the wrong room to do a lumbar puncture Hold judgment, but consider – Incidence and prevalence vary widely in major journals – Focus is reducing harm to the patient
    12. 12. Working definitions of patient safety, errors, and adverse events VA: Adverse events are: – Are untoward incidents, therapeutic misadventures, iatrogenic injuries or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic or other facility. – May result from acts of commission or omission (e.g., administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.). Human error is irrelevant
    13. 13. Patient Safety Epidemiology How many adverse events? How many close calls? Inpatient vs outpatient? Very dependent on definitions and methodology
    14. 14. And consider the research evidence… Retrospective studies (Brennan, et al, 1991))Retrospective studies (Brennan, et al, 1991)) – 2-4% of hospitalizations2-4% of hospitalizations – 10-40% including close calls10-40% including close calls Cross-sectional (Ely, et al 1995)Cross-sectional (Ely, et al 1995) – 50% with survey of Family Practice docs 2-20 years50% with survey of Family Practice docs 2-20 years experienceexperience Prospective studies (Gopher, 1991; Andrews,Prospective studies (Gopher, 1991; Andrews, 1999)1999) – ICU observation: 1.7 events/patient/dayICU observation: 1.7 events/patient/day – Internal Medicine rounds: 50% of all admittedInternal Medicine rounds: 50% of all admitted patients with 1-10 eventspatients with 1-10 events
    15. 15. 96 - 98% Reliability in Hospitals? What wouldWhat would 99.9%99.9% reliabilityreliability mean?mean? – 1 hour of unsafe drinking water every month1 hour of unsafe drinking water every month – 2 unsafe plane landings per day at O’Hare Airport in2 unsafe plane landings per day at O’Hare Airport in ChicagoChicago – 16,000 pieces of mail lost every hour16,000 pieces of mail lost every hour – 22,000 checks deducted from the wrong bank22,000 checks deducted from the wrong bank account each houraccount each hour – 20,000 incorrect prescriptions every year20,000 incorrect prescriptions every year – 500 incorrect operations each week500 incorrect operations each week *Multiply above numbers by 20 to 40X ~ Hospital*Multiply above numbers by 20 to 40X ~ Hospital ReliabilityReliability
    16. 16. Systems Approach to Patient Safety Systems model examples Systems versus Person-Focused No accountability?
    17. 17. It’s usually the system! (from UW-Madison Systems Engineering Initiative in Patient Safety)
    18. 18. What is the difference between focusing on the person and focusing on the system? Person approachPerson approach – Focus on individualsFocus on individuals – Blaming individuals forBlaming individuals for forgetfulness, inattention, orforgetfulness, inattention, or carelessness, poor productioncarelessness, poor production – Methods: poster campaigns,Methods: poster campaigns, writing another procedure,writing another procedure, disciplinary measures, threatdisciplinary measures, threat of litigation, retraining,of litigation, retraining, blaming and shamingblaming and shaming – Target: IndividualsTarget: Individuals System approachSystem approach – Focus on the conditions andFocus on the conditions and environment in whichenvironment in which individuals workindividuals work – Building fault tolerance in aBuilding fault tolerance in a system of work to reducesystem of work to reduce harm or mitigate its effectsharm or mitigate its effects – Methods: creating betterMethods: creating better systemsystem – Targets: System (team,Targets: System (team, tasks, workplace,tasks, workplace, organization, physicalorganization, physical environment)environment)
    19. 19. High Reliability Organizations Main theoretical construct in safetyMain theoretical construct in safety literatureliterature Learning organizations that makeLearning organizations that make “everything everybody’s business”“everything everybody’s business” Lessons learned from industryLessons learned from industry – Nuclear PowerNuclear Power – AviationAviation
    20. 20. Patient Safety Challenges Medicine Views Errors as Failings WhichMedicine Views Errors as Failings Which Deserve Blame - FaultDeserve Blame - Fault – Train and blame mentality pervadesTrain and blame mentality pervades – Corrective Actions Focus on IndividualCorrective Actions Focus on Individual No Blood No Foul PhilosophyNo Blood No Foul Philosophy – Many in health care ignore or downplay close callsMany in health care ignore or downplay close calls – Is experience the best teacher? Who pays the tuitionIs experience the best teacher? Who pays the tuition for learning from experience of managingfor learning from experience of managing complications?complications?
    21. 21. A More Productive Approach People Don’t Come to Work to HurtPeople Don’t Come to Work to Hurt Someone or Make a MistakeSomeone or Make a Mistake Systems Issues > Individual’s Fault orSystems Issues > Individual’s Fault or ProblemProblem Common vulnerabilities that can be foundCommon vulnerabilities that can be found and fixed for EVERYONE, not just oneand fixed for EVERYONE, not just one person/placeperson/place
    22. 22. Awareness and Shame May be Largest Hurdles 1999 Survey at VA and Private Healthcare1999 Survey at VA and Private Healthcare OrganizationsOrganizations – Only 27% Agreed that Errors were a SeriousOnly 27% Agreed that Errors were a Serious ProblemProblem – 49% “Ashamed” by Error49% “Ashamed” by Error 1999 IOM report concurs1999 IOM report concurs
    23. 23. Multi-Causal Theory “Swiss Cheese” Diagram (Reason, 1991)
    24. 24. “Culture of Safety” and “High Reliability Organizations” Safety is always on the “agenda” –Safety is always on the “agenda” – especially for top managementespecially for top management Embrace information from close calls andEmbrace information from close calls and hazard analysishazard analysis Communication up and down the “foodCommunication up and down the “food chain”chain” If you are not sure it is safe, it is not safeIf you are not sure it is safe, it is not safe
    25. 25. Empirical Evidence that Culture and Attitudes are Key Effective system fixes with evidence meetEffective system fixes with evidence meet resistance from frontlinesresistance from frontlines – Sign the site for wrong-site surgerySign the site for wrong-site surgery – High concentration potassium removed from wardsHigh concentration potassium removed from wards Root cause analyses keep finding the issuesRoot cause analyses keep finding the issues – Communication between various disciplinesCommunication between various disciplines – Failure to “speak up” when something looks “out ofFailure to “speak up” when something looks “out of whack”whack”
    26. 26. Close Calls and High Reliability Organizations Close calls 10-100 times > adverse eventsClose calls 10-100 times > adverse events Noting them and dealing with them is aNoting them and dealing with them is a marker for HRO, culture of safetymarker for HRO, culture of safety People more willing to analyze and delvePeople more willing to analyze and delve into close calls (less shame?)into close calls (less shame?)
    27. 27. Three Related Concepts Human error is a symptom of troubleHuman error is a symptom of trouble deeper in the system (it is the startingdeeper in the system (it is the starting point, not the end)point, not the end) To explain failure, do NOT try to findTo explain failure, do NOT try to find where people went wrongwhere people went wrong Find how people’s assessment and actionFind how people’s assessment and action made sense at the time, given themade sense at the time, given the circumstances that surrounded themcircumstances that surrounded them
    28. 28. Fundamental Skill Sets Trainees Need to be Successful
    29. 29. Skill Sets that are Needed Process Improvement ApproachesProcess Improvement Approaches and Toolsand Tools Research Methodology & DesignResearch Methodology & Design Measurement and Data ManagementMeasurement and Data Management Skills in Change ManagementSkills in Change Management
    30. 30. Process Improvement Approaches and Tools Demming ModelDemming Model CQI and the PDSACQI and the PDSA FADEFADE Six SigmaSix Sigma Lean ThinkingLean Thinking Industrial engineering principlesIndustrial engineering principles
    31. 31. Patient Safety Safety StandardsSafety Standards – PracticesPractices – EquipmentEquipment Sentential EventSentential Event – Root Cause Analysis (RCA)Root Cause Analysis (RCA) Failure AnalysisFailure Analysis – FMEAFMEA Process ImprovementProcess Improvement
    32. 32. Change Management All Too Often NeglectedAll Too Often Neglected – To affect positive change you need to engageTo affect positive change you need to engage people from multiple disciplines to changepeople from multiple disciplines to change their behaviors and the way they havetheir behaviors and the way they have functioned in the past.functioned in the past. Understands motivational theoryUnderstands motivational theory Can help lead the change processCan help lead the change process
    33. 33. Vehicles Department SpecificDepartment Specific – M&MM&M – Exit Rounds – Log and learning plan – Yearly reviewYearly review – Improvement project – Chief Resident LeadersChief Resident Leaders CEQSCEQS – FellowshipFellowship – RCA and other activitiesRCA and other activities – Audit and Feedback sessionsAudit and Feedback sessions Both (?) – Practice-based Small Group Learning Program – Evidence-based Medicine Curriculum
    34. 34. Vehicles Example Exit Rounds Mortality & Morbidity Conference Practice-based Small Group Learning Program Evidence-based Medicine Curriculum Log and learning plan Improvement project Other Program not listed
    35. 35. Arseneau R. Exit rounds: a reflection exercise. Acad Med 1995;70:684-7. Exit Rounds Group session with attendingGroup session with attending Each resident reviews a dischargedEach resident reviews a discharged patient for whom he/she was responsiblepatient for whom he/she was responsible Describes what was learned from caringDescribes what was learned from caring for that patientfor that patient
    36. 36. Mortality & Morbidity Conference Focus on adverse on teaching servicesFocus on adverse on teaching services Analyzes causes and consequences of each eventAnalyzes causes and consequences of each event Should result in proposals for actions to avoid recurrenceShould result in proposals for actions to avoid recurrence of similar eventsof similar events M&M case assigned to each resident who analyzes caseM&M case assigned to each resident who analyzes case in terms of his or her own practice behaviors that could bein terms of his or her own practice behaviors that could be improvedimproved Resident presents these issues during conferenceResident presents these issues during conference Ziegelstein RC, Fiebach NH. “The Mirror” and “The Village”:Ziegelstein RC, Fiebach NH. “The Mirror” and “The Village”: a new method for teaching practice-based learning and improvementa new method for teaching practice-based learning and improvement and systems-based practice. Acad Med 2004;79:83-8.and systems-based practice. Acad Med 2004;79:83-8.
    37. 37. Practice-based Small Group Learning Program Residents meet to review currentResidents meet to review current information about a specific clinicalinformation about a specific clinical problem and to reflect on theirproblem and to reflect on their experiences and challenges with it.experiences and challenges with it. Group discussion is stimulated byGroup discussion is stimulated by prepared material and led by a trainedprepared material and led by a trained peer facilitatorpeer facilitator Foundation for Medical Practice Education (www.fmpe.org/en/programs/pbsg.html)Foundation for Medical Practice Education (www.fmpe.org/en/programs/pbsg.html)
    38. 38. Evidence-based Medicine Curriculum Residents rotate as leaders of group session to discuss applicationResidents rotate as leaders of group session to discuss application of EBM to one of their own patientsof EBM to one of their own patients As prep, residents develop focused clinical question, conduct a litAs prep, residents develop focused clinical question, conduct a lit search, critically appraise evidence, and apply to care of their ownsearch, critically appraise evidence, and apply to care of their own patientspatients Test using different scenarios or abstracts to assess ability to – compose relevant, concise, & searchable clinical questions – conduct efficient literature search – choose relevant & methodologically sound evidence – calculate statistics relevant to diagnosis & treatment Green ML, Ellis PJ. Gen Intern Med 1997;12:742-50. Smith CA, et al J Gen Intern Med 2000;15:710-5.
    39. 39. Log and Learning Plan Working with a mentor, residents keep a log ofWorking with a mentor, residents keep a log of significant events or clinical surprises andsignificant events or clinical surprises and develop a plan to address learning needsdevelop a plan to address learning needs revealed by these events.revealed by these events. Resident submits written analysis of critical incident or pattern of practice behaviors Related learning plan are rated against specific criteria Fung Kee Fung M. et al An internet-based learning portfolio in resident education: theFung Kee Fung M. et al An internet-based learning portfolio in resident education: the KOALATM multicentre rogramme. Med Educ 2000;34:474-9.KOALATM multicentre rogramme. Med Educ 2000;34:474-9. ACGME. Advancing education in Practice-based Learning & Improvement. ACGME, 2004.
    40. 40. Improvement Project Residents work with a mentor to identify anResidents work with a mentor to identify an aspect of their own practice that needs to beaspect of their own practice that needs to be improvedimproved Implement the improvementImplement the improvement Determine its effectiveness during senior yearDetermine its effectiveness during senior year Completes it within 12 months Rater uses a checklist to assess it Lough JRM, Murray TS. Audit and summative assessment: a completed audit cycle.Lough JRM, Murray TS. Audit and summative assessment: a completed audit cycle. Med Educ 2001;35:357-63.Med Educ 2001;35:357-63.
    41. 41. At UK Example Perform in your program (yes/no) Exit Rounds Ortho-postoperative conference Surgery Mortality & Morbidity Conference Path Cardiology Otolaryn Pulm/CC Diag Radiology OMS Surgery Nephr Ortho Medicine Anesthesia Practice-based Small Group Learning Program Path Otolary Psych Pulm/CC Ortho Cardiology Anesthesia Nephr Evidence-based Medicine Curriculum Path Cardiology Otolary Pulm/CC Ortho (Journal Clubs) Anesthesia Surgery Nephr Log and learning plan Diag Rad Cardiology Otolary Ortho Anesthesia Improvement project Path OMS-prn Oto lary Pulm/Critical Care Anesthesia Nephr Other Program not listed Pulm/Critical Care-Systems Based Practice Project Nephr CQI
    42. 42. National Peer Review Protection? Patient Safety and Quality andPatient Safety and Quality and Improvement ActImprovement Act – June 2005June 2005 – Established broad confidentiality and privilegeEstablished broad confidentiality and privilege protections for info reported to PSOsprotections for info reported to PSOs – Data, reports, records, memos, analyses,Data, reports, records, memos, analyses, written or oral statements that are reportedwritten or oral statements that are reported
    43. 43. Litigation? Federal Rules of Evidence – Relevance (similarity and timing) – Danger of unfair prejudice Admissibility as evidence – Process measures – Outcomes measures – Rankings Specificity vs Aggregation Kesselheim, et al.JAMA. 2006;295:1831-1834.
    44. 44. Conclusions QI/Patient Safety activities should be focused on the system and not the individual Patient Safety is proactive with a focus to prevent patient harm Blame free Engage trainees in Institution wide initiatives and aggregate data as needed
    45. 45. Useful Web Sites http://www.improvementskills.orghttp://www.improvementskills.org (excellent tutorial site –(excellent tutorial site – free or $10 if you want CME)free or $10 if you want CME) http://www.patientsafety.govhttp://www.patientsafety.gov (tools and links to improve(tools and links to improve patient safety)patient safety) http://www.pqe.orghttp://www.pqe.org (partnership for quality education –(partnership for quality education – joint sponsor by RWJ and Pew Trust)joint sponsor by RWJ and Pew Trust) http://www.mceconnection.org/mce/http://www.mceconnection.org/mce/ (managed care(managed care education connection)education connection) http://www.ihi.orghttp://www.ihi.org (Institute for Healthcare Improvement)(Institute for Healthcare Improvement) http://www.ahrq.govhttp://www.ahrq.gov (Agency for Healthcare Research(Agency for Healthcare Research and Quality)and Quality) http://www.hce.orghttp://www.hce.org (Health Care Excel)(Health Care Excel)

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