Ambulatory Care Practice Improvement For Residents: Tools, Challenges, and Solutions

Transcription

1 Ambulatory Care Practice Improvement For Residents: Tools, Challenges, and Solutions April 13, APDIM Spring Conference Lucy Gordon, MD Rand David, MD Lawrence Reich, MD Mount Sinai School of Medicine (Elmhurst) ELMHURST HOSPITAL CENTER

2 Primary Goal Become familiar with various methods of carrying out an ambulatory based practice improvement curriculum that can be adapted to your institution

3 Session Content 1. ACGME Program Requirements for PBLI 2. Basic Concepts of Practice Improvement 3. Assessing Competency in PBLI 4. Implementing an Ambulatory Based PI Curriculum 5. Group Exercise 6. Wrap-Up/ Results of our Projects

4 ACGME Program Requirements for Practice-based Learning and Improvement ELMHURST HOSPITAL CENTER

5 Practice-based Learning and Improvement Residents must demonstrate the ability to investigate and evaluate their care of patients and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals: set learning and improvement goals; systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; From ACGME Program Requirements for Graduate Medical Education in Internal Medicine (note above are common program requirements)

6 Each resident s longitudinal continuity experience: must include evaluation of performance data for each resident s continuity panel of patients relating to both chronic disease management and preventive health care. Residents must receive faculty guidance for developing a data based action plan and evaluate this plan at least twice a year. From ACGME Program Requirements for Graduate Medical Education in Internal Medicine

7 The program must provide objective assessment of competence Practice-based learning and improvement: The program must assess resident performance in: practice improvement, Assessment of practice must include use of performance data. From ACGME Program Requirements for Graduate Medical Education in Internal Medicine

8 Fundamentals of Practice Improvement ELMHURST HOSPITAL CENTER

9 Practice Improvement Residency = practice improvement Fundamental clinical quality Yet, it remains elusive

10 Many clinicians lack the knowledge and the skills to be effective practitioners of practice improvement More clinicians lack the knowledge and the skills to be effective teachers of practice improvement

11 Until recently, hospital s QI activities not seen as compatible with residency training. Residents systematically excluded from much of a hospital s QI activities.

12 Rules change Needs change Paradigm shift

13 It is hoped that by the next generation of clinician educators, performance improvement will be such a fundamental part of a clinician s day to day practice that performance improvement would no longer need to be singled out into a special competency.

14 QI Methodologies PDSA Six sigma Lean

15 PDSA Cycle Plan-Do-Study-Act Roots in manufacturing industry Small-scale, short-cycles tests linked to reflection

16 PDSA Cycle

17 Six Sigma One SD, excludes 5% Six SD s 99,9996% of values Motorola Identify and remove causes of error

18 Six Sigma Define Create project charter Measure Define the data collection plan Multiple sources Analyze Focus on deviations from standard Improve Creative solutions and implementation plans Control Implementing policy and guidelines

19 Lean Methodology Toyota Focuses on removing non value added activities (waste) Value stream mapping

20 Assessment Portfolio Project Medical Record Review Performance rating Self assessment/learning plan

21 Implementing an Ambulatory Based Practice Improvement Curriculum ELMHURST HOSPITAL CENTER

22 Implementing a PI Curriculum Why use the Ambulatory Care setting? -residents are required to review performance data about their continuity patients -most ambulatory blocks have time for scheduling didactic/group sessions -weekly continuity clinic allows ongoing projects during the year

23 Literature about PI Curricula: common themes Didactic component Project participation/experiential Learning Evaluation/Assessment of learning experience Uncertainty about specific learning objectives: What exactly do our residents need to learn?

24 Ambulatory Care PI Curriculum: essential steps Choosing Topics Using established modules or creating your own Methods of Collecting Data Interpreting Data with residents Establishing Aims for Improvement Implementing and Testing Changes Integrating Background Knowledge

25 Establishing Your Own Modules Ability to choose topics of interest to residents Can format the data collection tool to reflect your clinic system/ EMR Flexibility Our modules for Diabetes, Osteoporosis Screening, and Mammogram/Cervical cancer screening are provided as examples/takehome tools

26 Establishing your own modules: tips Pick commonly encountered topics Define continuity patients Use valid measures Set clear inclusion criteria Collect data for 5-10 patients per resident Confidentiality (eliminate full patient identifiers) Comments section

27 Choosing measures Will a change in measure lead to an improvement in patient care? Use practice guidelines/evidence based medicine Can refer to CMS/Physician Quality Reporting System: #TopOfPage list of measures and detailed guide explaining rationale For each measure: What is defined as the ideal goal? What will be considered out of control and what is the rationale? Process or an outcome?

28 Example: Choosing cut-offs for measures PQR 2011 Measure 1: Hb A1C Poor Control In Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% From 2011 Physician Quality Reporting System (Physician Quality Reporting) Measures List

29 Example: Women s Cancer Screening Screening Mammography: 2011 PQR Measure #112: Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months Cervical Cancer Screening: Referred to current practice guidelines (ACOG 2009)

30

31 Using Established modules ABIM PIMS for Training Programs 14 topics (asthma, colonoscopy, Diabetes, Preventive Cardiology) Cost: $100 per module plus $25 per participant Recommend 5 patient surveys per participant (minimum of 25 surveys)

32 ABIM PIMS Guided through medical record audit, patient survey, and/or systems examination After data are submitted an aggregate report given to group Develop/implement QI exercise

33 ABIM PIMS: Advantages Guides group through process Good for faculty with less experience in PI Literature supports use

34 Disadvantage Funding Less flexible Must name all participants when order is placed and names cannot be changed or added All participants must work along the same time frame

35 Use of PIMS in Literature Use of PIMS alongside didactic curriculum was effective as indicated by resident s selfassessment 1 Use of PIMS resulted in statistically significant improvements in measures 2. 1 Shunk et al. Using the American Board of Internal Medicine Practice Modules to Teach Internal Medicine Residents Practice Improvement. Journal of Graduate Medical Education, March 2010; 2(1): Oyler et al. Teaching Internal Medicine Residents Quality Improvement Techniques Using the ABIM s Practice Improvement Modules. J Gen Intern Med 2008; 23(7):927-30

36 Data Collection Prospective, sequential sample Residents collect data as they encounter patients in clinic Retrospective sample Use appointment log/chart review to find the resident s continuity patients Use of a registry if it is available Be systematic, avoid cherry picking Remember: not scientific research, a small number of charts is fine

37 Interpreting Data: Ideas for change Residents should describe and assess their individual data If working on common topics can combine data for overall trends as well A team or an individual can target an area for improvement Make a specific aim for improvement Make a plan for a change A plan can be carried from one resident group to another Include relevant staff on team: clerks, nurses

38 Group Session We meet as a group at end of each block Residents present their personal data Leads to group discussion Other content introduced as appropriate Flow charts, root cause analysis, identifying stakeholders, PDSA, chronic care model Certain tasks are delegated to residents to carry out the plan/test

39 Other Administrative Tasks Keeping track of the PI projects and performance data of all residents over 3 years is a lot of work In addition to scheduled group sessions also need individual follow up Formal documentation of completion of projects Need dedicated faculty with time to devote to this curriculum

40 Time Challenges Enough time to collect data (if prospective) Enough time to try out and test changes Faculty Knowledge, faculty development, time Interns The goals and expectations for interns needs to be adapted Not realistic for them to review continuity performance data every 6 months

41 Time Solutions Need time to collect data (if prospective) Pick commonly encountered topics Use retrospective data/registry if available Enough time to try out and test changes Focus on process measures rather than outcome

42 Solutions Faculty Knowledge: faculty development Various resources (some provided end of slides) Use PIMS Time Delegate to faculty who can dedicate time to this May need multiple faculty depending on size of program

43 Solutions Interns Establish different goals and expectations More didactic based, introduce key concepts Data-review of continuity panel/action plan once at end of year rather than twice a year for interns

44 Group Exercise Practice a group session ELMHURST HOSPITAL CENTER

45 Conclusion: Results of Our Residents Work ELMHURST HOSPITAL CENTER

46 Our Experiences Residency program at a municipal hospital 60,000 visits a year to our primary care clinic 9 prelim, categorical per year PGY-1: 1 month ambulatory PGY-2: 2 months ambulatory +1mo specialty clinics PGY-3: 3 months ambulatory, 1 mo Community Medicine Ambulatory months have dedicated time for didactic sessions

47 Overview of our Schedule Week 1 didactic: brief introduction to the projects (assign data collection or role in project) Collect data during the month and continuity clinic sessions 1 hour session end of each month Topics: Diabetes, Osteoporosis Screening, Mammogram, Cervical Cancer Screening, HIV testing, Medicine Reconciliation

48 Examples of Projects Diabetes: Microalbumin Screening Ordering microalbumin/cr urine testing required multiple steps in our EMR Quick-pick list of commonly ordered tests in the EMR but microalbumin was not on it Process Outcome: Residents suggesting adding the test to the quick-pick order list

49 Microalbumin Screening

50 Percentage of Residents Diabetic Patients With microalbumin checked annually Improved from 67% to 89% Before After Patients with microalbumin checked Before Group: 7 residents (6 pgy-3, 1 pgy-2), 42 patients (summer/fall 2009) After Group: 7 residents (3 pgy-3, 4 pgy-2), 38 patients (spring 2010)

51 Other Projects Diabetes Hyperlipidemia education handouts: did not work medicine reconciliation (ongoing) Mammogram/Pap Screening most residents felt that they were doing well Decided to move on to other topics

52 Educational Objectives Learn about a variety of methods that could be used in an ambulatory based Practice Improvement curriculum for residents at your institution Be aware of challenges that arise in working to fulfill the program requirements for PI in the ambulatory setting, and have some practical solutions

53 Future Goals ACGME IM Program requirements for PBLI should be more specific Goals should not be the same for all resident levels: and should be more progressive by milestones/pgy level

54 Take Home Tools Examples of our curriculum handouts and instructions for residents Data collection sheets for diabetes, mammogram, cervical cancer screening, osteoporosis screening Sample project completion form

55 Faculty Resources ACP Quality Improvement Programs ement/ Institute for Healthcare Improvement Mayo Clinic CME: Teaching Quality Improvement - PIM Support: good resource even if you are not using PIMS es/default.aspx MedEdPORTAL:

56 Thank you! Contact us with any questions: Lucy Gordon: Rand David: Lawrence Reich: ELMHURST HOSPITAL CENTER

57 Ambulatory Care Practice Improvement: -Sample Handout Materials for Residents Intro to Curriculum/ Practice Improvement Background Explanation of Projects/data collection and evaluation -Sample Project Completion Form for faculty sign-off Developed by Lucy Gordon, MD Mount Sinai School of Medicine (Elmhurst)

58 Practice Improvement: Ambulatory Care Resident Project Why learn about practice improvement? To reflect upon and improve the care we provide to our patients; to encourage ongoing selfassessment. ACGME requirement (Practice Based Learning and Improvement) Part of requirements for maintenance of certification by ABIM pay for performance Quality/Practice Improvement 1 Quality consists of the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (evidence) - Institute of Medicine IOM 6 Aims for Improvement of Healthcare: Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable The Process of Practice Improvement Always start by considering the following questions: What are we trying to accomplish? How will we know that a change is an improvement? ` What changes can we make that will result in improvement? 1) Forming a Team. Ideally the team should include both administrators/leaders and those involved in daily processes: doctors, nurses, front desk staff, pharmacists, etc. The team should include willing, eager participants. 2) Setting Aims for improvement. Set a focused goal that is time specific and can be measured. This may be a change in patient health status or behavior, patient satisfaction, etc. Consider improvements at the level of an individual provider as well as the overall system. 3) Measurements are an essential part of the process of practice improvement. -Measuring Outcomes: a result, such as HbA1C (reflects the patient) -Measuring a Process: a step in the system, such as ordering a Hba1c test (reflects the system) -Balance: make sure a new change is not causing a problem in another part of the system -choice of measurement: choose a valid measure by established organization, such as PQRS, practice guidelines, etc. -inclusion criteria: ensure the patients you are choosing to include are appropriate Note that measuring for PI is different than measuring for research. For PI we only need to gather just enough data to learn about our practice and evaluate changes. There can be many small, sequential test of change rather than one large test that takes a long period of time. 1 (adapted from ACP Closing the Gap and AAIM PIM support materials)

59 4) Testing Changes. Study a change to see if it is helping to meet the aim for improvement. PDSA Cycle. Plan, Do, Study, Act. Plan: Plan the observation or test. Define the objective and how data will be collected, and predict outcome. Do: Carry out the change and document problems; begin to look at data. Study: Analyze the data, compare to initial prediction, and reflect on what was learned. Remember that not all changes will result in improvement. Act: Refine the change and plan for the next test. Data Collection Methods The approach used may vary, but should be determined so as to avoid any selection bias. Some examples include: Prospective, sequential sample. This means that you will review the chart of all patients who have an appointment with you going forward and include all patients who meet inclusion criteria until your goal sample size is complete. Retrospective, sequential sample. Use an appointment log or registry to identify patients with recent visits and who meet inclusion criteria. Review the charts of these patients going back in time, including all patients who meet inclusion criteria until the sample is complete. Chronic Care Model (information adapted from ACP Closing the Gap training materials) The Chronic Care Model identifies elements of a health care system that support high-quality care for chronic diseases. Quality improvement plans that are based on elements of the chronic care model are more likely to be successful. Elements of the CCM Self-management: Well-informed patients will be more active in managing their health; selfmanagement can encompass support groups, telephone follow up. Decision support: Treatment decisions should be consistent with scientific evidence and patient preferences. Providers should use evidence-based guidelines, share guidelines with patients, and be involved in ongoing education/training. Guidelines can be integrated into reminders, feedback. Delivery system: To deliver effective care, establish a system in which the roles and tasks of team members are clearly defined; ensure regular follow-up by the care team. Clinical information systems: Organize patient data to facilitate efficient and effective care. A registry or EMR can be used to follow individual patients, identify groups of patients that need additional care, and monitor performance. Community: Use community resources to meet the needs of patients. Health system: Create a culture that promotes high quality of care.

60 Resources: ACP: Alliance For Academic Internal Medicine: PIM Support Physician Quality Reporting System (a list of measures developed by various organizations): JAMA. 2002; 288: Improving Primary Care for Patients with Chronic Illness. Robert Wood Johnson Foundation: Institute for Healthcare Improvement

61 Practice Improvement: Ambulatory Care Resident Project Details Block 10. Group presentations: 4/8/11, 8:15am. Project Requirements: Oral presentation if you are on block when it is scheduled Written summary of findings Copy of your data collection form to be turned in Data Collection: During your ambulatory care block you will collect some personal performance data about chronic diseases and/or preventive care. Throughout the year we will focus on different areas (such as diabetes, hypertension). You will either collect your own data or be provided with data for your patient panel from a registry. If you are collecting your own data, when you encounter patients in clinic for whom you are the primary care provider (patients you have seen at least twice, including the present visit), please collect data on the form provided. To protect patient privacy the form will only ask for the last 2 digits of the MRN. Try to collect data from 5-10 patients on the form. Although the sample of patients will not be random, do not intentionally omit a patient you had initially chosen because the outcomes are not good. As some of you are only on block for 2 weeks at a time, you should start to collect data and can complete the form during your continuity clinics and the next ambulatory care block. Oral Presentations: You will be asked to share what you have learned with the group in a brief oral presentation during a designated session. You can discuss both what you did well and what areas might need improvement, as well as ideas for changes you might make to improve outcomes. There will be a few presentations in each session, so plan to make yours about 5 minutes. During this session we will also brainstorm as a team on ways to improve practice in the areas discussed. Throughout the year we will try to test some of your ideas. Written Summary: The written summary and oral presentation should touch on the same concepts. Description of your data (such as 7/10 patients with DM had a1c at goal) Set an aim for improvement (such as I will try to do more monofilament exams) Describe a plan of change to make the improvement Describe what you plan to measure to test the change and see if improvement occurred. Goal: By end of the year residents should feel comfortable studying their practice, brainstorming, implementing and testing ideas for change, and should be familiar with general concepts of quality improvement and the chronic care model. Project Mentor: Lucy Gordon gordonlu@nychhc.org pager Please contact me with any questions about this project!

62 Sample Project Completion Documentation Form (Can print on letterhead) Academic Year Performance Data Requirement Resident: PGY: Each resident in the Elmhurst Internal Medicine Residency Program is expected to review performance data for his/her continuity panel twice a year, and to develop a data-based action plan under the guidance of a faculty member. This resident has reviewed his/her performance data with a faculty member and developed a databased action plan for the following: Topic: Chronic Disease Management Preventive Health Care Date reviewed: Faculty Signature: Faculty Name, MD Project Supervisor

63 Ambulatory Care Practice Improvement Materials: Sample Data Collection Forms (for Diabetes, Mammogram/Pap Screening, Osteoporosis Screening) Materials Developed by Lucy Gordon, MD Mount Sinai School of Medicine (Elmhurst)

64 Ambulatory Care Performance Data: Diabetes Resident Name: PGY Note: Please collect data for patients you have personally seen at least twice (including the present visit). If a test was ordered but not completed please record ordered and the date. Pt last 2 digits of MRN Date of Visit 1. %: Last Hb A1c GOAL: <7% Last LDL GOAL: <100 #: Blood Pressure GOAL: <130/80 Date of last monofilament foot exam GOAL: annually Date last eye exam GOAL: annually Date Last Nephropathy Screen (microalbumin or urine protein) GOAL: annually Comments Date: 2. %: Date: #: Date: 3. %: Date: #: Date: 4. %: Date: #: Date: 5. %: Date: #: Date: 6. %: Date: #: Date: 7. %: Date: #: Date: 8. %: Date: #: Date: 9. %: Date: #: Date: 10. %: Date: #: Date: Date:

65 Resident: PGY Screening and Prevention for Osteoporosis Inclusion Criteria: (of patients you have seen at least twice) Women 65 years and older Men 70 years and older Postmenopausal women with risk factors* Men ages with risk factors* *Risk factors include Low body mass index Prior osteoporotic fracture Oral glucocorticoids >5mg/day prednisone for >3 months (ever) Smoking Excess alcohol intake Parental history of hip fracture Rheumatoid Arthritis Secondary Causes of Osteoporosis (including hypogonadism/premature menopause, endocrine disorder such as hyperthyroid, cushing, hyperparathyroidism, IBD, chronic liver disease) Date of Visit Last 2 digits MRN Sex M/F Age Inclusion Criteria Has patient ever had BMD tested? If not tested, was test ordered? Is patient on pharmacotherapy for osteoporosis? Is there documentation of counseling or RX for calcium intake? Is there documentation of counseling/testing or RX for Vitamin D intake? M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N M/F Y/N Y/N Y/N Y/N Y/N Y/N Is there documentation for counseling about weight bearing exercise? Comments

66 Resident: PGY Mammogram and Pap Screening Practice Review: For Women ages years old (please pick patients you have seen at least twice in clinic, including the current visit.) Last 2 # MRN Date of Visit Date Last Mammogram Mammogram up to Date by guidelines? (see below) If no, had a mammogram been ordered? Date Last Pap Pap up to date by Guidelines? (see below) 1. Yes/ No Yes/ No 2. Yes/ No Yes/ No 3. Yes/ No Yes/ No 4. Yes/ No Yes/ No 5. Yes/ No Yes/ No 6. Yes/ No Yes/ No 7. Yes/ No Yes/ No 8. Yes/ No Yes/ No 9. Yes/ No Yes/ No 10. Yes/ No Yes/ No If no, was pt referred to pap clinic or gyn? Comments Pap Smears: ACOG 2009 recommendations: Start age 21. Ages every 2 years. age >30, 3 years after 3 normal consecutive smears, no history CIN 2 or 3, and no increased risk. (also for women >30. option to do HPV screening +pap together) Mammogram: Differing recommendations. Most organizations (ACS, ACOG, AMA) advise starting at age 40 years old with screening every 1-2 years; yearly after age 50; USPSTF 2009 recs: screen age every 2 years. No routine screening for average risk, discuss with patient. (see attached). WHO 2009: mammo q 1-2 years women