Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A...

Vanderbilt University Medical Center

Linking Outcomes of Care to the ACGME Core

Competencies: A Matrix Solution• 3:15 pm – 3:25 pm Introduction

Berend Mets, MB, Ph.D., Moderator

• 3:25 pm – 3:55 pm Embedding the Core Competencies Using the MatrixJohn BinghamDirector, Center for Clinical ImprovementVanderbilt University Medical Center Nashville Tennessee

• 3:55 pm – 4:10 pm Question & Answer Session

• 4:10 pm – 4:40 pm Practical Examples of the MatrixDoris Quinn, Ph.D.Assistant Professor, Division of Medical EducationVanderbilt University Medical Center Nashville Tennessee

• 4:10 pm – 4:55 pm Question & Answer Session


Linking Outcomes of Care and the ACGME Core Competencies:

A Matrix Solution

John Bingham, MHADirector

Center for Clinical Improvement

SAAC/AAPD Annual MeetingWashington, DC

November 5, 2005

Doris Quinn, PhDAssistant Professor

Division of Medical Education


Objectives for today:

1. Discuss the Institute of Medicine (IOM) Aims for Improvement and the ACGME Core Competencies.

2. Describe how the Healthcare Matrix helps link outcomes of care to learning the core competencies.

3. Provide examples of how the Healthcare Matrix is used to improve education and the delivery of care.


1999 2001 2002 2003 2004

Emerging public

reporting of

quality

measures

“Hospital Compare”

“Kyros” Events in Healthcare:


Extrapolated study results imply that between 44,000-98,000 U. S. hospital patients die each year as

a result of medical errors.March 2000


“Five Years After To Err is Human: What Have We Learned?”

Lucian L. Leape, MD; Donald M. Berwick, MD JAMA, May 18, 2005

“If the experience of the past 5 years demonstrates anything, it is that neither strong evidence of ongoing serious harm

nor the activities, examples, and progress of a courageous minority are

sufficient to generate the national commitment needed to rapidly advance

patient safety.”

And what about today?


Patient Care should be:

Safe, Timely, Effective,Efficient, Equitable, Patient-

Centered(STEEEP)


Phase I Phase II Phase III Phase IV

7/2001 6/2002 7/2002 7/20116/2006 7/2006 6/2011 Beyond

• Improve the evaluation processes for all six of the Competencies.

• Provide aggregated resident performance data for Internal Review Process.

• Use resident performance data as the basis for improvement.

• Begin to use external quality measures to verify resident and program performance levels.

• Identify benchmark programs.

• Involve community in building knowledge about good GME.

• Define specific objectives for residents to demonstrate learning of the competencies.

• Begin integrating the teaching and learning of competencies into residents’ didactic and clinical experiences.


“Clinical education simply has not kept pace with or been responsive enough to:

• shifting patient demographics,• changed health system

expectations,• evolving practice requirements,• new information,• a focus on improving quality,• new technologies.”


– Reporting of CMS Quality Measures tied to Annual “CMS Market Basket Update”

• November 2004

– “Recommend to Congress that it adopt pay-for-performance for physicians, hospitals, and home health agencies”

• Medicare Payment Advisory Commission: March 2005

“Hospital Compare”

Emerging public

reporting of quality

measures


Patient Care

(Assessing it …and getting ready for physician report

cards!)

The first Core Competency:


Patients with

Needs

Patients with Needs

Met

What are you measuring to evaluate the quality of Anesthesia care?

How and where are these data reported?

How is the information utilized to improve:

•the education of residents?

•the quality of care provided?

Access Diagnosis Treatment Follow-upAssessment


Patient Care should be:

Safe, Timely, Effective,Efficient, Equitable, Patient-Centered

(STEEEP)


PRACTICE-BASED LEARNING AND IMPROVEMENT

(What have we learned, what will we improve)

Improvement

SYSTEM-BASED PRACTICE

(What is the Process?On whom do we depend and who depends on us)

PROFESSIONALISM(How must we act)

INTERPERSONAL AND COMMUNICATION

SKILLS(What must we say)

MEDICAL KNOWLEDGE

(What must we know)

PATIENT CARE(Overall Assessment)

Yes/No

Assessment

PATIENT-CENTERED

EQUITABLE

EFFICIENTEFFECTIVETIMELYSAFE AimsCompetencies

Healthcare Matrix: Care of Patient(s) with….


“Avoiding injuries to patients from the care

that is intended to help them”

PATIENT CARE that is…

Safe



Safe

•What is our Anesthesia performance for:

•% Patients with appropriate prophylactic antibiotic?

•% Cardiac Surgical Patients with controlled perioperative serum glucose (200 mg/dL)

•% Cases with documented Time Out?

•Intra- or postoperative:

•Cardiac arrest during hospitalization?

•PE during hospitalization?

•DVT during hospitalization?

•Anesthesia Complications/1000 surgeries?


Is Care Is Care Safe ?Safe ?VUMC Goal: Achieve lowest mortality in VUMC Goal: Achieve lowest mortality in

nationnationVUMC 2004

VUMC 2005

Observed to Expected Mortality:53 UHC AMCs with Level I Trauma

Centers


9 9 7 5 0 4 2 3 0 2 2 3 3 1 1 2 1 0 2 4 3 3 3 2 2 2 4 2 4 2 0 4

3 42 3

13

1 10

3 2 3 41 3 3 2 4 3

4 4 4 4 5 5 7 43

60 8 4

1828

2432

24

31 40 3330

3327 28

18 26

35 30 31 28

37 3730

4034 31

3427

40 2535

3137

4226

36

41

34

41 34

32

28

2630

56

39 30

3940

31 2147

5040

4531 42

4137

37

40

43 3640

50

1415

6

10

5

158

17

1313

10

9

712

11 14

6 13

18

14

818

1310

10 13

12

12

1116

13

14

37

0

20

40

60

80

100

120

140

Jan-

03

Feb-

03

Mar

-03

Apr-

03

May

-03

Jun-

03

Jul-0

3

Aug-

03

Sep-

03

Oct

-03

Nov

-03

Dec

-03

Jan-

04

Feb-

04

Mar

-04

Apr-

04

May

-04

Jun-

04

Jul-0

4

Aug-

04

Sep-

04

Oct

-04

Nov

-04

Dec

-04

Jan-

05

Feb-

05

Mar

-05

Apr-

05

May

-05

Jun-

05

Jul-0

5

Aug-

05

Month

Act

ual n

umbe

r of

Mor

talit

ies

0

0.2

0.4

0.6

0.8

1

1.2

O/E

Rat

e

Peds

Medicine

Surgical Science

Neurology

Other

VUMC O/E

0.85

VUMC Overall O/ E Ratio Line

(.77 for 2Q 2005)

VUMC Elevate Goal: .85

Best AMC

VUMC Observed to Expected Mortality and Actual Number of Mortalities 2003-2005


“Reducing waits and sometimes harmful delays for both those who receive and those who give care”


Timely

Safe



Timely

Safe


•% Patients with Anesthesia Prep Time < 15 Minutes?

•% Patients with on-time prophylactic antibiotics?

•% Patients with prophylactic antibiotics? discontinued <24 hours after surgery end time?

•% cases completed < 15% of scheduled length?

•% cases with surgical consent before day of surgery?

•Average time between cases (Gap Time)?

•Average time between “room ready” and “in room”?


Percentage of Surgery Patients Who Received Preventive

Antibiotic (s) One Hour Before IncisionTop Hospitals:

93%

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES

AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE

VANDERBILT UNIVERSITY HOSPITAL

69%

64%

47%

Top Hospitals represents the top 10% of hospitals nationwide (Data displayed are from data reported July-Dec.04)


What is the infection rate for surgical patients (in total, by procedure, by specialty, by surgeon; by site of surgery) ?

Exceptions by procedure, by specialty, by surgeon; by site of surgery ?

Received the appropriate antibiotic?

Received prophylactic antibiotics?

Received within one hour prior to surgical incision?%

% with Infectio

n

No Yes

No

% with Infection

% with Infection

% with Infection

Yes

No Yes

Exceptions

Patients with

Needs

Patients with Needs

Met



Percentage of Surgery Patients Whose Preventive Antibiotics

are stopped Within 24 Hours After Surgery

Top Hospitals:100%

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES

AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE

VANDERBILT UNIVERSITY HOSPITAL

64%

58%

78%

Top Hospitals represents the top 10% of hospitals nationwide

(Data displayed are from data reported July-Dec.04)


“Providing services based on scientific knowledge to all who

could benefit and refraining from providing services to those not

likely to benefit”


Timely

Effective

Safe



Timely

Effective

Safe


•% Patients that received preoperative prophylaxis for VTE?

•% non-cardiac vascular surgery patient receiving beta-blockers during perioperative period

•% Patients with CAD who received beta blockers during perioperative period?

•% Patients on a ventilator whose post op orders included elevating bed >= 30 degrees?


“Avoiding waste, including waste of equipment, supplies, ideas, and

energy”


Timely

EfficientEffective

Safe



Timely

EfficientEffective

Safe

•What is our Anesthesia performance (over time) for:

•Total cost per case?

•Supply cost per case?

•Supply waste per case?

•OR non-billable time delays due to Anesthesia?

•Rate of increase in revenue vs. expenses?


“Providing care that does not vary in quality because of personal

characteristics such as gender, ethnicity, geographic location, and

socio-economic status”


Timely

EfficientEffective

Equitable

Safe


Is Care Is Care Equitable?Equitable?AHRQ 2004 National Healthcare Disparities

Report Released 2/22/2005•Blacks:

• had worse access than whites for about 40% of access 40% of access measuresmeasures• received poorer quality for about 66% of quality measures66% of quality measures

•Asians:• had worse access than whites for about 33% of access 33% of access measuresmeasures• received poorer quality than whites for about 10% of quality10% of quality measuresmeasures

•Hispanics:• had worse access than non-Hispanic whites for about 90% 90% of access measuresof access measures• received lower quality of care than non-Hispanic whites for 50% of quality measures 50% of quality measures

•Poor people:• had worse access for about 80% of access measures80% of access measures than those with high incomes • received lower quality of care for about 60% of quality 60% of quality measuresmeasures


“Providing care that is respectful of, and responsive to:

•individual patient preferences,

•needs and values,

•and ensuring that patient values guide all clinical decisions”


Timely

EfficientEffective

Equitable

Patient Centered

Safe


Is Care Is Care Patient Centered?Patient Centered?HCAPS/CMS Patient Perception Surveys

Effective in 2006-Public in 2007

What are our patients’ perceptions of:

•Communications with Nurses? •Communications with Doctors?•Communications about medications?•Nursing services?•Pain management?•The hospital environment?•Adequacy of discharge information?•Our system overall?•Their willingness to recommend us?


“…about established and evolving biomedical, clinical, and cognate sciences, (e.g. epidemiological and social-behavior) and the application of this knowledge to

patient care”

Medical Knowledge


Timely

EfficientEffective

Equitable

Patient Centered

Safe

What must we know?


Medical Knowledge

Interpersonal and Communication Skills

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

“…that result in effective information exchange

and teaming with patients, their families, and

other health professionals.”

What must we say?


“…as manifested through a commitment to carrying out professional responsibilities,

adherence to ethical principles, and sensitivity to a diverse patient population.”

Medical Knowledge

Interpersonal and Communication SkillsProfessionalism

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

How must we behave?


“…as manifested by actions that demonstrate an awareness of, and responsiveness to, a

larger context and system of healthcare and the ability to effectively call on system resources to

provide care that is of optimal value.”

Medical Knowledge


System-Based Practice

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

What is the Process?On whom do we depend?

Who depends on us?


“…involves investigation and evaluation of their own patient care, appraisal and

assimilation of scientific evidence, and improvements in

patient care.”

Medical Knowledge


System-Based Practice

Practice-Based Learning & Improvement

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

What have we learned?What will we improve?


Patients with

Needs

Patients with Needs Met


Linking it all together….Linking it all together….

-Medical Knowledge

-Interpersonal and Communication Skills

-Professionalism

-Practice-Based Learning & Improvement

Timely EfficientEffective Equitable Patient CenteredSafe

-System-Based Practice

Clinicians competent in:

Patient Care that is…


QUESTIONS?


“Residents live in the cracks of our health care systems and give

voice to what life is like there.”

Paul Batalden, MDDartmouth Medical School


Five Applications of the Matrix

I. Individual Resident Learning

II. Case Presentations

III. M & M Conference

IV. Panel of Patients for Group Learning

V. Medical Students


Individual LearningCase Presentation


IOM

ACGME

SAFETY TIMELINESSEFFECTIVE-

NESSEFFICIENCY

EQUITA-BILITY

PATIENTCENTERED-

NESS

PATIENT CARE

MEDICAL KNOWLEDGE & APPLICATION

X X

PROFESSIONALISM

INTERPERSONAL & COMMUNICATION SKILLS

SYSTEMS- & TEAMS-BASED PRACTICE

X

PRACTICE-BASED LEARNING & IMPROVEMENT(Process to Improve)

Anesthesia: One resident’s learning

Case presentation preparation before expose to the Matrix


IOM

ACGME

SAFETY TIMELINESSEFFECTIVE-

NESSEFFICIENCY

EQUITA-BILITY

PATIENTCENTERED-

NESS

PATIENT CARE

MEDICAL KNOWLEDGE X X X

X

PROFESSIONALISM

X X

X X

INTERPERSONAL & COMMUNICATION SKILLS X X X X

X

SYSTEMS- & TEAMS-BASED PRACTICE X X X X X

PRACTICE-BASED LEARNING & IMPROVEMENT(Process to Improve)

P and P changed for Mom/Child in

trouble

Changed STAT pages

to Anes. From OB

Class on care of Mom

with DIC

Procedure outlined for fastest prep

for OR

Assure Mom aware of what is

happening. Communication

with father.

Case presentation after dialogue with faculty using the Matrix.


Patient with Pregnancy and D.I.C (Disseminated Intravascular Coagulopathy)Case Presentation

IOM ACGME

SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED

Assessment of Care

PATIENT CARE(Overall

Assessment)

NOPatient

nearly died

NOLife saving

treatment was delayed for

variety of reasons

NODelays in treatment

impaired effectiveness of

therapy

NOResources (blood

products, staff time) were not utilized in an efficient manner.

NOLanguage was a

problem

NOPatient was not

adequately apprised of her own health

problems and did not participate fully in her

care decisions

MEDICAL KNOWLEDGE(What must we

know)

Priorities in hemorrhagic shock are ABC: ensure oxygen delivery, support BP, aggressive IV resuscitation, treat cause

Hemorrhagic shock is life-threatening emergency: Prompt diagnosis, recognize urgency, initiate therapy, incl. timely transport to OR. Diagnosis was made late. No urgency to treat. Delay in contacting Anesth. Inadequate assistance in transport to OR

D.I.C. in pregnancy: Physiology, diagnosis, causes, treatment. Regional v. General Anesth? Post resuscitation pulmonary edema. Hypocalcemia due to massive transfusion. Invasive monitoring indications. Pharmacology of uterotonic drugs.

Survival in postpartum hemorrhage requires aggressive IV resuscitation: always consider combining procedures (start 2nd IV while drawing blood sample for transfusion cross match).

INTERPERSONAL AND

COMMUNICATION SKILLS

(What must we say)

Safety is jeopardized unless team members are fully apprised of patient’s condition (blood loss following delivery, vital signs, plans for intervention).

Orders (blood cross match) must be prioritized and fully implemented in a timely fashion.

Effectiveness of life-saving intervention depends on effective communication between team members.

Communications of a defensive or argumentative nature are counter-productive to efficient and safe care. The focus should be patient care, with analysis of misunderstandings at a later time.

Must communicate patient’s condition and intended interventions (blood transfusion, emergency hysterectomy), and in a way that is understandable and useful to the patient, respecting patient autonomy.


Professional duty to accompany critically ill patient to the OR, to ensure safety, and to expedite therapy.

Patient’s ethnic, socio-economic, “service patient” status should have no effect on quality of care.

Professional duty to attempt to preserve patient autonomy (make sure patient understands situation and interventions)


SYSTEM-BASED

PRACTICE(On whom do

we depend and who depends

on us)

System must ensure that appropriate consultants are notified when needed to ensure safety in life-threatening medical condition.

During postpartum bleeding, type & cross match must be drawn, sent, and verified promptly. Failure to do so threatens life.

Failures to draw, send, and verify cross match blood sample jeopardizes effectiveness of life-saving therapy.

Standard of care should not vary due to differences in staffing that result from time of day / night (availability of lab medicine physician, timely transport of blood samples, adequate number & expertise of obstetrics, anesthesiology, & nursing staff)

Improvement

PRACTICE-BASED

LEARNING AND

IMPROVEMENT(How must we

improve)

Policy and Procedures changed for Mother/Baby in trouble

Revise the criteria for and system of communicating urgent / emergent request for Anesthesiology consultation

Departmental Teaching Conference on management of parturient with D.I.C.

Procedure outlined for fastest prep for OR

Increased awareness of need to consider patient centeredness even in emergent or crisis situations. Communication with father / family members when appropriate and possible.

© Bingham, Quinn Vanderbilt University (Used with permission from Anesth. Dept)


Patient with Coronary Artery Disease

(Internal Medicine ResidentsAmbulatory Rotation)


Panel of Patients with Coronary Artery Disease


Panel Management of CAD Patients:

(AHA Guidelines)• Medications:

– Aspirin– Beta Blocker, – Statin if LDL > 100

• Blood Pressure Control• ACE-Inhibitor/ARB• Smoking Cessation• Diabetes Screen / HgA1c


Internal Medicine ResidentsAmbulatory Rotation


Practice-based learning and Improvement

(based on care of patients with CAD)


NewPatient.

?

Follow-upon CADPatient

Y

2

Y

Physical Exam

Wait time for testsresults

Location ofpatients while they

wait

All patients mayhave long list ofcomplaints. MD

has to see pt in 15minutes

N

Patient with CADInternal Medicine Residents

February, 04April, 04 (class 3)May, 04 (class 4)

Page 3

Seen at VUMCbefore

?

Acute visit?

Get as muchinformationas possible

Focused/Directed

H&P

Get pt.Information

fromStarPanel

Review ofsystemsapproach

-Meds-EBM-etc

N

Previous info notavailable. Can wehave pt fill in infoin waiting room?

Problem list shouldinclude what hasbeen tried and

failed (with meds)

Explain computerissues with pt (esp

problem list) sothey don’t feel

ignored

N

Location ofcomputer and notbeing able to look

at patient

Othercomplaints to be

addressed?

Does MD havetime to address

all issues?

Address only acutecomplaint and

reschedule for otherissues if needed

Get updatedhistory includingall risk factors

Review: VS

Medication listProblem list

Y

N

N

Could we have timefor visit match whatneeds to be done?

Especially for pts withChronic diseases

Physician in room withPatient

SynthesizeInformation

Information sharedwith patient

Formulate Plan(confer withAttending as

needed)

NeedHospitalization

?

Y

Different Process

Patient Education(or other

preventive healthissues)

N

3


Delays in Patient Care

NURSING &TECH INFO

PRE-VISIT INFORMATIONFROM PATIENTS

PROBLEM LIST& MEDS

ROOMUTILIZATION

MEDICINERESIDENT CLASS

04/01/045/21/04

STAR PANELPATIENTVISIT ISSUES

DOCUMENTATIONOF NEW PTS.

ROOMENVIRONMENT

LATEARRIVALSTESTS

Not using pt waiting timeto capture info

Obtaining outside records

Test from OSH (Imaging,Labs, Vaccinations, etc.

Pt needs to bring meds orlist of meds to confirm

Previous infonot available

Room turnover is an issue.Other rooms are not ready togo or there are pts in waiting rmw/ no tech to bring them back

Variation in whether ornot vitals are even done

Variation in time it takes eachnurse to check in a pt

Room for pt to wait whileMD sees next pt

Location of pts while they wait

Nurse write down medsor put on problem listwhen doing intakeassessment

Time lost: time spent w/tech in room should notexceed 2 - 3 min.

If no available problemlist, a hard copy of lastStar note in chart or doorto review last times visit

Current Med list/Previous Med list

Problem list should includewhat has been tried &failed (meds)

Meds I don’t like - why?

Most important problem/issue today (SMIP - singlemost important problem!)

Start Labs (MP, CBC w/ diff,Lipid profile, HgAIC, EKG)

Allergies (true)

StarPanelnote organization

StarPanel tutorials to showthe ins & outs of new toolsin StarPanel

Window popup w/ age, gender-specific standard of careguidelines for ICD-9 code or dx

StarPanel too slow, alwayspops up w/ wrong pt

OPOC too slow, takes toomuch time to get pt out ofroom (the only room we have!)

Search engine for Meds!

List of formulary meds forthat pt’s ins. Available in apopup/menu, also timeliness

Log into system - slow!!

Location of computer -not being able to see pt

Explain computerissues to pt (i.e.problem list) so theydon’t feel ignored

Communicating w/referring physician/pt: typeletter or call

Proper followup: interventions,referrals, tests, teaching

Benefits of each medicineby class; “your Dr has startedyou on a B Blocker because…"“this medicine will help with…"

6th grade level educationalmaterials for Dx (i.e. highcholesterol: diet/nutrition, quitsmoking, etc)

Documentation hold-up ofencounters, particularlynew pts

Documentation: typingnew pt note

Having to type noteson new pts

Typing new ptnotes too slow

Wait time for testresults too long

No definition for pt appointmenttime (check-in, vitals, to room, tosee Dr?)

Parking for patients

No-show patients

No pt in room when ready to see pt

Confusion about who does whatin clinic (tech/nurse/secretary)

Check-in takes too long

Redundant info (tech gets cc)we redo this

Vital signs are optional

Too many formsto fill out for tests

Paper charts were designed by?- not easily useful to physicians

SCHEDULING

Staff: Decision chartregarding what to dowith late arrivals

Pt scheduled for f/u apptwith another appt previously scheduled, ends up as noshow for one

All residents in clinic have ptsscheduled at same time

Except for new pts & femalephysical, all appts are samelength of time (20 mins)

Multiple pts scheduled atsame time for physician

Appointment template isnever right!

Scheduler will not allow foralternate ways to schedulepts

Resident workrooms arepoorly configured andpoorly furnished

Malfunctioning diagnosticequipment

Too few rooms for 4residents

Residents all waitingfor preceptor at sametime, major holdup inschedule

Insufficient room space

One location for labs to be drawn & vitalstaken by nurse for all pts, creates roadblock


Improvements From Medicine Residents:

Pat Covington RN, Manager

EMR: We can now text message across departments. Use of pt waiting time: Have Kiosk in exam room to fill in review of systems. Questionnaires being sent to pts ahead of time. Those with email get questionnaire and can return via email. Availability of techs: Modified schedule of techs to improve service. Residents’ schedules were also changed to better utilize staff. Patient visit survey and phone calls will now be done after visit. Patient Letter revised: “Bring old records, come 15 minutes before appt.”


Transforming M&M Conferences

into

Practice-based Learning and Improvement


Care of Child with Hyperleukocytosis M&M 3/25/04 (Peds Hem/Onc)

IOM ACGME

SAFE1 TIMELY

2 EFFECTIVE

3 EFFICIENT

4 EQUITABLE

5 PATIENT -CENTERED

6

Assessment

I.PATIENT CARE 7

Mostly yes

(Toxicity of chemo needed better monitoring)

Yes

Yes (but variation

exists) WBC dropped from

324K to 37K by midnight

Yes

Yes

Yes

Family told of possible Dx within 2

hours of ED visit.

II. A MEDICAL

KNOWLEDGE 8 (What must I know)

-Hypercalcemia led to hypotension. -Respiratory distress secondary to fluid overload and atelectasis required intubation Complications of Leukopheresis was discussed.

Full dose Chemotherapy started quickly

Management of Hyperleukocytosis: was major discussion for M&M conference.

Discussed lack of benefit and increase cost of cranial irradiation

How to tell family bad news (lecture at VU). Pediatrics Oncologists have a lot of experience and are very family centered. Family was well informed of likely dx and plan of action.

II. B PROFESSIONALIS M 9

(How must I act)

PCP referred child to ED for evaluation very quickly (from community 40 miles away).

Feedback to PCP was done as soon as a concern was voiced.

Some physician variation noted at VU for treatment. Can we standardize with pathway?

Able to talk to family and PCP in professional and evidenced -based manner.

II. C INTERPERSONAL AND

COMMUNICATION SKILLS 10

(What must I say)

Experienced physicians and researchers communicated well.

Hand -offs were smooth and well executed.

Pare nts felt comfortable providing inform consent by 7 PM the same day.

II. D SYSTEM -BASED

PRACTICE11

(On whom do I depend

and who depends on me)

Toxicity was an issue and the team needed to do a better job of recording what was happening.

Quick response by VCH to PCP. hyperleukocytosis 5 hours to Dx 8 hours to start of Tx

Discussed issue of dialysis for treatment. Consulted nephrology and PICU. Dialysis nurse notified early and circuit primed.

Lab results were done quickly from ED. Team worked well to have treatment begin quickly with good results within 10 hours

ED good communication with House Officer. Social worker met with family to explain what was happening.

Improvement

III. PRACTICE -BASED

LEARNING AND IMPROVEMENT

12

(How can I improve)

Be s ure everyone knows the toxicity and complications and document.

Create pathway for hyperleukocytosis to decrease variation

© 2004 Bingham, Quinn Vanderbilt University


System Based Practice

(What is the process? On

whom do I depend? Who depends on

me?)

The Team did not always know what was going on. Hand-offs were not well managed

All steps of the process of care were not known (including who was key in each step) therefore delays occurred.

Plan of care should have been shared with all (Pharmacy, surgeons, residents, support services to make system work for pt rahter than hinder care.

Needless variation among clinicians is a problem and caused inefficiency of care.

Team should advocate for pt in a complex system. Care was not coordinated and integrated. Expectations and comfort of pt were not known and addressed.

Improvement

PRACTICE-BASED

LEARNING AND

IMPROVEMENT(How must we

improve)

Residents need to know principles of flowcharting and RCA to address these issues.

Anesthesia residents should take the lead in getting the team to discuss pain mgmt and changes needed while pt still in our system.

Team could share talk of lit review for this complex pt. Run chart of pain scale could be one metric to determine results of care.

Patient and family should be included in improvement and monitoring of his own care. Feedback to be sought and used for further improvement.

Information Technology

© Bingham, Quinn Vanderbilt University (Used with permission from Anesth. Dept)


Healthcare Matrix: Care of Patient with postpartum respiratory arrestOB M&M April 29, 2005

AIMS Competencies

SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLEPATIENT-

CENTERED

Assessment of Care

PATIENT CARE(Overall Assessment)Yes/No

NoResp arrest during awake intubation.

Yes Yes: had proper tx.No: Tx could have been better.

Yes Yes until arrest occurred.

?

MEDICAL KNOWLEDGE and SKILLS

(What must we know?)

DDX eval and Tx for ooCO abd SOB:PE/MI/CHF/ flashpulm edema/ pneumonia

Pt evaluation and work-up organized and timely.

Appropriate tx given the DDx and evolving clinical picture (CxR #1 read as c/w pneumonia w no edema. Lasix Tx.

Anesthesia initially used CPAP/OUOAO to manage low O2 sats. Unfamiliar modality in this clinical setting.


SKILLS(What must we say?)

Awake intubation choice by anesthesia 2/2 airway edema.

Order given and executed promptly.

Pt did not fill Rx for BP meds. despite d/c instructions given.

PROFESSIONALISM(How must we behave?)

Emotional reaction to stressful situation took the staff by surprise.

Managing the family’s hysteria during code situation was very challenging.


(On whom do we depend and who depends on us?)

Nurses on 4E assessed situation and contacted MDs promptly. Timely anesthesia consult and response.

Did busy service delay Tx? (don’t think so)Monitor malfunction might have shown arrest when she wasn’t.

The team worked very well together.

Good procedure of nurses reviewing meds and discharge instructions. Getting meds filled after reg hours a problem.

Improvement


(What have we learned? What will we improve?)

Could we have prevented the resp arrest? C. Osmotic pressures need to be done.

Could have transferred to L&D faster.

Reviewed lit on non-cardiogenic Pulm Edema.Need to be more aggressive with Lasix.

Be mindful of cultures that tend to react more physically and emotionally to stressful events.

Can anything be done about getting a few doses of meds for pts being discharged at odd times?

© 2004 Bingham, Quinn Vanderbilt University All rights reserved.


Care of Patient with Femoral Vein Cannulation

AIMS

Competencies


CENTERED

Assessment

PATIENT CARE(What must I

do)

NO

Pt not always safe as evidence by several adverse events

Yes No

Need to find/learn best method.Evidence of Ultrasound for dialysis line placement.

Yes Not Sure

How informed is patient/family? No post procedure instructions.

MEDICAL KNOWLEDGE (What must I

know)

Need additional anatomy lessons for performing this procedure. Need to know what to do with arterial punctures. What to do when patient cannot be still?

No guidelines in literature for Fem. Cannulation.

HCT not efficient way to monitor bleeding

INTERPERSONAL AND

COMMUNICA-TION SKILLS

(What must I say)

Nurses need to know when cannula has been pulled in order to have more observation

Communicating use of Niagra cath that other areas have found less favorable.

Use of patches used on other specialties for punctures not well known.

Better instructions for patient and family.

Nephrology M&M 4/2/04


PROFESSIONAL-ISM

(How must I act)

Sharing complications and near misses among all specialties will increase learning.

Sharing expertise from colleagues in surgery, radiology and cardiac cath for most effective and efficient way to do cannulation.


(On whom do I depend and

who depends on me)

No nursing orders for post-procedure care. Change of shift dangerous time for patients.

Improvement

PRACTICE-BASED


(How can I improve)

Keep QA log on all procedures to detect trends. Need to monitor near misses and complications to learn.

Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation.

© Bingham, Quinn Vanderbilt Univ. (Used with Permission from Nephrology Dept.)

(Femoral Cannulation Cont’d)

Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation


ACTION PLAN


Medical Students(Neurology Clerkship)


Healthcare Matrix: Care of Patient with stroke - occlusion of the ICA of unknown origin.

AIMS Competencies


CENTERED

Assessment of Care

I.PATIENT CARE

(Overall Assessment)Yes/No

Yes No Yes Yes, from VUMC,

No for placement.

Yes from VUMC

No b/c of insurance issues

Yes – patient was informed and incorporated in decision making process

II. AMEDICAL

KNOWLEDGE(What must we know)

Yes. Everyone on the stroke service was on top of the latest in knowledge.

Yes. Yes. Yes. Yes.

II. BINTERPERSONAL AND

COMMUNICATION SKILLS

(What must we say)

Yes. Communication between neuro and surgery was clear. Attendings and residents were in contact

Yes – phone calls and meetings were used when things couldn’t wait for note in chart

Yes and no – comm. Between medical teams was great. Ins issues led to placement problems though

Yes yes Yes – always kept in mind patients perspective

II. CPROFESSIONALISM(How must we act)

Yes There was no breakdown in safety due to pro problems

Yes – there were never any delays in doing anything for the pt in terms of pro

Yes Yes

Yes and no – pt was on service for a while,– but not really treated much better than others

Yes –

II. DSYSTEM-BASED

PRACTICE(On whom do we depend and who depends on us)

Yes – patient was monitored and kept in system

Yes and no – no delays in providing emergent care, but getting rehab was hard.

Yes No– consultants used appropriately. Problem was not in Vanderbilt system, but in insurance system

Yes Yes – all resources were used according to pts own goals for rehab

Improvement

III.PRACTICE-BASED


(What have we learned and what do we

improve)

Patient safety was maintained at all times. We still don’t know what caused stroke after surgery though.

Rehab placement took too long – everyone worked hard, but maybe could have worked harder

Care was administered effectively within limits – not much treatment for strokes like this yet

A lot of energy and time was used ineffectively trying to place him

Everyone worked hard for him because he was there so long and trying hard to rehab. not more than everyone else

Pt was very involved in his own care and course and his wishes were always respected.


Practice-based Learning and Improvement

Tools and Methods


What are we trying to accomplish?- AIM -

What are we trying to accomplish?- AIM -

How will we know that a change is an improvement?- Data Over Time –

(Tools: Run Charts, Control Charts)

How will we know that a change is an improvement?- Data Over Time –

(Tools: Run Charts, Control Charts)

What changes can we make that will result in an improvement?- Process Analysis –

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)

What changes can we make that will result in an improvement?- Process Analysis –

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)

IMPROVEMENT MODEL

Planthe

Improvement

Studythe

Results

Dothe

Improvement

Act

Act to keep changeor Abandon and try

another change

PDSA Cycle—Small rapid cycles of change

P

A D

S


Operating Room Team

AIM:Reduce “Start Time” Delays in O.R.

©VUMC2001


Run Chart of DelaysOR Delays in Start Time

0

15

30

45

60

75

90

105

120

1 3 5 7 9 11 13 15 17 19 21 23 25

Patients

Tim

e

©VUMC2001


Process Flowchart

©VUMC2001

Nursing evaluation

done?

Surgery H&P done?

Yes Surgical consent signed?

Yes Anesthesia evaluation

done?

Yes Risk & medicolegal

issues addressed?

YesNeed pre-op lines in holding?

Yes OR ready?

Yes

Perform nursing

evaluation weight

No

Perform H&P

No

Obtain signed consent

No

Perform evaluation:H&P

Indicated tests:labsECGCXR

No

Cancel Surgery

No

Place indicated lines

No

Wait

No


Cause and Effect Diagram

©VUMC2001

OR StartTime

Delays

PEOPLE PROCEDURES

EQUIPMENT POLICY

Surgeon Late

Anesthesia latePatientcomplications

Consultationnot done

Consult notesnot in chart

No pre-opeducation

Meds notgiven

Tests notdone

H&P not done

Nursing evaluation not done

Anesthesia evaluationnot done

Test resultsnot in chart

Doublebooked

Instrumentsnot ready

Not available

Medical record missing

Instruments notavailable

No patientconsent

Noauthorization

Registrationnot complete

No pre-op check list


Pareto Chart

42.37

59.32

72.88

83.05

89.8394.92

100

A B C D E F G

11.80

0.00

23.60

35.40

47.20

59.00

PARETO CHART

0.00 # of errorsCum Freq

Cum

. Fr

eq.

©VUMC2001


New Aim (Based on Data)

To reduce the number of preoperative tests performed so that only those which are important to the medical mgmt of adult surgical pt during pre-op period are ordered.

©VUMC2001


How Will We Know a Change Is an Improvement?

Measurement:

Percentage Excess Tests Per Specialty

Based Upon Agreed Upon Guidelines

©VUMC2001


What Changes Can We Make?

Develop disease and surgical proceduraltesting guidelines for:

-laboratory testing, -electrocardiography

-chest radiography

in adult surgical patients

©VUMC2001


Preoperative Testing Variation Rates by Service

25

464

38

310

7 28 53

330

108 94

951 51

157120 12

19

323940

545555596162636667

86

0

100

200

300

400

500

600

700

800

900

1000O

ncol

ogy

Ort

ho

Ora

l/Max

il

Gen

eral

Tra

uma

Ren

al/T

x

Gyn

-Onc Oto

Neu

ro

Gyn

ecol

ogy

Hep

atob

il/T

x

CT

Sur

g

Vas

cula

r

Pla

stic

s

Uro

logy

Surgical Service

Ad

dit

ion

al T

esti

ng

Rat

e (%

)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Nu

mb

er o

f P

atie

nts

# Patients

% Excess Tests

©VUMC2001


System-Based Practiceat the

Organization Level


When organizations are not “Systems”

Average LabTurnaround Time

Average Time to MakeClinical Decisions

AverageLength of Stay

HospitalProfit

Phlebotomists

+ +

-

-

R

Hiring

+

+

Quality ofPatient Care

-

+

R

Death Spiral

QualityErosion


Average LabTurnaround Time

Average Time to MakeClinical Decisions

AverageLength of Stay

HospitalProfit

Phlebotomists

+ +

-

-

R

Hiring

+

+

Quality ofPatient Care

-

+

R

Death Spiral

QualityErosion

Lab Manager

Residents

Hospital CEO


History Physical Exam Labs Tests Consults Etc.

DiagnosisCare of Patient(Matrix)

Using the Matrix


“Closing the Loop”

• Start with diagnosis as basis for assessment

• Identify issues of care related to Aims and Competencies

• Identify lessons learned and improvement needed

• Complete action plan for improvements with accountabilities and timeline


Upcoming Matrix Enhancements

Vanderbilt University Medical Center © 2004 Bingham, Quinn Vanderbilt University



Improvement






MEDICAL


PATIENT CARE(Overall Assessment)

Yes/No

Assessment

PATIENT-CENTERED

EQUITABLE


Healthcare Matrix: Care of Patient(s) with Stroke

An Oracle Database is being built that will collect

data from each cell and allow analysis and reports

to be generated by:

InstitutionDepartmentDiagnosisIOM Aim

Competency


positiveLung Cancer with Brain Mets

Team took the time to know the patient and her desire for treatment.Medical Knowledge

Patient-Centered2

TranslatorsnegativeHydrocephalus

This patient spoke Spanish. Skilled interpreters were not available. Medical students and family were used often as interpreters which was not ideal.

Interpersonal Communication skillsEquitable12

EBMnegativeCeliac Sprue

Repeated imaging and brain biopsies were unnecessary. Reduce switching of primary neurologists to avoid repeat testing.System-basedEfficient18

Care PlanimprovementStroke

We could have taken the time to do a better initial H&P to better discern what his condition was like at initial presentation to compare it to discharge condition

Practice-Based Learning & ImprovementEffective4

Teamworknegative

Pregnancy IntracerebralHemorrhage

Delays in communication increased the time it took to get an initial head CT and begin treatment.

Interpersonal Communication skillsTimely19

EBMpositiveStroke

Decisions were made based on accepted algorithms and consensus within the team.ProfessionalismSafe3

Secondary Code

Primary Code (positive, negative,

improvement)Diagnosis ContentCompetenciesAimsStudent ID

Excel Spreadsheet for Matrix Analysis


Matrix as “Front Door” to Data and Education




Improvement

Process Flowcharts






Evidence basedOrder sets

MEDICAL


Pt and family satisfaction data

Outcomes by race, gender, SES

Cost per discharge

Outcomes data

Time Studies

FMEA

EventsPATIENT CARE


Assessment

PATIENT-CENTERED

EQUITABLE



Data linked directly to cells

in the Matrix




Improvement

Process Flowcharts*






Evidence basedOrder sets

MEDICAL


Pt and family satisfaction data

Outcomes by race, gender, SES

Cost per discharge

Outcomes data

Time Studies

FMEA

EventsPATIENT CARE


Assessment

PATIENT-CENTERED

EQUITABLE



Link to Web based

Education


How to Flowchart a Process

• On-line web site for Improvement education

http://mot.vuse.vanderbilt.edu/mt322

(Dr. Quinn’s current course being redesigned for managers and physicians)


On Transformation:“And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous

to administer than to introduce a new system of things; for he who introduces it

has all those who profit from the old system as his enemies, and he has only lukewarm allies in all those who might

profit from the new system.”Machiavelli


Healthcare Matrix Summary Points:

• Is a framework for integrating competencies into existing educational activities

• Provides a new mental model for Clinicians

analyzing patient care

• Facilitates use of “resident performance data as the basis for improvement”

• Encourages use of “external quality measures to verify resident and program performance levels”


Thank You!


Implementation of Healthcare Matrix


Internal Review QuestionnaireCore Competencies

1. How does your program provide education that develops patient care practice that is

compassionate, appropriate and effective?

How effective is that training?

1Not

effective

2Somewhat effective

3Moderately

Effective

4Effective

5Very

effective


ImplementationInternal Review Process:

– Analyze responses to competency questionnaire and discuss with program director; suggest improvements if needed

– Provide information on competencies and use of Matrix

– Offer to assist in the integration of competencies in M&M and case conferences, etc.


Implementation• Introduction to Matrix: Program Director or

Dept. Chairs invite us to do lecture or Grand Rounds to introduce competencies and Matrix.

• Using the Matrix: – Attend M&M or case conferences as

observers – Note the discussion on a blank Matrix

showing which cells/competencies were discussed and which were omitted

– Send Matrix to program director and discuss next steps


Implementation• Residents and the Matrix:

– Residents fill in Matrix on their own – Best to let them struggle a little with the

competencies as they think about care of their patient

– Get someone (coach) to review Matrix with them – If the situation/case is difficult, Dept Chair,

Program Director and mentors may assist with filling out Matrix and presentation

• Helpful hint: – Find a “coach” to help residents. At the outset,

we work with the residents and faculty. Then Chief residents or interested faculty take the lead. Sometimes nurses can be coaches such as in Psychiatry at VU.


Phase I Phase II Phase III Phase IV

7/2001 6/2002 7/2002 7/20116/2006 7/2006 6/2011 Beyond

• Improve the evaluation processes for all six of the Competencies.

• Provide aggregated resident performance data for Internal Review Process.

• Use resident performance data as the basis for improvement.

• Begin to use external quality measures to verify resident and program performance levels.

• Identify benchmark programs.

• Involve community in building knowledge about good GME.

• Define specific objectives for residents to demonstrate learning of the competencies.

• Begin integrating the teaching and learning of competencies into residents’ didactic and clinical experiences.


Research Agenda to Validate Matrix

(Based on Kirkpatrick, Evaluation of Training, 1994)

• Does the Matrix provide a useful framework for teaching and evaluating the performance of clinicians around the competencies?

• Phase I of ACGME : – Define objectives for learning– Begin integrating the teaching and learning

of competencies into didactic and clinical educational experiences



• What are we learning about the care (columns) and education (rows) from completed matrices?

• Phase II of ACGME: – Improve the evaluation processes for all

six of the Competencies– Provide aggregated resident performance

data for Internal Review Process


• Are the behaviors of clinicians changing based on their completion of practice-based learning and improvement?

• Phase III of ACGME:– Use resident performance data as the

basis for improvement– Begin to use external quality measures to verify

resident and program performance levels



• Are the processes and outcomes of care improving?

• Phase III of ACGME:– Begin to link clinical quality indicators

and patient surveys with education

• Phase IV of ACGME: – Adapt and adopt generalizable

information about emerging models of excellence. Involve community building knowledge about good GME.



Learning Core Competencies Evaluation of Evaluation of Residents (2006) Tools (2011)

Care of Patient with …… Suggested Tools based on Matrix

data

Appropriate tools?

AIMS

Competencies

Safe Timely Effective

Efficient

Equitable

Patient-Centered

Assessment

Patient Care

MedicalKnowledge

Interpersonal Communication

Skills

Professionalism

System-based Practice

Improvement


Information Technology(Dr. Paul Batalden provided the idea for this graph)

Based on matrices for a dept or diagnosis,

which evaluation tools best fit the

need?


Care of Patient with …… Suggested Tools based on Matrix

data

Appropriate tools?

AIMS

Competencies

Safe Timely Effective

Efficient

Equitable

Patient-Centered

Assessment

Patient Care

MedicalKnowledge

Interpersonal Communication

Skills

Professionalism

System-based Practice

Improvement


Information Technology(Dr. Paul Batalden provided the idea for this graph)

Are the evaluation tools appropriate and

providing useful data?

Learning Core Competencies Evaluation of Evaluation of Residents (2006) Tools (2011)

Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A...

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