Patient Safety & Quality Improvement
in
Graduate Medical Education
Ariane Marie-Mitchell, MD, PhD, MPH
Preventive Medicine & Pediatrics
October 24, 2013
OUTLINE
I. What do all residents need to know about
PSQI
II. What resources are available to learn about
PSQI
III. How can residency programs integrate
training in PSQI
Training physicians to participate in
Quality Improvement is a positive
trend in health care.
77%
23%
0%
0%
0%
0%
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Ag
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0%
ly
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat Disagree
Disagree
Strongly Disagree
St
ro
ng
A.
B.
C.
D.
E.
F.
G.
Deaths Due to Surgical or Medical Mishaps
per 100,000 Population, 2006
0.6
0.6
0.6
0.6
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.1
0.1
0.0
0.0
France*
Germany
United
United
States*
Kingdom*
* 2005
**2004
Source: OECD Health Data 2008, “June 2008.”
Canada**
OECD
Median
Netherlands
New
Zealand**
THE
COMMONWEALTH
FUND
Exhibit ES-1. Overall Ranking
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
AUS
CAN
GER
NETH
NZ
UK
US
OVERALL RANKING (2010)
3
6
4
1
5
2
7
Quality Care
4
7
5
2
1
3
6
Effective Care
2
7
6
3
5
1
4
Safe Care
6
5
3
1
4
2
7
Coordinated Care
4
5
7
2
1
3
6
Patient-Centered Care
2
5
3
6
1
7
4
6.5
5
3
1
4
2
6.5
Cost-Related Problem
6
3.5
3.5
2
5
1
7
Timeliness of Care
6
7
2
1
3
4
5
Efficiency
2
6
5
3
4
1
7
Equity
4
5
3
1
6
2
7
Long, Healthy, Productive Lives
1
2
3
4
5
6
7
$3,357
$3,895
$3,588
$3,837*
$2,454
$2,992
$7,290
Access
Health Expenditures/Capita, 2007
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International
Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians;
Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for
Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
THE
COMMONWEALTH
FUND
PSQI IS ABOUT
HOW TO PRACTICE MEDICINE
LLUMC Physician Lounge
PSQI
www.lluphysicianlounge.com/psqi/
• Overview
• Faculty
• Introduction to PSQI
• Advanced Practice of PSQI
• Models for Integrating PSQI into GME
• Selected References
Introduction to PSQI
Core Competencies
Practice Based Learning and Improvement
(how good is my practice?)
• Use QI methods to analyze practice and implement changes
Systems Based Practice
(how good is the health care system?)
• Advocate for quality patient care and optimal patient care
systems
• Work in inter-professional teams to enhance patient safety and
improve quality
• Participate in identifying system errors
• Use QI methods to implement system solutions
Introduction to PSQI
Learning Objectives
Patient Safety
• Know the scope of medical errors and main types
• Distinguish between error and harm
• Use voluntary reporting systems to report errors and
near-misses
• List key methods for reducing errors
• Use key communication skills including SBAR (Situation,
Background, Assessment, Recommendation), briefings,
read-backs, and CUS (Concerned, Uncomfortable, Safety)
• Describe a root cause analysis
• Structure an effective apology
Introduction to PSQI
Learning Objectives
Quality Improvement
•
•
•
•
•
•
•
•
•
•
List six dimensions of quality health care
Describe how U.S. health care system compares to others
Create a specific aim statement
Select outcome, process and balancing measures
Select appropriate measures of change
Use PDSA (Plan, Do, Study, Act) cycles
List key differences between QI and research
Understand basics of sampling methods for QI
Create and use key QI tools
Understand the basics of spread and diffusion
Does your program require residents
to complete any IHI Open School
Modules during training?50%
17%
Co
n
sid
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in
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No
17%
17%
Do
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tk
no
w
Yes
No
Considering
Don’t know
Ye
s
A.
B.
C.
D.
Does your program require residents
to participate in an Improvement
Project using QI methods?
73%
Yes
No
Considering
Don’t know
18%
9%
Do
n’
tk
no
w
Co
n
sid
er
in
g
No
0%
Ye
s
A.
B.
C.
D.
My program has enough faculty to
mentor residents on an Improvement
Project using QI methods.
29%
21%
21%
14%
7%
7%
Ag
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Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat Disagree
Disagree
Strongly Disagree
St
ro
ng
A.
B.
C.
D.
E.
F.
G.
Introduction to PSQI
Online Learning
IHI Open School (Institute for Healthcare
Improvement)
• Patient Safety – 101-105 meet objectives or
~6 hours (2 required pre-intern)
• Quality Improvement- 101-104 meet objectives or
~4 hours
Alternatives
• Mayo Clinic Quality Academy
• AMA Introduction to Practice of Medicine
Introduction to PSQI
Didactics
See “Selected References- PSQI Education”
• WHO Patient Safety Curriculum
• University of Chicago Medical Center Internal
Medicine Quality Curriculum
Introduction to PSQI
Practice-Based Learning Project
Key Steps
•
•
•
•
•
•
•
•
#1 Identify a Faculty Mentor
#2 Describe your Professional Opportunity
#3 State your Aim
#4 Diagram a Cause-Effect Analysis
#5 Define your Measures
#6 Conduct an Evidence Review
#7 Collect Baseline Data
#8 Test a Change (repeat tests until outcome achieved)
Improvement Projects
Practice-Based Learning
• Data source = your patient
encounters
• Change focuses on your
practice behaviors
Systems-Based Practice
• Data source = your clinical
microsystem
• Change requires team effort
Describe Cause-Effect Analysis
Use Evidence
Collect and Study Data
Test Changes
PBL Project Example
• Professional Opportunity: Underuse of influenza
vaccination in my adult patients
• Aim Statement: “I will increase my influenza
vaccinations rate to 80% in my eligible adult
patients age 18-64 by December 30, 2013”
• Evidence Review: ACIP Vaccine
Recommendations for 2013
PBL Project Example: Cause-Effect Diagram
Patients
Physician
I know the guidelines
I remember to order
Declined
_Contraindicated
Insurance coverage
Vaccine availability
Vaccine Record_
Nurse Schedule
Materials
Processes
I effectively counsel
Influenza
Vaccination
Rate
PBL Project Example (cont’d)
• Outcome measure =
# patients age 18-64 who received influenza vaccination /
total # eligible patients age 18-64 seen during time period
• Process measures =
– Proportion missed opportunities to order
– Proportion orders declined
• Balancing measures =
– Proportion patient complaints re: billing
PBL Worksheet
LET’S PRACTICE:
1. Obtain a PBL Worksheet at your table
2. Draft items #2-5
3. Discuss with others at your table
TIME ~ 10 minutes
How many total hours are dedicated in
your current curriculum to learning
PSQI?
38%
25% 25%
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13%
PS
QI
i
A. None (any PSQI is outside
regular work hours)
B. Less than 1 hour per month
(<12 hours per year)
C. More than 1 hour per month
but <1 hour per week
D. About 1 hour or more per
week
Models for Integrating PSQI into GME
Pre-Residency Model
• Complete IHI Open School Certification
Intern Model
• Complete IHI Open School Certification OR monthly
didactics
• Improvement Project, conducted by small groups,
mentored by faculty from clinic during monthly
meetings
• Improvement Project final presentations at Grand
Rounds
Models for Integrating PSQI into GME
One Block Model
PGY1/PGY2
• Complete IHI Open School Certification OR monthly didactics
PGY3
• One month long rotation including ~24 hours of scheduled time
– Didactic sessions related to PSQI
– Review and presentation of patient cases at quality assurance
or mortality review committee meetings
– Serve as auditors in bi-weekly hospital wide Joint Commission
Accreditation mock surveys
– Improvement Project, identified and completed by individual
residents, presented at end of month OR year
Models for Integrating PSQI into GME
Two Block Model
PGY2 e.g. during 2 months of ambulatory care
• Weekly meetings for didactics or development of
Improvement Project- first PDSA cycle
PGY3 e.g. during 2 months of ambulatory care
• Weekly meetings for didactics or continuation of
Improvement Project- second PDSA cycle
Models for Integrating PSQI into GME
Longitudinal Model
PGY1:
• IHI Patient Safety modules and Readings
• PBL Project, conducted over 6 months, mentored by faculty,
presented by individual residents at noon conference
PGY2:
• IHI Quality Improvement modules and Readings
• SBP Project, join existing team and conduct over 12 months,
mentored by faculty, presented by group at Grand Rounds at end
of the year
PGY3:
• IHI Quality Improvement/Leadership modules and Readings
• SBP Project, lead QI team over 12 months, mentored by faculty,
presented by group at Grand Rounds at end of the year
SUMMARY
• See our PSQI website
www.lluphysicianlounge.com/psqi/
– Learning Objectives
– Online Resources
– Project Guidance
– Models for Integrating PSQI into GME
• Encourage senior residents to participate in the
Advanced Practice of PSQI Concentration
The one thing to teach about PSQI
Physician participation in Patient Safety
and Quality Improvement initiatives…
is Good Medicine