Advanced Curriculum Development:
Creating Education Models in Practice
Based Learning and Improvement and
Systems Based Practice to
“Geriatricize” Your Environment
Kathryn E. Callahan, MD
Helen M. Fernandez, MD, MPH
Kirsten Feiereisel, MD
William P. Moran, MD, MS
Paula M. Podrazik, MD
Patty J. Iverson, MA
Objectives
• Identify the resources, strengths, and needs in your home
institution’s educational environment to support the design
of a PBLI/SBP curriculum with a geriatric focus
• List at least 2 strengths and 2 weaknesses of differing
curricular approaches to teaching PBLI and SBP
• Generate at least 1 goal and 3 objectives for a curriculum in
PBLI/SBP at your home institution
• Operationalize the needs, goals, objectives, strengths, and
weaknesses of your institution’s educational environment
to craft the basics of a curriculum in PBLI or SBP using
geriatric content.
QI in Ambulatory Geriatrics
Implementation of the Practice
Improvement Module for Care of the
Vulnerable Elderly: CoVE PIM
Care of the Vulnerable Elderly
Practice Improvement Module (CoVE PIM)
Wake Forest School of Medicine
CoVE Sites
Downtown Health Plaza (IM)
Piedmont Plaza (FM)
OPD Clinic (IM)
Wake Forest School of Medicine
Implementing the CoVE PIM
 Phase 1: Collect practice data to evaluate
performance measures
 All PGY-2’s perform a medical record audit on at least 5
older patients in their continuity clinic panel
•
•
Family Medicine- incorporated into clinic experience
Internal Medicine- incorporated into inpatient geriatrics
 At least 25 patient surveys per practice
 Submit 1 practice site survey
Wake Forest School of Medicine
Implementing the CoVE PIM
 Phase 2: Implement Quality Improvement Project
 All PGY-3’s review ABIM aggregate data report
 Develop, implement and evaluate a quality
improvement project to target deficiencies
 One project per site
Wake Forest School of Medicine
CoVE PIM: Internal and Family Medicine
• 2009 Cohort:
• 35 residents completed Phase Two.
• OPD: 12 residents; 60 charts audited; 25 patient surveys.
• DHP: 13 residents; 65 charts audited; 30 patient surveys.
• FM: 10 residents; 60 charts audited; 56 patient surveys.
• 2010 Cohort:
• 38 residents completed Phase One (10 FM/28 IM).
• Phase Two starting Fall 2011.
• 2011 Cohort:
• 38 residents, beginning Phase One.
Wake Forest School of Medicine
CoVE PIM, operationalized:
• IM: Two teams (OPD and DHP), each with:
• 2 faculty mentors
• 3 Resident Leaders: Team Leader, Communication
Czar, Interdisciplinary/Staff Liaison
• Additional roles defined as project develops (e.g.,
Information Technology Liaison, Literature Reviewer)
• FM: Two teams, each with:
• 1 faculty mentor
• 1 Chief Resident
Wake Forest School of Medicine
CoVE PIM: IM 2009 Cohort Impact
• Leadership roles inspire Geriatrics interest:
• Team Leaders presented at Grand Rounds
• Team Leaders plan Geriatrics fellowship
• Systems-Based Practice Outcomes:
• Resident-designed Geriatrics Screening Template in
hospital-wide EMR
• Interdisciplinary team leadership experience
• Practice-Based Learning Outcomes:
• “I didn’t realize there were guidelines for older adults!”
• “I laminated the Falls Algorithm and posted it…”
Wake Forest School of Medicine
Experiential and Longitudinal
QI Curriculum for Geriatrics Fellows
• Didactic: QI Curriculum
• Application: Practice Improvement Module for
Care of the Vulnerable Elderly (CoVE-PIM)
• Assessment:
– Pre- and Post-Test with the Quality Improvement
Knowledge Application Tool (QIKAT)
– Structured Interview with fellows
– Audit and Feedback with mentored QI project
QI Curriculum
• Institute of Healthcare Improvement
– Courses designed by IHI: self-paced
•
•
•
•
•
•
QI 101: Fundamentals of improvement
QI 102: The Model of Improvement
QI 103: Measuring for improvement
QI 104: Putting It All Together
QI 105: Human side of QI
QI 106: Level 100 tools
– Each session duration time is from 30 minutes to 1
hour
QIKAT
• Assesses prior experience with QI
• Three scenarios reflecting quality of care
problem:
– Identify aim of improvement project
– Appropriate measures
– Desired outcome for scenario
• Assesses attitudes:
– Does learner feel QI is essential to future career?
– Does learner possess confidence in his/her ability
to bring about change?
Practice Improvement Module
Holmboe et al. JCEHP 2006; 26: 109-19.
Curriculum, continued
• Fellows reviewed the needs assessment
• Three small groups (clinic day); presented
ideas for QI projects
• Single project identified (cognitive screening)
and implemented
• Outcomes:
– Re-measure process indicator
– QIKAT post-test
– Qualitative interview with fellows
Curriculum for the Hospitalized Aging Patient
CHAMP
Teaching PBLI/SBP:
Incorporating CHAMP Teaching Tools into your Curriculum
Paula Podrazik, MD
Program Director, Geriatrics Fellowship
University of Arkansas for Medical Sciences
CHAMP developed at the University of Chicago
Supported by a D.W. Reynolds Foundation educational grant
16
http://champ.bsd.uchicago.edu
17
Process Mapping as a teaching tool
”The first step is to draw a flow diagram then everyone understands what
his job is. If people do not see the process, they cannot improve it.” W.E.
Deming, 1993
A process map or flowchart is a picture of the sequence of steps in a process as it
actually occurs. Can be a “higher level” or “drilled-down” view of the process.
• In the health care industry useful for
– Planning a project
– Describing a process
– Documenting a standard way for doing a job
– Building consensus about the process & correct misunderstandings
• In resident & student teaching useful for
– Teaching about PBLI– holding the “mirror ” to your practice
– Teaching about SBP-understanding the “village” that delivers care
CT Abd. needed
EMR order
Stat?
YES
Process map of a clinical care issue—
”higher level” process view
Call Radiology
Tech.
NO
Patient
transported
Exam
Completed
Teaching Case Audit
Case Audit: What is it?
A structured review of clinical care
across a single patient’s hospital stay
▪
▪
▪
▪
Addresses a relevant clinical issue
Accepted quality measures exist
Performed by the team
Fits PBLI construct
Inouye S, et al. Ann Intern Med 1992; 119:474.
Inouye S., et al. Ann Intern Med 1990; 113:941.
Inouye S, et al. JAMA 1996; 275:852.
From Whelan, Podrazik, Johnson. Semin Med Pract 2005; 8:70.
Developed by Dr. Podrazik @ University of Chicago.
Teaching Census Audit
Census Audit: What is it?
A review of clinical care across patients
▪
▪
▪
▪
Addresses a focused clinical issue
Simple quality measures exist
Performed by the team
Fits PBLI construct
From Whelan, Podrazik, Johnson. Semin Med Pract 2005; 8:71.
Developed by Dr. Whelan @ University of Chicago.
MUSC
Aging Q3
http://mcintranet.musc.edu/agingq3
Knowledge to Performance
Academic Detailing
Resident Cue
Participation
Falls
9/8/09 – 12/14/09
Activity
n (%)
Faculty attending in-service
Residents attending didactic
Detailing encounters
17/27 (77.8%)
37/100 (37%)
Detailed
86/100
(86%)
Skill - TUG
64/100
(64%)
Teaching Attendings detailing
Teaching Attendings observing skill - TUG
Based on all Teaching Attendings:
18/21 (85.7%)
13/15 (87%)
EMR
Template