THE HEATLHCARE MATRIX
Erin Hurley, PGY 4
June 16, 2020
“Every hospital should follow every patient it
treats long enough to determine whether the
treatment has been successful, and then to
inquire ‘If not—why not?’ with a view to
preventing similar failures in the future.”
Ernest Codman M.D. , 1914
PATIENT SAFETY
Anesthesia coined the term “patient safety”
 Institute of Medicine (IOM) of the US Academy of
Sciences

1999: “To Err is Human”
 2001: “Crossing the Quality Chasm”

QUALITY CHASM


“Health care we have and the care we could
have– represents more than a gap, but rather a
chasm”
Medical education chasm
IOM
Care of every patient has the potential to
improve the care of all patients yet to come
 Competencies are integrated into the routine
practices of daily care
 Decision making regarding care of the patient is
guided by the best evidence available
 The quality of health care is positively related to
the quality of medical education

IOM– AIMS FOR IMPROVEMENT
Safe
 Timely
 Effective
 Efficient
 Equitable
 Patient Centered

ACGME
The content of graduate education is aligned with
the changing needs of health systems
 Residency programs use sound outcome
assessment methods for both residents’ and
programs’ achievement of educational outcomes.

ACGME COMPETENCIES
“Quality of health care is positively related to
quality education”
CORE COMPETENCIES
Patient Care
 Medical Knowledge
 Interpersonal and communication skills
 Professionalism
 Systems-based practice
 Practiced-based learning and improvement

CORE COMPETENCIES

Teaching


No prescribed formulas
Assessment
Interpersonal and communication skills
 System-based practice
 Practice based learning and improvement

HEALTHCARE MATRIX
A formative approach to the presentation of
core competencies to residents, which in turn is
having an effect on the faculty and their patient
care
 A response to the challenge of linking all six
competencies with the realities of the current
medical education system– which is focused on
acquisition of medical knowledge

Healthcare Matrix: Care of Patient (s) with…
AIMS
Safe
Timely
Effective
Competencies
Patient Care
Medical Knowledge
Interpersonal/
Comm. Skills
Professionalism
Systems Based
Practice
IMPROVEMENT
Practice-Based
Learning
/Improvement
The Healthcare Matrix, 2004, John Bingham &
Doris Quinn, Vanderbilt University
Efficient
Equitable
PatientCentered
PATIENT CARE SHOULD BE:






Safe: Avoiding injuries to patients from care intended to help
them
Timely: Reducing waits and sometimes harmful delays for those
who receive and give care
Effective: Providing services based on scientific knowledge to
all who could benefit; refraining from providing services to
those likely not to benefit
Efficient: Avoiding waste of equipment, supplies, ideas, energy
Equitable: Providing care that does not vary in quality
because of personal characteristics
Patient-Centered: Providing care that is respectful of and
responsive to individual patient preferences, needs, values;
ensuring that patient values guide all clinical decisions
MEDICAL KNOWLEDGE:
WHAT MUST WE KNOW?
Patient care
Safe
Timely
Effective
Efficient
Equitable Patient
Centered
Medical
Knowledge
“…about established and evolving
biomedical, clinical, and cognate
sciences, and application of this
knowledge to patient care.”
INTERPERSONAL/COMMUNICATION SKILLS: WHAT
MUST WE SAY?
Patient care
Safe Timely Effective Efficient
Equitable Patient
Centered
MK
Interpersonal &
Communication
Skills
“…that will result in effective
information exchange and teaming
with patients, their families, & other
health professionals.”
PROFESSIONALISM: HOW MUST WE BEHAVE?
Patient care
Safe
Timely Effective Efficient Equitable Patient
Centered
MK
ICS
Professionalism
“…as manifested through
commitment to carrying out
professional responsibilities,
adherence to ethical principles, &
sensitivity to diverse patient
population.”
SYSTEMS-BASED PRACTICE: WHAT IS THE PROCESS? ON WHOM
DO WE DEPEND? WHO DEPENDS ON US?
Patient care
Safe
Timely Effective
Efficient
Equitable Patient
Centered
MK
ICS
Prof
SystemsBased
Practice
“…as manifested by actions that
demonstrate an awareness of, and
responsiveness to, a larger context &
system of healthcare and ability to
effectively call on system resources to
provide care of optimal value.”
PRACTICE-BASED LEARNING & IMPROVEMENT: WHAT HAVE WE
LEARNED? WHAT WILL WE IMPROVE?
Patient care
Safe Timely
Effective Efficient
Equitable Patient
Centered
MK
ICS
Prof
SBP
Practice-Based
Learning &
Improvement
“…involves investigation &
evaluation of residents’
(program’s, or institution’s)
own patient care, appraisal and
assimilation of scientific
evidence, and improvements in
patient care.”
VALUE OF THE MATRIX

Healthcare Matrix: Improving Care by Linking
Outcomes to Competencies
Over 100 matrix presentations at Vanderbilt
 Guide learners in analyzing the care of their own
patients by using Core competencies to identify
opportunities for improvement
 Change the environment of case presentations and
MM conferences from one of blame to one of
system analysis and quality improvement

EFFECTIVENESS
Provides a learning format that is part of daily
education and delivery of care by residents
 Addresses the multidisciplinary culture in which
residents practice
 Being used by many health professions besides
residents
 Provides a solution that is standardized so that
multiple programs and institutions can have a
common framework to teach the competencies
and learn from each other

EDUCATIONAL ENVIRONMENT

The matrix allows transformation of the
educational environment





Team learning
Patient care– structures and systems
Collaborative decision-making
Collective analysis and improvement
Connections/trends between cases
MATRIX AT VANDERBILT
100 matrices were analyzed to look at safety
concerns across institutions
 Four major themes identified

Communication
 Teamwork
 “workarounds” (circumventions of a system)
 Inadequate or poor documentation

CEDARS-SINAI MEDICAL CENTER

Using the healthcare matrix to teach and
improve patient safety culture in an OB/GYN
residency training program

Utility of healthcare matrix in teaching about safety
and improvement of care
METHODS
HCMC is held at least once monthly in our
residency education program
 The selected resident chooses the case & develops
a draft matrix under faculty supervision
 A multidisciplinary team is invited based on the
case
 The matrix is presented at conference and a
consensus action plan for implementation is
generated after discussion

METHODS
 Two
years after the initiation of the
program, the residents completed an
anonymous 15-item survey about their
perception of the program using a 5
point Likert scale
RESULTS
26 HCMC were held from 2007 to 2009
 PGY-4 residents prepared & conducted 77%
sessions

Case Distribution (n=26)
Management concerns
Medication errors/concerns
Bleeding complications
Clinical distribution
42.3%
23.1%
34.6%
Gynecology cases
46.2%
Obstetrical cases
53.8%
SUB-OPTIMAL CARE BY IOM AIMS
100%
96%
80%
65%
60%
50%
46%
40%
19%
20%
23%
0%
Safe
Timely
Effective
Efficient
Equitable
Patient
Centered
SUB-OPTIMAL CARE BY ACGME
COMPETENCIES
System-based Practice
77%
Professionalism
46%
PBL & Improvement
100%
Patient Care
96%
Medical Know ledge & Skills
69%
Interpersonal & Communication Skills
65%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
Residents perception of the utility of
the Healthcare Matrix
Figure 1: *Residents perception of the utility of the Healthcare Matrix (n=21)
Should be interdisciplinary
100%
Effective for teaching ACGME competencies & IOM Aims
81.00%
Would use in my clinical practice in future
57.10%
47.60%
Preparation is time consuming
Great, continue to use
Should be canceled
95.20%
0%
Improved ability debrief
90.50%
Improved my communication skills
38.10%
Useful for quality improvement
95.20%
Helped analyze a complex situation
100%
Changed my practice
Felt awkward presenting errors of my superiors
Review errors in blame free environment
Helped assess errors
Fosters learning
0.00%
85.70%
28.60%
71.40%
95.20%
90.50%
10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
RESULTS- RESIDENTS’ SURVEY
Effective, fosters learning, and should be
continued
 Improved their ability to debrief, was useful for
quality improvement, helped analyze a complex
situation, changed their practice, and helped
assess errors
 Some felt awkward presenting medical errors
made by their superiors, but the majority felt
that the HCMC provided them with a blame free
environment to discuss errors

CONCLUSION
 Residents
can use the healthcare
matrix in a multidisciplinary setting
to evaluate and improve patient
care.
 HCMC allows the IOM Aims to
become a framework for reviewing
patient safety culture.
 Allows residents to integrate the
ACGME Competencies as part of
their routine clinical practice.
CONCLUSION
Timeliness, medical knowledge, &
communication issues were major contributors to
patient safety concerns.
 Residents’ survey highlights areas that need
more attention.
 Healthcare matrix provides a foundation for
systematic transformation in patient care,
medical education, and team dynamics that could
be useful for residency training programs.

MATRIX 2007
Healthcare Matrix: Care of Patient with uterine atony after D+E with DIC
AIMS
Competencies
SAFE
TIMELY
EFFECTIVE
EFFICIENT
(Avoiding injury from care intended
to help)
(Reducing delays for pts and
providers)
(Evidence-based medicine, avoiding
underuse and overuse)
(Avoiding waste of equipment,
supplies, ideas, and energy)
EQUITABLE
PATIENT-CENTERED
(Care does not vary based on race,
(Care with respect for
ethnicity, gender, SES)
preference, needs, values)
Assessment of Care
No - patient nearly died from
hemorrhagic shock
No - Life saving treatment was No – intrauterine ballon,
delayed at several levels
uterotonics and fluid
resuscitation ineffective.
Yes
No – resources such a blood
products, mobilization of staff
not utilized in efficient manner.
PATIENT CARE
(Overall Assessment)
Yes/No
Ensure oxygen delivery,
support BP, aggressive IV
MEDICAL
rescuscitation, treat cause
KNOWLEDGE and
SKILLS
(What must we know?)
Debriefing of all teams
INTERPERSONAL involved even if ICU is closed
AND
COMMUNICATION
SKILLS
(What must we say?)
Do no harm
PROFESSIONALISM
(How must we
behave?)
System should ensure that
SYSTEM-BASED appropriate consultants notified
such as anaethestiologist for
PRACTICE
(What is the process? intubation,
On whom do we
depend? Who depends
on us?)
Yes – Patient and
family informed at all
times. Patient desired
to avoid hysterectomy
at all costs.
Prompt diagnosis, recognize
urgency, initiate therapy, timely
transport to OR.
Urgency to treat delayed.
Treatment of uterine atony –
Aggressive IV resuscitation,
uterotonics, intrauterine ballon repletion of blood products,
correction of DIC
used. Delayed decision to
hysterectomy.
N/A
N/A
Blood results – stat should be
available sooner than 3 hrs.
Crossmatched blood should be
available sooner.
More effective communication Private MD patient involve
faculty MD
between team members.
Better communication better
ICU and gyn residents.
N/A
Good communication
with patient and family
for intended
intervention.
Professional duty to
Mobilize team members to
accompany critically ill patient collect blood products.
to the OR, to ensure safety and
to expedite therapy.
N/A
Preserve patient
autonomy
D+E should be done in a
Crossmatch in life-threatening
tertiary facility so that blood can situations should be a priority.
be mobilized as soon as
possible.
Availability of lab medicine,
physician, timely transport of
blood, expertise of gyn,
anesthesiology should not vary
from time of day/night
SUMMARY--CREATING AND REINFORCING
A
CULTURE OF LEARNING
The matrix is intended to help consider patient
care in terms of the IOM Aims and the ACGME
Core Competencies
 Enhance learning for every resident
 Team learning/ team dynamics
 Collaborative decision
 Resident– part of a system of care
 Common framework for evaluating and
improving patient care across disciplines
 Integrate the ACGME Competencies as part of
their routine clinical practice
 Improve quality of care

THANK
YOU
The End
Erin Hurley, PGY 4
June 16, 2020
REFERENCES





Institute of Medicine: Crossing the Quality Chasm. Washington
D.C.: National Academy Press, 2001
Using a Healthcare Matrix to Assess Patient Care in Terms of
Aims of Improvement and Core Competencies. Journal on Quality
and Patient Safety, February 2005
Quinn D , The Healthcare Matrix: Improving Care by Linking
Outcomes to Competencies. MedEdPORTAL; 2007.
Using the Healthcare Matrix to teach and improve patient safety
culture in an OB/GYN residency training program
Steven Rad, Connie Chung, Jessica Y. Hsu, Carolyn Alexander,
and Dotun Ogunyemi. APGO 2010
Shine, K.: Crossing the quality chasm: The role of postgraduate
training Am J Med113: 265–267, Aug. 15, 2002