Download PATIENT CARE that is…

Linking Outcomes of Care and
the ACGME Core Competencies:
A Matrix Solution
Competencies Working Group
January 5, 2007
Doris Quinn, PhD
Assistant Professor
Division of Medical Education
 2006 Vanderbilt University Medical Center
John Bingham, MHA
Director
Center for Clinical Improvement
Objectives for today:
1. Review the link between:
• Outcomes of Care (IOM Aims for
Improvement)
• The ACGME Core Competencies
2. Demonstrate how the Healthcare
Matrix is used to improve the delivery
of care and education
 2006 Vanderbilt University Medical Center
2
Drivers of Change in Healthcare:
1999
2001
2002
2003
Emerging
public
reporting
and
awareness
of quality
measures
 2006 Vanderbilt University Medical Center
3
Patient Care should be:
Safe, Timely, Effective,
Efficient, Equitable, Patient-Centered
(STEEEP)
 2006 Vanderbilt University Medical Center
4
7/2001
6/2002 7/2002
Phase I
• 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.
6/2006
7/2006
6/2011
7/2011
Beyond
Phase II
Phase III
Phase IV
• Improve the
evaluation
processes for all six
of the
Competencies.
• Use resident
performance data as
the basis for
improvement.
• Identify
benchmark
programs.
• Provide
aggregated
resident
performance data
for Internal Review
Process.
 2006 Vanderbilt University Medical Center
• Begin to use
external quality
measures to verify
resident and program
performance levels.
• Involve
community in
building
knowledge about
good GME.
5
Public Reporting of Quality
•
•
•
•
•
•
CMS Quality Measures (CMS Compare)
Accreditation Bodies (JCAHO)
Statewide Organizations (QIOs)
Business Coalitions (Leapfrog)
Employers (Annual Enrollment Process)
Commercial Health Care Scorecards
– (www.healthgrades.com)
 2006 Vanderbilt University Medical Center
6
The future…. in a few words:
Transparency
Process Reliability
 2006 Vanderbilt University Medical Center
7
So…what should we do?
Patients
with Needs
Patients with
Needs Met
Access
Assessment
Diagnosis Treatment
Follow-up
1. Define the measures that matter
2. Measure our performance
3. Utilize the results of measurements to improve:
•
•
The education of residents and allied professionals
The quality of care that we provide
 2006 Vanderbilt University Medical Center
8
Patient Care should be:
Safe, Timely, Effective,
Efficient, Equitable, Patient-Centered
(STEEEP)
 2006 Vanderbilt University Medical Center
9
Healthcare Matrix: Care of Patient(s) with….
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
 2006 Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
10
PATIENT CARE that is…
Safe
“Avoiding injuries to patients from the care
that is intended to help them”
 2006 Vanderbilt University Medical Center
11
PATIENT CARE that is…
Safe
•Percent of Surgeries with appropriate “timeout”
•Prophylactic Antibiotics for all surgeries
•Use of Central-line Bundle
•Use of Ventilator Acquired Pneumonia Bundle
•Glycemic Control
•Hand Hygiene
•Leapfrog’s 30 Safe Practices
 2006 Vanderbilt University Medical Center
12
PATIENT CARE that is…
Safe
Timely
“Reducing waits and sometimes harmful
delays for both those who receive and
those who give care”
 2006 Vanderbilt University Medical Center
13
PATIENT CARE that is…
Safe
Timely
Effective
“Providing services based on scientific
knowledge to all who could benefit and
refraining from providing services to
those not likely to benefit”
 2006 Vanderbilt University Medical Center
14
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
“Avoiding waste, including waste of
equipment, supplies, ideas, and energy”
 2006 Vanderbilt University Medical Center
15
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
“Providing care that does not vary in
quality because of personal characteristics
such as: gender, ethnicity, geographic
location, and socio-economic status”
 2006 Vanderbilt University Medical Center
16
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
“Providing care that is respectful of, and
responsive to:
•individual patient preferences,
•needs and values,
•and ensuring that patient values guide
all clinical decisions”
 2006 Vanderbilt University Medical Center
17
What must we know?
PATIENT CARE that is…
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
“…about established and evolving biomedical,
clinical, and cognate sciences, (e.g.
epidemiological and social-behavior) and the
application of this knowledge to patient care”
 2006 Vanderbilt University Medical Center
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What must we say?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
“…that result in effective information exchange
and teaming with patients, their families, and
other health professionals.”
 2006 Vanderbilt University Medical Center
19
How must we behave?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
“…as manifested through a commitment to
carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to
a diverse patient population.”
 2006 Vanderbilt University Medical Center
20
What is the Process?
On whom do we depend?
Who depends on us?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
“…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.”
 2006 Vanderbilt University Medical Center
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What have we learned?
What will we improve?
PATIENT CARE
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
Interpersonal and
Communication Skills
Professionalism
System-Based Practice
Practice-Based
Learning &
Improvement
“…involves investigation and evaluation of
their own patient care, appraisal and assimilation
of scientific evidence, and improvements in
patient care.”
 2006 Vanderbilt University Medical Center
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Linking it all together….
Patients
with Needs
Patients with
Needs Met
Access
Patient Care that is…
Assessment
Safe
Timely
Diagnosis
Effective
Treatment
Efficient
Follow-up
Equitable
Patient Centered
Clinicians competent in:
-Medical Knowledge
-Interpersonal and
Communication Skills
-Professionalism
-System-Based Practice
-Practice-Based Learning
& Improvement
 2006 Vanderbilt University Medical Center
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Healthcare Matrix: Care of Patient(s) with….
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
INTERPERSONAL AND
COMMUNICATION
SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
 2006 Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
24
Applications of the Matrix
I.
Individual Resident Learning
II.
Case Presentations
III. M & M Conference
IV.
Linking to External Quality Metrics
V.
Curriculum Framework
VI.
Medical Students
 2006 Vanderbilt University Medical Center
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Using the Matrix






History
Physical Exam
Labs
Diagnosis
Tests
Consults
Etc.
 2006 Vanderbilt University Medical Center
Care of
Patient
(Matrix)
26
Anesthesia: One resident’s learning
A resident prepared for a case presentation and
addressed the following cells.
IOM
SAFETY
TIMELINESS
EFFECTIVENESS
EFFICIENCY
EQUITABILITY
PATIENT
CENTEREDNESS
No
No
ACGME
PATIENT CARE
MEDICAL KNOWLEDGE &
APPLICATION
No
No
No
No
X
X
PROFESSIONALISM
INTERPERSONAL &
COMMUNICATION SKILLS
SYSTEMS- & TEAMS-BASED
PRACTICE
X
PRACTICE-BASED LEARNING &
IMPROVEMENT
(Process to Improve)
 2006 Vanderbilt University Medical Center
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After a dialogue with faculty and using the Matrix, she then
addressed all of the following cells in her presentation. The
presentation resulted in the improvements outlined below.
IOM
TIMELINESS
EFFECTIVENESS
X
X
X
X
X
X
X
X
X
X
X
X
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
SAFETY
EFFICIENCY
EQUITABILITY
PATIENT
CENTEREDNESS
ACGME
PATIENT CARE
MEDICAL KNOWLEDGE
X
PROFESSIONALISM
INTERPERSONAL &
COMMUNICATION SKILLS
SYSTEMS- & TEAMS-BASED
PRACTICE
PRACTICE-BASED LEARNING &
IMPROVEMENT
(Process to Improve)
 2006 Vanderbilt University Medical Center
X
X
X
X
X
Assure Mom aware
of what is
happening.
Communication
with father.
28
Simple Matrix
• Not all cells need to be filled in, but
it’s important to address those cells
pertinent to the case.
• One or more cells may be critical or
significant to the case (hot cells).
 2006 Vanderbilt University Medical Center
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Healthcare Matrix: Care of Patient with left knee pain, dx of MTB
Department of Pathology
AIMS
SAFE
Competencies
1
2
TIMELY
EFFECTIVE
3
EFFICIENT
4
EQUITABLE
5
PATIENT6
CENTERED
Assessment of Care
7
PATIENT CARE
(Overall Assessment)
Yes/No
Yes
MEDICAL KNOWLEDGE and
8
SKILLS
(What must we know?)
Differential for
monoarticular
arthritis and how
to work it up.
No
Yes
Sports medicine
clinician unsure of sig
of MTB in joint and
whether to treat it.
Microbiology identified
and called a second
clinician involved in the
patient’s care with the
results.
Clinician not called with
surgical pathology
results so treatment not
initiated for weeks.
INTERPERSONAL AND
9
COMMUNICATION SKILLS
(What must we say?)
No
Yes
Yes
Lack of knowledge
regarding surgical
pathology results
resulted in delayed
treatment and
repeat office visit
with no definitive
diagnosis given.
Ultimately effective
as microbiology
grew MTB in joint
and called clinicians
with the results.
10
PROFESSIONALISM
(How must we behave?)
11
.
SYSTEM-BASED PRACTICE
(What is the process?
On whom do we depend? Who
depends on us?)
Surgical pathology
report issued but not
read by treating
clinicians.
Improvement
PRACTICE-BASED LEARNING
12
AND IMPROVEMENT
(What have we learned? What
will we improve?)
We should call clinician
with unusual or
/unexpected results.
Can perhaps use
automated features in
star panel to alert them
of their patients’ results.
Educate regarding
significance of MTB
in joint and how to
treat it. Related
issues such as
immune status,
infectivity.
Improved
communication
between different
departments
should result in
more efficient
care.
Information Technology
© 2004 Bingham, Quinn Vanderbilt University
 2006 Vanderbilt University Medical Center
30
Usual
Morbidity and Mortality
Conferences
 2006 Vanderbilt University Medical Center
31
Care of Child ingesting medications (Adderal and Zoloft) Residents 10/28/03
ACGME
IOM
SAFE
1
2
TIMELY
3
4
EFFECTIVE
EFFICIENT
5
EQUITABLE
6
PATIENT-CENTERED
Assessment
?
PATIENT CARE7
(Actions Taken)
MEDICAL
KNOWLEDGE8
Yes
Child was kept in
busy ED
Kn. Of meds and
affect on child
especially
elevation of BP
?
ED getting busy, who can
provide best care?
Drug screen done
quickly.
When is it
appropriate to
admit?
What should be done,
if anything beside
observation?
How is child “restrained” to
take BP when it is very
important?
Care of child may be frightening.
What is role of family or parents in
care?
Evidence for treating
child taking Adderal?
PROFESSIONALISM9
When do we call specialist?
INTERPERSONAL AND
COMMUNICATION
SKILLS10
VS done on time.
SYSTEM-BASED
PRACTICE11
PRACTICE-BASED
LEARNING AND
IMPROVEMENT12
Major focus on Medical Knowledge
 2006 Vanderbilt University Medical Center
32
With All Competencies
Reviewed
 2006 Vanderbilt University Medical Center
33
Healthcare Matrix: Care of Patient(s) with respiratory distress
Otolaryngology: Head and Neck Surgery October, 2005
AIMS
Competencies
SAFE
1
2
TIMELY
EFFECTIVE
3
EFFICIENT
4
EQUITABLE
5
PATIENT6
CENTERED
Assessment of Care
No
7
No
No
No
?
?
PATIENT CARE
(Overall Assessment)
Yes/No
Red rubber catheters too
flexible and can bend
easily – may be hard to
MEDICAL KNOWLEDGE remove or suction
8
and SKILLS
hardened secretions
(What must we know?) (unknown frequency of
suctioning and use of
saline to loosen
secretions
Better way to
INTERPERSONAL AND communicate likelihood
of obstruction and
COMMUNICATION
9
SKILLS
difficult airway anatomy
(What must we say?)
Delay in obtaining Airway obtained
flexible
through tracheotomy
bronchoscope
site with apparent
during oral attempts distal obstruction,
at intubation
oral intubation
unlikely to bypass
obstruction
Patient with poor
Poor communication
lung reserve, time about steps required
wasted during oral to secure airway
attempts – patient
unable to tolerate
prolonged apnea
MICU very
responsive to code
initially
There is often a problem
of safety when multiple
PROFESSIONALISM
specialties are involved.
(How must we behave?) There is no clear system
to know what the plan is.
Knowledge of where Determine role of
This sometimes leads to
bronchoscopes are nurses, respiratory
disagreement when none
SYSTEM-BASED
located for each ICU therapists, and
11
should exist.
PRACTICE
physician in
(What is the process?
managing
On whom do we depend?
tracheotomy patients
Who depends on us?)
10
There was a good
discussion with
family after this
event.
Inefficient
Trach care may
system for
vary depending
tracheotomy
upon patient floor
care (ie supplies
specified,
nursing
instructions)
Patients may
receive different
levels of
tracheotomy care
depending upon
nursing staff,
hospital ward, and
managing service
Improvement
Need variety of suction
catheters available.
PRACTICE-BASED
Determine the essential
LEARNING AND
equipment for
12
IMPROVEMENT
(What have we learned? tracheotomy care. Know
What will we improve?) where to have a plan of
care for everyone to see.
Need clear steps to
be taken if airway
emergency in
patients with
tracheostomy with
poor pulmonary
reserve and difficult
anatomic airway
 2006 Vanderbilt University Medical Center
Method to succinctly Create order set
communicate whether to specify
patient can be orally supplies
intubated to minimize necessary, as
unsuccessful
well as initial
attempts at securing steps if airway
airway
lost
Have standard order set available for
all ICU’s and floors
Make order set easy to use so
different services may implement
34
Analyzing Data from
Multiple Matrices
 2006 Vanderbilt University Medical Center
35
Excel Spreadsheet for Matrix Analysis
Student ID
3
19
4
18
Aims
Competencies
Content
Diagnosis
Primary Code
(positive, negative,
^improvement)
Secondary Code
Safe
Professionalism
Decisions were made based
on accepted algorithms and
consensus within t he team.
Timely
Interpersonal
Communication
skills
Delays in communication
increased the time it t ook to
get an initial head CT and
begin treatment.
Pregnancy
Intracerebral
Hemorrhage
negative
Teamwor k
Practice-Based
Learning &
Improvement
We could have taken t he time
to do a better initial H&P to
better discern what his
condition was like at initial
presentation to compare it t o
discharge condition
Stroke
^improvement
Care Plan
System-based
Repeated imaging and brain
biopsies were unnecessary.
Reduce switching of primary
neurologists to avoid repeat
testing.
Celiac Sprue
negative
EBM
This patient spoke Spanish.
Skilled interpreters were not
available. Medical students
and family were used of ten as
interpreters which was not
ideal.
Hydrocephalus
negative
Translators
Team took the time t o know
the patient and her desire for
treatment.
Lung Cancer with
Brain Mets
positive
Effective
Efficient
12
Equitable
Interpersonal
Communication
skills
2
PatientCentered
Medical
Knowledge
 2006 Vanderbilt University Medical Center
Stroke
positive
EBM
36
Healthcare Matrix: Care of Patient(s) with….
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
INTERPERSONAL AND
COMMUNICATION SKILLS
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED PRACTICE
(What is the Process?
On whom do we depend and
who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned, what
will we improve)
 2006 Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
37
Key Safety Issues Identified
for VUMC
• COMMUNICATION
• TEAMWORK (especially relationship between
specialties)
• WORKAROUNDS (time stealer)
• DOCUMENTATION
• Unnecessary Variation
• Complexity of patients and limited clinic time
• Updated medication and problem lists critical for optimal
care
• Getting lab values quickly and alerts for abnormal ones
• Interpreters for growing number of non-English speaking
patients (system not based on solely on people)
 2006 Vanderbilt University Medical Center
38
Closing the Patient Care 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
 2006 Vanderbilt University Medical Center
39
Healthcare Matrix: Care of Patient(s) with respiratory distress
Otolaryngology: Head and Neck Surgery October, 2005
AIMS
Competencies
SAFE
1
2
TIMELY
EFFECTIVE
3
EFFICIENT
4
EQUITABLE
5
PATIENT6
CENTERED
Assessment of Care
No
7
No
No
No
?
?
PATIENT CARE
(Overall Assessment)
Yes/No
Red rubber catheters too
flexible and can bend
easily – may be hard to
MEDICAL KNOWLEDGE remove or suction
8
and SKILLS
hardened secretions
(What must we know?) (unknown frequency of
suctioning and use of
saline to loosen
secretions
Better way to
INTERPERSONAL AND communicate likelihood
of obstruction and
COMMUNICATION
9
SKILLS
difficult airway anatomy
(What must we say?)
Delay in obtaining Airway obtained
flexible
through tracheotomy
bronchoscope
site with apparent
during oral attempts distal obstruction,
at intubation
oral intubation
unlikely to bypass
obstruction
Patient with poor
Poor communication
lung reserve, time about steps required
wasted during oral to secure airway
attempts – patient
unable to tolerate
prolonged apnea
MICU very
responsive to code
initially
There is often a problem
of safety when multiple
PROFESSIONALISM
specialties are involved.
(How must we behave?) There is no clear system
to know what the plan is.
Knowledge of where Determine role of
This sometimes leads to
bronchoscopes are nurses, respiratory
disagreement when none
SYSTEM-BASED
located for each ICU therapists, and
11
should exist.
PRACTICE
physician in
(What is the process?
managing
On whom do we depend?
tracheotomy patients
Who depends on us?)
10
There was a good
discussion with
family after this
event.
Inefficient
Trach care may
system for
vary depending
tracheotomy
upon patient floor
care (ie supplies
specified,
nursing
instructions)
Patients may
receive different
levels of
tracheotomy care
depending upon
nursing staff,
hospital ward, and
managing service
Improvement
Need variety of suction
catheters available.
PRACTICE-BASED
Determine the essential
LEARNING AND
equipment for
12
IMPROVEMENT
(What have we learned? tracheotomy care. Know
What will we improve?) where to have a plan of
care for everyone to see.
Need clear steps to
be taken if airway
emergency in
patients with
tracheostomy with
poor pulmonary
reserve and difficult
anatomic airway
 2006 Vanderbilt University Medical Center
Method to succinctly Create order set
communicate whether to specify
patient can be orally supplies
intubated to minimize necessary, as
unsuccessful
well as initial
attempts at securing steps if airway
airway
lost
Have standard order set available for
all ICU’s and floors
Make order set easy to use so
different services may implement
40
Care of Patient in Respiratory Distress (Dr. Seth Cohen)
Item
#
1
2
3
4
5
6
7
8
9
10
What needs to be done
Results
Speak with nurse educators in charge of
teaching tracheotomy care
Discuss possibility of creating
computerized tracheotomy orderset
Determine equipment currently
specified to be in tracheotomy patient
rooms
Create order set
Classes taught to surgical nurses.
Only fraction of nurses who take care of tracheotomy patients attend these classes
Done
Have order set placed in hospital wide
computer ordering system
Make all otolaryngology service aware
of order set and how to implement
Make heads of ICU’s aware of order set
and how to implement
Discuss current emergency room
protocol for replacing displaced
tracheotomy tubes
Create and present specific protocol for
replacing tracheotomy tubes in ER and
when to contact otolaryngology support
Assure that appropriate equipment
identified in 3 is available for
tracheotomy patients
Done
Done
Orderset in place and accessible to all medical services.
Presented orderset to department.
Presented orderset to head of ICU’s.
Done
Presented protocol to ER chair.
Done
 2006 Vanderbilt University Medical Center
41
Healthcare Matrix: Care of Patient(s) with Stroke
Competencies
Aims
SAFE
TIMELY
EFFECTIVE
EFFICIENT
EQUITABLE
PATIENTCENTERED
Assessment
PATIENT CARE
(Overall Assessment)
Yes/No
MEDICAL KNOWLEDGE
(What must we know)
An Oracle Database is being
built that will collect data from
each cell and allow analysis
and reports to be generated
by:
INTERPERSONAL AND
COMMUNICATION
SKILLS
•Institution
•Department
•Diagnosis
•IOM Aim
•Competency
(What must we say)
PROFESSIONALISM
(How must we act)
SYSTEM-BASED
PRACTICE
(What is the Process?
On whom do we depend
and who depends on us)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT
(What have we learned,
what will we improve)
 2006 Vanderbilt University Medical Center
© 2004 Bingham, Quinn Vanderbilt University
42
 2006 Vanderbilt University Medical Center
43