Lavjay Butani

 

Goal: To increase the knowledge and attitudes of medical students related to quality improvement and patient safety in the health care environment

 

Reason: To inculcate in learners, the importance of thinking beyond the traditional role of physicians as providers of care to only individual patients, and to make them advocates for improving quality of care at a more global level and using systems resources to achieve that 

 

Learner Level: 3^rd year medical students during the pediatrics clerkship; 8 week clerkship duration

 

Objectives: By the end of the clerkship, learners should be able to:

1)       Explain in their own words the 6 goals of quality improvement put forth by the Institute of Medicine

2)       Value the importance of working in inter-professional teams to improve care, and

3)       Propose systems based strategies to improve care using a collaborative practice style

 

Instructional strategies/methods:

 

Preassignment: Completion of IOM modules on quality of care; Pre clerkship RIPLS scale (see reference).

Learners will be paired to mentors knowledgeable in QI and systems based practice. Mentors will be available on an as needed basis to learners to help guide them through the curriculum.

 

End of week 1: 2 hour Interactive group discussion session on the meaning of and need for the IOM goals of quality improvement and systems based approach to patient care, including the critical importance of inter-professional teams to improve outcomes             

 

Weeks 2-4: Learners to analyze work place environment for one area of improvement that resonates with them with respect to patient care.

 

Identify at least one non-physician health care professional in that system who could help provide perspective/input into that area and interview that person to learn about their roles and responsibilities, educational and training background an scope of expertise/practice.

 

End of week 4: Summary of knowledge gained by learner regarding the health care associate and a one page reflection on the learning that arose from that interview process.

They are then expected to pair up with that health care associate and explore systems based issues at the clinical site that could help improve patient care related to their pre-identified area.

 

End of week 6: A one page essay describing the area of concern, suggestions for improvement and reflection on learning from this assignment.

 

Post clerkship RIPLS scale

 

Learner outcome evaluation:

 

1)       MCQs on IOM goals and quality of care (end of rotation)

2)       360 degree evaluations by patients, health care associates and self evaluation, regarding collaborative practice style, patient centeredness, communication skills

3)       Analyses of the 2 reflective essays using the REFLECT rubric

4)       Pre and post change in learner scores in the RIPLS scale

 

Reference: The development of a questionnaire to assess the readiness of health care students for interprofessional learning (RIPLS). Parsell G, Bligh J: Med Educ. 1999 Feb;33(2):95-100.

 

_________________________________________________________________

Ivan Wong

Assignment:

Systems based practice is far reaching and diverse. As you know, the Patient Protection and Affordable Care Act (Health care reform) requests a number of assessments of community health needs, there is also the Medical home, the ACOs, ICD 10 coding, etc.

If you could pick one intiative that is key for your learners to know about and consider, what is it, and why did you choose it? How would you teach it to them and assess the outcomes?

 

Background:

ICD-9-CM was adopted for use in the U.S. in 1979 – 32 years ago! When one considers how much medicine has changed and improved over the past 32 years, it is easy to understand how the transition to ICD-10-CM will impact the success of healthcare reform. For example:

  ICD-10-CM offers significantly better specificity and detail, enabling more precise coding of diagnostic and procedural information. This reflects the many advances in medicine and medical technology, making the code sets more relevant to today’s understanding of disease processes.           

  ICD-10-CM standardizes healthcare terminology, making it consistent with national and international public health data reporting.

  ICD-10-CM is a critical element for implementing EHRs as it will help speed up the adoption of health information technology by healthcare providers, thus improving efficiency and providing information essential to improve patient care, care coordination and public health at large.

  ICD-10-CM is at the core of healthcare reform because it provides the standard and high-quality data a modern healthcare delivery system requires.

 

Learners: PGY1-5 Orthopaedic Residents during a sports medicine rotation

Duration: 3 months

Goals: To increase knowledge, skills, and attitudes related to SBP

Objectives: by the end of the rotation, learners should be better able to:

1. list the 6 goals of Systems Based Practice

2. Value the importance of ICD10 coding

 

Teaching Techniques:

Self-directed reading assignments regarding ACGME Core competencies – especially that of systems based learning.

A project will be assigned during a 3 month sports medicine rotation. Project goals are to identify a population of patients that we see and improve their access, prevention, and quality of care (i.e. adolescent girls with ACL injuries playing soccer). Project will include a chart review of the current patients over the past month (that they have participated in clinics with). Identification of patients will be determined with ICD coding (better way for searching through an electronic means). Those without coding already, will require a code to be entered.

 

Assessment:

Project proposal will be reviewed at the end to determine about the quality: project rationale, choice of intervention (and supporting evidence), preparation, implementation plan, data collection, and planned conclusions.

 

Resources:

Teaching tutorial of Nightingale Electronic Medical Records filing and data collection (currently ICD-9).

Online resources regarding ICD-10 coding

 

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Rima Jubran

ACMD 512

Systems Based Practice

 

 

Strategy for teaching and assessing systems based practice:

 

Learners are Pediatric hematology/oncology fellows

Time frame: 3 years of fellowship

Objectives:

Fellow will demonstrate ability to coordinate care of complex patients

Fellow will demonstrate abilty to function as a member fo a multidisciplinary team

Fellow will demonstrate ability to reflect on patient outcomes and how helath care delivery can be improved

 

 

As part of their continuity clinic fellows are responsible to coordinate the care of their complex patients. This includes referring to outside sub-specialties such as cardiology, dentistry or gastroenterology.   They also provide documentation requested by insurance companies to obtain authorization for care. They correspond with referring physicians and advocate for their patients within the hospital.  In addition, fellows work with team members to coordinate CCS (California Children Services) multi-disciplinary care for their patients.  These experiences provide fellows with opportunities to navigate the health care system first hand and to interact closely with multiple ancilary care providers to give the best care for their complex patients.

 

Assessment methods:  

Fellows are required to write comprehensive reports that demonstrate complex coordination of care for their CCS patients. These reports are reviewed by the PD and are included in the fellows’ portfolios.

 

I like the idea of using a Health Care Matrix to assess the fellows in this competency. This tool can be used by fellows to reflect on the delivery of care for a particular patient and how it could have been improved. I could ask the fellows to complete one HCM on a patient/month  and use it in both in their formative semi annual evaluation as a catalyst  to discuss SBP and at the summative evlauation to demonstrate competency in this area.

 

__________________________________________________________________________________________________________________________

 

Ann Spangler  

 

The Institute of Medicine has identified a gap in our provision of quality health care, and has recommended aims for a health care system in which care is safe, timely, effective, efficient, equitable and patient-centered.  This is the initiative I would like to focus on with my learners, by using the Healthcare Matrix as described by Bingham et al, and applying it to the diagnosis and treatment of spinal cord compression.

 

Spinal cord compression is a serious occurrence in patients with advanced cancer¹ and care must be coordinated and initiated in a short timeframe in order to prevent permanent neurologic consequences.  It is imperative that these patients undergo rapid evaluation and initiation of treatment, but delays can occur when there are failures in communication across specialties, or lack of recognition of the seriousness of the situation.  Optimal treatment requires recognition of the signs and symptoms of impending spinal cord compression; timely consultation of surgeons, medical oncologists and radiation oncologists; urgent imaging studies and tissue diagnosis; and initiation of treatment.  In addition, these patients frequently require nutritional and psychosocial support, and often lack insurance or ability to pay for services – their needs extend across the entire hospital system. 

 

Curriculum:  Emergency management of patients with malignant spinal cord compression

 

Learners:  Radiation Oncology residents, PGY-2 through PGY-5

 

Goals:  By the completion of this curriculum, the learners will be able to:

Construct a health care matrix

Analyze a complex health care management issue (malignant spinal cord compression), using the IOM Aims for Improvement and the ACGME core competencies

Identify core learning topics

Suggest specific improvements in care at a systems level to address the issues identified in the matrix

 

Materials:

Bingham JW et al.  Using a health care matrix to assess patient care in terms of aims for improvement and core competencies.  Joint Commission Journal on Quality and Patient Safety 2005; 31(2): 98-105.

 

Methods:

Independent reading of Bingham article on health care matrix

Residents will work as a group to analyze the process of diagnosis and treatment management for patients with malignant spinal cord compression, and present their report at the department Quality Improvement committee meeting

Recommendations will be presented at Combined Modality Conference for dissemination to other oncology specialties

 

Assessment:

Review of matrix by faculty and quality improvement committee

Resident self-reflection on how they can apply this process to other patient care issues

Track new patients with malignant spinal cord compression to see if there has been a change in timeliness of diagnosis and initiation of treatment

 

¹Sun H, Nemecek AN.  Optimal management of malignant epidural spinal cord compression.  Hematology/Oncology Clinics of North America. 2010; 24(3): 537-551.