Myers, MD, FHM, FACP, Jennifer

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Undergraduate and Graduate Curriculum in Quality

Jefferson Digital Commons

A Quiz • I am comfortable going to any healthcare provider or hospital anywhere in the country.  • I am comfortable going to any healthcare provider or hospital in my city/town.  • I am comfortable going to my hospital or any healthcare provider in my institution.   QUESTION:  Should you consider yourself a high quality physician if you train in a health care system  that is not systematically trying to improve the value of care it provides?          – Larry Casalino  No Yes What?! The “Good Doctor” Present Solid Fund of Knowledge Gatherer of Information Team Player Embrace Quality, Safety, & Public Reporting  Evidence-based Patient-centered Past Encyclopedic Knowledge Independent Always Available Master of Rescue Care Swensen SJ, et al. N Engl J Med. 2010. How Do We Get There? What Do We Value & Teach? Commitments to recognize and address anomalies in professional behavior Continual pursuit of safety in healthcare Awareness of economics, healthcare costs, and social stewardship Continual reduction in waste Honesty, openness, transparency and disclosure Teamwork & accountability across disciplinary lines  Patient-centeredness in all things Berwick and Finkelstein, Acad Med, 2010   Quality &  Patient Safety Graduate Medical  Education Finally Coming Together Jennifer S. Myers MD December 5, 2014 Timeline for Quality and Safety Education  1999 - 2001 2011 2010 ACGME introduces a competency framework for residency training; understanding systems are now part of the required curriculum  ACGME introduces New Duty Hour Requirements with more quality and safety training expectations  IOM commissions a report on GME and safety 2003 IOM Reports  2014 ACGME Next  Accreditation System   2013 IOM Report on GME Funding 020406080100Patient Safety QualityImprovementInpatientHandoffsDischargeTransitionsHigh Value CostConscious CareQSEA 2012 QSEA 2013 QSEA 2014Percent of Residency Programs Teaching the Following Topics; National Sample A Call to Action  020406080100Patient Safety QualityImprovementInpatientHandoffsDischargeTransitionsHigh Value CostConscious CareQSEA 2012 QSEA 2013 QSEA 2014 Penn Fall 2013Penn is Not That Much Better! Barriers: • Hidden Curriculum • Lack of faculty expertise & buy-in • Time • Change • “QI” can be seen as a bad word Incentives: • Public opinion • External Regulations • GME funding • OUR PATIENTS  “QI” “…graduate medical education must include training and active participation in quality and safety initiatives by every resident physician”.  Dr. Tom Nasca; JAMA 2013       ACGME has the aspirational goal of demonstrating to the public that America’s teaching hospitals and institutions are safe and of high quality.  MILESTONES: Demonstrate Competency   in Quality & Safety    Clinical Learning Environment Review Program: Engage Residents & Faculty in Institutional Quality & Safety Efforts  Milestones for Quality & Safety  Patient Care PBLI (QI) SBP (Safety) “Ready for Unsupervised Practice”  Clinical Learning Environment Review Program (CLER)  Six Key Focus Areas for CLER: 1. Quality Improvement 2. Patient Safety 3. Handoffs & Transitions 4. Supervision 5. Professionalism 6. Duty Hours/Fatigue Management  Key Questions:  How engaged are the residents and fellows? How integrated is the GME leadership and faculty in the hospital/medical center efforts across the six focus areas?   University of Pennsylvania Health System • Tertiary care health system  in Philadelphia (3 hospitals) • 789 beds at our primary academic teaching hospital • 78 accredited GME programs – 1147 housestaff • Department of Clinical Effectiveness & Quality Improvement (CEQI) • National reputation for quality and safety Acknowledgements: PJ Brennan MD; CMO Jeffrey Berns MD; DIO Pat Sullivan PhD; VP QI/PS Neha Patel; MD MS Lisa Bellini MD; Vice-Dean Faculty Affairs   Penn Medicine   Blueprint for Quality and Patient Safety Penn Medicine will eliminate preventable deaths and preventable 30-day readmissions by July 1, 2014 Imperatives Priority Actions Accountability For Perfect Care “Always” events - strive to provide perfect care  Implement clear lines of accountability that span inpatient and ambulatory environments Patient And  Family Centered Care Provide consistent and thorough communication regarding plan of care  Increase patient and family involvement in UPHS forums and integrate patient feedback into clinical and service improvement efforts Transitions In Care/Coordination Of Care Redesign clinical processes to ensure that patients and their information are safely transitioned from one setting of care to another Reducing Unnecessary Variations In Care Eliminate variations in care processes where evidence exists Balance conformity in practice with needs for personalized care  Improve  the value of our health care processes and outcomes Provider Engagement, Leadership, And Advocacy Strengthen organizational capacity and capability for continuous improvement  Increase involvement of housestaff in quality, safety and service excellence efforts Penn’s Blueprint for Quality & Patient Safety (2009)  Increase involvement of house staff in quality, safety and service excellence efforts The Beginning of Our Story  Rogers, Diffusion of Innovation Curve Identifying & Engaging the Residents and Fellows Who Wanted to be Leaders and Change Agents for Healthcare Improvement Healthcare Leadership in Quality Track  • UBCL physician leaders • Process improvement specialist • Quality/safety leaders • QI research mentors • QI Operation Project • QI Research Project • 2 years timeline • Abstract (minimum requirement) • UBCL teams (Ambulatory, CICU, CCU, MICU, Founders 12/14, Oncology) • IT (mobile health, clinical decision support) • Didactics:  • Year 1 (August2014) • Year 2 (1 week) • Process Improvement In Action Training  Core Curriculum Quality Improvement On the Front Line Mentorship Capstone QI Project Established in 2009-2010 Patel N, Brennan PJ, et al. Academic Medicine 2014  Housestaff & Advanced Practitioner Quality Council   Department of Clinical Effectiveness & Quality Improvement   Housestaff & Advanced Practitioner Quality Council   A forum for QI “problem-solving” with residents from diverse departments  Connect health system quality priorities with resident/AP ideas & leadership  Annual QI Project  Established 2011 at UPHS The Middle of our Story: Reaching the Majority Rogers, Diffusion of Innovation Curve Created by Penn Healthcare Leadership in Quality Track Residents (n=24); August 2013 CULTURE TIME Lack of  Resident  Engagement in Quality & Safety Activities EDUCATION/ AWARENESS    STRUCTURE Limited time in day for “non clinical” tasks Apathy / learned helplessness /   lack of confidence in ability  to affect change Fear of repercussions /      punitive nature of reporting   Limited protected time for QI Little or no role modeling by                            attending or upper year residents Lack of Formal Curriculum  Competing learning priorities Transient nature of residency: residents float from floor to floor; hospital to hospital Lack of interdepartmental, interdisciplinary interaction Large, difficult system  to change Lack of feedback on Safety Net Reports Lack of awareness of  “back end” of QI/PS processes What Do The Residents Think ?  Conceptual Framework for Resident Engagement in Quality & Safety Resident & Fellow Engagement in Quality & Safety Culture Health System-GME Alignment Educational Resources Faculty Development Inter-Professional Collaboration Infra-structure A Tess & JS Myers Shared Responsibility: New Relationships, Roles, and Work Trainees Hospital Quality Office GME Office Infrastructure,  Shared Work Plan   Oversight Centralized resources Curriculum development, Teaching, Mentorship Daily supervision, role modeling, & practice enforces local quality/safety culture Core QI/PS Faculty Frontline  Faculty & All  Staff A Tess & JS Myers  Penn’s GME Quality/Safety Efforts   Culture Safety Reporting Campaign  FOCLE “Walk Rounds” Educational Resources Quality & Safety Toolkit on GME website  Video-based Orientation Module to Introduce Penn’s Culture of Quality & Safety  Faculty Development  Faculty Development – as much as humanly possible! Infrastructure Associate DIO for QI/PS – new position Quality/Safety Educator(s) in each department Hstaff Quality/Safety Leadership Council Healthcare Leadership in Quality Track New relationships with Quality Data managers to make data more accessible to programs and trainees Health System – GME Alignment Associate DIO for QI/PS – sits in both worlds Shared QI-CLE “Dashboard” with Outcome measures to focus our work measure progress Interprofessional Collaboration  RN/NP involvement in  HS Council Partnering with Nurses for svc orientation Thank You jennifer.myers@uphs.upenn.edu 

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1003&amp;context=flqs

Undergraduate and Graduate Curriculum in Quality

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