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Practice Based Learning - Quality Improvement |
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*PBLI-Curriculum*Curriculum for outcomes-based Practice-based Learning and Improvement (one of the ACGME six general competencies): (updated 2/1/04 by James Hellerman, MD)
Outline
I. Nuts and Bolts (or Introduction) II. Measurable Goals & Objectives ("Outcomes") III. Teaching Methods ("How you will learn") IV. Outcome Assessment and Feedback
I. Nuts and Bolts (or Introduction)
The ABIM states that “Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care.
Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.
Analyze and evaluate practice experiences and improvement strategies to continually improve the quality of patient care.
Develop and maintain a willingness to learn from and use errors to improve the systems or processes of care.
Use information technology to access and manage information, support patient care decisions, and enhance both patient and physician education.”
Understanding the quality improvement, patient safety, error reduction goals of JCAHO as well as the practice-improvement aspects of EBM are important components of this competency.
A. Key Faculty
EBM Overview: Debra Bonelli Drs. Kulshrestha, Patel, Dharapak
Quality Assurance: Debra Kramer JCAHO: Dr. Barmecha
Chart Reviews: All faculty
B. Practice-based learning and Improvement will be taught By floor teaching attendings, clinic preceptors, and at Orientation. Residents will also have prescribed independent study activities.
II. Measurable Goals and Objectives for Practice-based Learning and Improvement
A. Outcomes required to document competency
The fundamental goals of this curriculum are for residents to: [ ] demonstrate a desire for formative feedback [ ] participate in QI activities of the Hospital, such as M&M conferences, journal clubs, CPCs, etc [ ] demonstrate strategies to reduce medical risks, reduce errors, and the ability to learn from mistakes [ ] write accurate, legible, appropriate prescriptions [ ] review autopsy findings to understand illness [ ] respect patient rights [ ] maintain a secure patient log [ ] analyze own patient population and perform practice-based quality improvement activities
[ ] utilize information technology to support efficient evidence-based medical care and consultations [ ] use new patient-care medical problems as an opportunity to learn (rather than just calling a consult) [ ] know when to apply expert consensus and/or evidence-based population guidelines to a specific patient, and when it is preferable to rely on clinical “pearls” and/or “mindful practice.”
The paragraphs below describe the knowledge, skills, attitudes, and habits that residents will demonstrate to indicate competency at each level of training. Such competency progresses from "knowing" to "knowing how" to “can teach”.
B. Demonstrate the following: Knowledge/Skills PGY-1 - Recognize situations where the individual(s), not the system, is responsible for errors - Know what SOTP and SHCOOL have to do with Quality - See how hospitalization may be experienced from the patient’s view (Annals of Int Med 2002) - Mistakes occur at Duke, at Children’s Hospital in Boston, and - Know JCAHO goals of quality, safety, and rights for patients and current JCAHO QI initiatives - Know how illegible prescriptions (AMA News) contribute to error - Know how failure to wash hands/follow infection control protocol can lead to serious infections - Recognize the risk that medical errors will occur from the discontinuity of care that occurs on transitioning from inpatient to outpatient care
(JGIM-2003, Carlton Moore) - Review what residents had to say about issues that increase the risk of errors (including poor sign out) (NEJM) as well as Dr. Berwick’s editorial (Cries for Help) - Know strategies to reduce errors, especially when it comes to prescriptions - Mayo Clinic 2003: Transfusion errors - Medication errors (in the ICU) - Break out from the Culture of Silence
- Know how to use technology to perform computerized search using OVID, PubMed, Google.
PGY-2 will also
- Be familiar with current CMS Quality initiatives - Know what is the AHRQ? And why is AHRQ important? - What is IHI? And who is Dr. Donald Berwick? - Be familiar with Dr. Berwick’s efforts to improve - And Dr. Leape? - Know who is the IOM, and do they forgive if we err? - What are the 10 points to improve patient care listed in Crossing the Quality Chasm, published by the IOM - Be familiar with 20 areas for quality improvement focused on by the IOM Bridge to Quality now
PGY-3 will also be familiar with the following:
- The physician’s role in chasing quality - How we implement PBLI at SBH (Dr. Barmecha) - Who was Dr. Deming? (Dr. PDCA/PDSA) - Using PDSA to improve diabetes care - PDSA in the classroom or by the NHS - PDSA used by a family practice office - PDSA used by family practice, step 2 - PDSA used by family practice, step 3 - PDSA used by family practice curriculum - NCQA for physician QI - What is a sentinel event? What is root cause analysis? - Resident Research as QI
III. Teaching Methods and How You Will Learn
Residents will acquire the above knowledge, skills, attitudes and habits by utilizing the following:
Videos/DVDs:
Reading: Online references above plus: Epstein RM. Mindful practice. JAMA. 1999; 282:833 Callahan M, Fein O, Battleman D. A practice- Profiling system for residents. Acad Med. 2002; 77:34-9 Making Medical Decisions - Richard A. Gross
Conferences:
Dr. Barmecha on PBLI, PDSA, RCA, sentinel event IOM, IHI, NCQA, AHRQ, JCAHO Debra Kramer on QA/QI Pharmacy: error reduction Dr. Schwartz: systems to avoid transfusion errors Deborah Bonelli: Boolian searches on OVID and PubMed
Experiences: Clinic, Hospital observation of Faculty PGY-1 participate in OSCE with “standardized resident” PGY-2 function as “standardized residents” PGY-3 and CMRs record and review [see also other Curricula: Adolescent, Cultural Geriatric]
Vignettes: planned for future
IV. Outcome Assessment and Feedback
Competency at each level of training in this discipline will be documented by the resident by means of the following:
Knowledge: PGY-1 Quiz or paper on QA/QI Documentation of literature search Skills Utilize PDA for QI Portfolio (CTC) ABIM Global Rating
PGY-2 Quiz or paper on QA/QI Utilize PDA for QI Portfolio ABIM Global Rating
PGY- 3 Quiz or paper on QA/QI Utilize PDA for QI Complete research project Portfolio
"In theory there is no difference between theory and practice - in practice, there is." ---Yogi Berra
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