2006 vanderbilt university medical center linking outcomes of care and the acgme core competencies:...

2006 Vanderbilt University Medical Center

Linking Outcomes of Care and the ACGME Core Competencies:

A Matrix Solution

John Bingham, MHADirector

Center for Clinical Improvement

Competencies Working GroupJanuary 5, 2007

Doris Quinn, PhDAssistant Professor

Division of Medical Education

2 2006 Vanderbilt University Medical Center

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


1999 2001 2002 2003

Emerging public

reporting and

awareness of quality measures

Drivers of Change in Healthcare:


Patient Care should be:

Safe, Timely, Effective,Efficient, Equitable, Patient-

Centered(STEEEP)


Phase I Phase II Phase III Phase IV

7/2001 6/2002 7/2002 7/20116/2006 7/2006 6/2011 Beyond

• Improve the evaluation processes for all six of the Competencies.

• Provide aggregated resident performance data for Internal Review Process.

• Use resident performance data as the basis for improvement.

• Begin to use external quality measures to verify resident and program performance levels.

• Identify benchmark programs.

• Involve community in building knowledge about good GME.

• 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.


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)


The future…. in a few words:

Transparency

Process Reliability


So…what should we do?

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

Patients with

Needs

Patients with Needs

MetAccess Diagnosis Treatment Follow-upAssessment


Patient Care should be:

Safe, Timely, Effective,Efficient, Equitable, Patient-

Centered(STEEEP)


PRACTICE-BASED LEARNING AND IMPROVEMENT

(What have we learned, what will we improve)

Improvement

SYSTEM-BASED PRACTICE

(What is the Process?On whom do we depend and who depends on us)

PROFESSIONALISM(How must we act)

INTERPERSONAL AND COMMUNICATION

SKILLS(What must we say)

MEDICAL

KNOWLEDGE(What must we know)

PATIENT CARE(Overall Assessment)

Yes/No

Assessment

PATIENT-CENTERED

EQUITABLE

EFFICIENTEFFECTIVETIMELYSAFE AimsCompetencies

Healthcare Matrix: Care of Patient(s) with….

© 2004 Bingham, Quinn Vanderbilt University


“Avoiding injuries to patients from the care

that is intended to help them”

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


Safe


“Reducing waits and sometimes harmful delays for both those who receive and those who give care”


Timely

Safe


“Providing services based on scientific knowledge to all who

could benefit and refraining from providing services to those not

likely to benefit”


Timely

Effective

Safe


“Avoiding waste, including waste of equipment, supplies, ideas, and

energy”


Timely

EfficientEffective

Safe


“Providing care that does not vary in quality because of personal

characteristics such as: gender, ethnicity, geographic location, and

socio-economic status”


Timely

EfficientEffective

Equitable

Safe


“Providing care that is respectful of, and responsive to:

•individual patient preferences,

•needs and values,

•and ensuring that patient values guide all clinical decisions”


Timely

Efficient

Effective

Equitable

Patient Centered

Safe


“…about established and evolving biomedical, clinical, and cognate sciences, (e.g. epidemiological and social-behavior) and the application of this knowledge to

patient care”

Medical Knowledge


Timely

Efficient

Effective

Equitable

Patient Centered

Safe

What must we know?


Medical Knowledge

Interpersonal and Communication Skills

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

“…that result in effective information exchange

and teaming with patients, their families, and

other health professionals.”

What must we say?


“…as manifested through a commitment to carrying out professional responsibilities,

adherence to ethical principles, and sensitivity to a diverse patient population.”

Medical Knowledge

Interpersonal and Communication SkillsProfessionalism

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

How must we behave?


“…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.”

Medical Knowledge


System-Based Practice

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

What is the Process?On whom do we depend?

Who depends on us?


“…involves investigation and evaluation of their own patient care, appraisal and

assimilation of scientific evidence, and improvements in

patient care.”

Medical Knowledge


System-Based Practice

Practice-Based Learning & Improvement

PATIENT CARE Timely

EfficientEffective

Equitable

Patient Centered

Safe

What have we learned?What will we improve?


Patients with

Needs

Patients with Needs Met

Access Diagnosis Treatment Follow-upAssessment

Linking it all together….

-Medical Knowledge

-Interpersonal and Communication Skills-Professionalism

-Practice-Based Learning & Improvement

Timely EfficientEffective Equitable Patient CenteredSafe

-System-Based Practice

Clinicians competent in:

Patient Care that is…




Improvement






MEDICAL



Yes/No

Assessment

PATIENT-CENTERED

EQUITABLE





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


History Physical

Exam Labs Tests Consults Etc.

DiagnosisCare of Patient(Matrix)

Using the Matrix


IOM

ACGME

SAFETY TIMELINESSEFFECTIVE-

NESSEFFICIENCY

EQUITA-BILITY

PATIENTCENTERED-

NESS

PATIENT CARE

MEDICAL KNOWLEDGE & APPLICATION

X X

PROFESSIONALISM

INTERPERSONAL & COMMUNICATION SKILLS

SYSTEMS- & TEAMS-BASED PRACTICE

X

PRACTICE-BASED LEARNING & IMPROVEMENT(Process to Improve)

Anesthesia: One resident’s learningA resident prepared for a case presentation and addressed the following cells.

No No No No NoNo


IOM

ACGME

SAFETY TIMELINESSEFFECTIVE-

NESSEFFICIENCY

EQUITA-BILITY

PATIENTCENTERED-

NESS

PATIENT CARE

MEDICAL KNOWLEDGE X X X

X

PROFESSIONALISM

X X

X X

INTERPERSONAL & COMMUNICATION SKILLS X X X X

X

SYSTEMS- & TEAMS-BASED PRACTICE X X X X X

PRACTICE-BASED LEARNING & IMPROVEMENT(Process to Improve)

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

Assure Mom aware of what is

happening. Communication

with father.

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..


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).


Healthcare Matrix: Care of Patient with left knee pain, dx of MTB Department of Pathology

AIMS Competencies

SAFE1 TIMELY2 EFFECTIVE3 EFFICIENT4 EQUITABLE5 PATIENT-

CENTERED6

Assessment of Care

PATIENT CARE7 (Overall Assessment)

Yes/No

Yes

No

Yes

No

Yes

Yes

MEDICAL KNOWLEDGE and SKILLS8

(What must we know?)

Differential for monoarticular arthritis and how to work it up.

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.

Lack of knowledge regarding surgical pathology results resulted in delayed treatment and repeat office visit with no definitive diagnosis given.

INTERPERSONAL AND

COMMUNICATION SKILLS9 (What must we say?)

Clinician not called with surgical pathology results so treatment not initiated for weeks.

Ultimately effective as microbiology grew MTB in joint and called clinicians with the results.

PROFESSIONALISM

10 (How must we behave?)

SYSTEM-BASED PRACTICE11 (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 AND IMPROVEMENT12

(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



Usual Morbidity and Mortality

Conferences


Care of Child ingesting medications (Adderal and Zoloft) Residents 10/28/03

ACGME IOM SAFE1 TIMELY2 EFFECTIVE3 EFFICIENT4 EQUITABLE5 PATIENT-CENTERED6

Assessment

PATIENT CARE7 (Actions Taken)

?

Child was kept in busy ED

Yes

Drug screen done

quickly.

?

ED getting busy, who can

provide best care?

How is child “restrained” to

take BP when it is very important?

MEDICAL KNOWLEDGE8

Kn. Of meds and affect on child especially elevation of BP

When is it appropriate to admit?

What should be done, if anything beside observation? Evidence for treating child taking Adderal?

Care of child may be frightening. What is role of family or parents in care?

PROFESSIONALISM9


SKILLS10

When do we call specialist?

SYSTEM-BASED PRACTICE11

VS done on time.


Major focus on Medical Knowledge


With All CompetenciesReviewed


Healthcare Matrix: Care of Patient(s) with respiratory distress Otolaryngology: Head and Neck Surgery October, 2005

AIMS Competencies


CENTERED6

Assessment of Care


Yes/No

No No No No ? ?



Red rubber catheters too flexible and can bend easily – may be hard to remove or suction hardened secretions (unknown frequency of suctioning and use of saline to loosen secretions

Delay in obtaining flexible bronchoscope during oral attempts at intubation

Airway obtained through tracheotomy site with apparent distal obstruction, oral intubation unlikely to bypass obstruction


SKILLS9 (What must we say?)

Better way to communicate likelihood of obstruction and difficult airway anatomy

Patient with poor lung reserve, time wasted during oral attempts – patient unable to tolerate prolonged apnea

Poor communication about steps required to secure airway

There was a good discussion with family after this event.

PROFESSIONALISM


MICU very responsive to code initially


(What is the process? On whom do we depend?

Who depends on us?)

There is often a problem of safety when multiple specialties are involved. There is no clear system to know what the plan is. This sometimes leads to disagreement when none should exist.

Knowledge of where bronchoscopes are located for each ICU

Determine role of nurses, respiratory therapists, and physician in managing tracheotomy patients

Inefficient system for tracheotomy care (ie supplies specified, nursing instructions)

Trach care may vary depending upon patient floor

Patients may receive different levels of tracheotomy care depending upon nursing staff, hospital ward, and managing service

Improvement



Need variety of suction catheters available. Determine the essential equipment for tracheotomy care. Know 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

Method to succinctly communicate whether patient can be orally intubated to minimize unsuccessful attempts at securing airway

Create order set to specify supplies necessary, as well as initial steps if airway lost

Have standard order set available for all ICU’s and floors Make order set easy to use so different services may implement


Analyzing Data fromMultiple Matrices


positiveLung Cancer with Brain Mets

Team took the time to know the patient and her desire for treatment.

Medical Knowledge

Patient-Centered2

TranslatorsnegativeHydrocephalus

This patient spoke Spanish. Skilled interpreters were not available. Medical students and family were used of ten as interpreters which was not ideal.

Interpersonal Communication skillsEquitable12

EBMnegativeCeliac Sprue

Repeated imaging and brain biopsies were unnecessary. Reduce switching of primary neurologists to avoid repeat testing.System-basedEfficient18

Care PlanimprovementStroke

We could have taken the time to do a better initial H&P to better discern what his condition was like at initial presentation to compare it to discharge condition

Practice-Based Learning & ImprovementEffective4

Teamwor knegative

Pregnancy IntracerebralHemorrhage

Delays in communication increased the time it took to get an initial head CT and begin treatment.

Interpersonal Communication skillsTimely19

EBMpositiveStroke

Decisions were made based on accepted algorithms and consensus within the team.ProfessionalismSafe3

Secondary Code

Primary Code (positive, negative,

improvement)Diagnosis ContentCompetenciesAimsStudent ID

Excel Spreadsheet for Matrix Analysis




Improvement




INTERPERSONAL AND

COMMUNICATION SKILLS(What must we say)

MEDICAL KNOWLEDGE

(What must we know)


Yes/No

Assessment

PATIENT-CENTERED

EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE AimsCompetencies




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)


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


Healthcare Matrix: Care of Patient(s) with respiratory distress Otolaryngology: Head and Neck Surgery October, 2005

AIMS Competencies


CENTERED6

Assessment of Care


Yes/No

No No No No ? ?



Red rubber catheters too flexible and can bend easily – may be hard to remove or suction hardened secretions (unknown frequency of suctioning and use of saline to loosen secretions

Delay in obtaining flexible bronchoscope during oral attempts at intubation

Airway obtained through tracheotomy site with apparent distal obstruction, oral intubation unlikely to bypass obstruction


SKILLS9 (What must we say?)

Better way to communicate likelihood of obstruction and difficult airway anatomy

Patient with poor lung reserve, time wasted during oral attempts – patient unable to tolerate prolonged apnea

Poor communication about steps required to secure airway

There was a good discussion with family after this event.

PROFESSIONALISM


MICU very responsive to code initially


(What is the process? On whom do we depend?

Who depends on us?)

There is often a problem of safety when multiple specialties are involved. There is no clear system to know what the plan is. This sometimes leads to disagreement when none should exist.

Knowledge of where bronchoscopes are located for each ICU

Determine role of nurses, respiratory therapists, and physician in managing tracheotomy patients

Inefficient system for tracheotomy care (ie supplies specified, nursing instructions)

Trach care may vary depending upon patient floor

Patients may receive different levels of tracheotomy care depending upon nursing staff, hospital ward, and managing service

Improvement



Need variety of suction catheters available. Determine the essential equipment for tracheotomy care. Know 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

Method to succinctly communicate whether patient can be orally intubated to minimize unsuccessful attempts at securing airway

Create order set to specify supplies necessary, as well as initial steps if airway lost

Have standard order set available for all ICU’s and floors Make order set easy to use so different services may implement


Care of Patient in Respiratory Distress (Dr. Seth Cohen)

Item #

What needs to be done Results

1 Speak with nurse educators in charge of teaching tracheotomy care

Classes taught to surgical nurses. Only fraction of nurses who take care of tracheotomy patients attend these classes

2 Discuss possibility of creating computerized tracheotomy orderset

Done

3 Determine equipment currently specified to be in tracheotomy patient rooms

Done

4 Create order set Done

5 Have order set placed in hospital wide computer ordering system

Orderset in place and accessible to all medical services.

6 Make all otolaryngology service aware of order set and how to implement

Presented orderset to department.

7 Make heads of ICU’s aware of order set and how to implement

Presented orderset to head of ICU’s.

8 Discuss current emergency room protocol for replacing displaced tracheotomy tubes

Done

9 Create and present specific protocol for replacing tracheotomy tubes in ER and when to contact otolaryngology support

Presented protocol to ER chair.

10 Assure that appropriate equipment identified in 3 is available for tracheotomy patients

Done

42 2006 Vanderbilt University Medical Center © 2004 Bingham, Quinn Vanderbilt University



Improvement






MEDICAL



Yes/No

Assessment

PATIENT-CENTERED

EQUITABLE


Healthcare Matrix: Care of Patient(s) with Stroke

An Oracle Database is being built that will collect

data from each cell and allow analysis and reports

to be generated by:

•Institution•Department

•Diagnosis•IOM Aim

•Competency

2006 vanderbilt university medical center linking outcomes of care and the acgme core competencies:...

Documents

quality of care

medical knowledge

care of patients

issafe slide

patientcentered steeep

delivery of care

learning of competencies

mha director center