outcome-based professional training in quality … › fme2010 › (prof richard baker...nihrclahrc...

NIHRCLAHRCLeicestershire, Northamptonshire and Rutland (LNR)

Outcome-based professional training in quality assurance

Frontiers in Medical And Health Sciences Education University of Hong Kong10th December 2010

http://www.lnr-clahrc.org/


Define

Measure Improve

The quality assurance cycle


Quality assurance and outcomes-based learning• Quality assurance is something health professionals do

– Activity, not knowledge, has priority– All health professionals involved

• There are measureable outcomes• Quality assurance is key to the safety and effectiveness

of health care organizations• Individuals and teams• Attitudes and culture• Transfer of knowledge into practice


Presentation programme

• Outcomes-based training– Undergraduates– Hong Kong course– Teams

• Primary care• Hospitals

• Outcomes and organizations


Medical undergraduates (Leicester SSSM course)

• Must be competent to:– Find & appraise research evidence– Frame the evidence in terms of review criteria– Design an audit, including plan data collection– Collect and interpret data– Identify and have plans to address the barriers to

performance– Report findings to the clinical team– Work with health care staff


The course• 1 day per week, 12 weeks• Class-room sessions on:

– Basic methods– Finding evidence

• Live projects with clinical teams• Mentor

• Assessment on project reports – (some feedback from clinical setting)


Example projects, 2010• Opiate prescribing• Antibiotic use• Pain relief in ED (hip fracture)• Medical records• Management of pelvic inflammatory disease• Asthma exacerbations in children• Response to poor glycaemic control• Outcomes of minor surgery• Diagnosis of septicaemia


Some learning points

• The gap between evidence and practice• Barriers to effective care• Human behaviour and clinical performance


Training curriculum, Hong Kong

• Introduction to the principles• Selecting a topic• Finding & appraising

evidence• Use of patient

questionnaires• Methods of collecting data• Provision of feedback• Implementation of change

• Present & review project plans

• Introducing QA to the clinical setting

• Training needs of professionals

• Overcoming resistance• Sustaining QA

Hong Kong Practitioner 2001;23:484-9


Goals, competencies

• Ability to conduct a QA project in their own work place– To improve care– To demonstrate QA to others

• To develop some leaders in QA– Training the trainers


Methods

• 1 week intensive course• Participants worked throughout on planning a project• Conducted the project after the course• Peer support• Remote support


Course outcomes (year 1)• 20 participants on first course completed 18 projects in

the following year– E.g. management of diabetes, smoking habits, use of

allopurinol, management of hypertension• Increased confidence in methods

– Median score 4 (out of 5) post course evaluation, 6 methods questions

• Training and support necessary• Access to evidence resources necessary• Organizational support key


Practical component to training

• Potentially more difficult• Attach staff in training to existing teams• Introductory training and work-place training• Secondments • Opportunities in organizations


Professionals, teams & organisations

• Quality assurance is a team sport


Facilitating teams (primary care)

• Team quality system (no QA – QA part of our routine management)

• Facilitated team meetings (5) in work setting– Small group work, didactic, brainstorming, home work

• Identify current use of QA• Create agreed policy on QA• Identify topics• Compete QA cycle

Hearnshaw QHC 1994;3:164


Evaluation

• 4 intervention & 4 control teams• Attendance at meetings 79%-91%• High engagement• Projects completed (access/waiting times popular)• Improvements in QA and team functioning


Hospital teams • 22 teams randomised to control & intervention groups• Training by external facilitators• Same 5-session training programme• Outcomes

– Knowledge, skills, attitudes (questionnaire)– Collaborative behaviour (standard measure)– QA projects– Observations of teams

Cheater Int J Nursing stud 2005;42:779


Impact

• Improved knowledge, skills, attitudes• Increased collaborative behaviour• Improved teamwork observed• Assessment of QA projects

– Compliance with assessment criteria– Intervention group 79% (9), control 45% (2)


QA/redesign (integrated pathway for menorrhagia)

• Oversight team established• Guidelines to drive new pathway• Collaboration between teams & organisations• New pathway

– Increased management in primary care– Direct access to investigations and surgery– Controlled evaluation

• No differences in clinical outcome• Fewer hospital outpatient visits• Higher satisfaction (access)

Julian QSHC 2007;16:110


Outcomes & organizations• Benchmarking

• Preventing premature death• Quality of Life in long term

conditions• Recovery from ill health / injury• Experience of care• Avoidable harm


CHD Mortality rates, England 2008 (152 primary care trusts)

.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

Mor

talit

y/10

0,00

0 20

08

Primary Care Trusts


CHD mortality rates (per 100,000 population), England, primary care Trusts, in 4 groupsCHD mortality

Q1 (45-76) Q2 (77-85) Q3 (86-98) Q4 (99-147)

Deprivation(IMD)

14.5 18.1 27.0 31.4

Smoking (%) 21 23 26 27

Obesity (%) 22 23 24 26

Diabetes (%) 4.7 5.0 5.4 5.5

Hypertensiondetection (%)

13.4 13.4 13.1 12.8

JAMA 2010; 304;2028-2034


Hypertension Registers, England 2008 (152 primary care Trusts)

.0000

.0200

.0400

.0600

.0800

.1000

.1200

.1400

.1600

.1800

Prop

ortio

n of

pat

ient

s on

Hyp

erte

nsio

nR

egis

ters

Primary Care Trusts


Royal College of General Practitioners 1981: priority for action:

• Control of known hypertensives• Case-finding of new hypertensives

• ‘Fortunately for mankind, perhaps unfortunately for ourselves, the evidence is that we could do much more, even in the present state of knowledge. There are times when fundamental re-thinking becomes a necessity. We live in such a time.’

• Report from General Practice 19.


Organizations & QA training

• Training of professionals and organizational development together

• Organizations need– Leadership and expertise in QA– Evidence-mindedness


Towards a QA programme for CHD

• Integrate with organizational priorities and policies• Understand the reasons for current performance

– Organizational level– Clinical team level

• Provide – Information– Practical resources – Education and training opportunities– Examples of success


Conclusions

• Quality assurance well suited to outcomes-based training

• Individuals and teams, in the work place• Training for organizations

– Outcomes of training are improved clinical outcomes

[email protected]://www.lnr-clahrc.org/

mailto:[email protected]

outcome-based professional training in quality … › fme2010 › (prof richard baker...nihrclahrc...

Documents