Quality of Care problems in medicine?

A role for early educational intervention?

Dr Hub Wollersheim, internistCentre for Quality of Care Research

(WOK)Radboud University Medical Centre

Nijmegen; the Netherlands

Quality of Care (QoC) problems in medicine?

1) A problem?

2) What problem?

3) The consequences?

4) Is early undergraduate education a solution?

5) And if: How and what?

QoC in medicine; the problems

1) General: resistance to change external pressure: loss of autonomy (BMJ 2001: Why are MD’s so unhappy?)2) Quality Management/ Systems: standardisation: negative attitude: a threat to creativity

and livelong learning; innovation3) Quality of Care: insufficient knowledge/ skills improvement/ evaluation

QoC; the problem; skills

Insufficient knowledge and skills:

-Quality of Care = guideline development

-Methods:

how to find/ judge evidence?

how to implement improvement?

-Research:

how to design/ evaluate?

QoC: the problem; attitude

Not accustomed to transparancy or accountability:

Training/ working in:

- One to one situations (patient(s) and supervisors)

- A patriarchal culture; professional code: keep the problems inside

- University system: competition instead of cooperation

QoC: real problems

1) Bureaucracy: 30% paper, 20% meetings

2) Juridi(culi)sation: VS: 1980/1990/2000: 20X

3) The guideline as law: 30% deviation

4) No evidence: SR q-systems: minor effects (n=2)

5) Managers task, the move from patient care (5-45%)

The consequences

1) MD’s do not collaborate in QI projects (15%) despite that there participation is fundamental (37% more successfull)

2) Variation in care: prostatectomy (40x)3) Suboptimal care: -under/ over/ mis use: 30-60%; -misjudgement (with consequences): 50%; -unsafety: 50-90.000 (?) deaths US

Improving QoC in medicine

Make QoC attractive:

-Problem in stead of system oriented

-Support in stead of demands

-Internal drive in stead of external pressure

-Publish results of innovative improvements

-No quality slang

QoC: teaching

Teaching programs and methods:

1) Attitude,

2) Knowledge,

3) >SKILLS;

Experience and evidence:

not much to guide us

QoC: competences

60% QoC goals in competences CanMeds:

Canada> Denmark> Australia> Netherlands (2005):

>deliverance of effective and patient centered care

>communicative, cooperative and management skills

Teaching; baseline principles of QoC

A) Astonishment:

Why? How?

B) Reflection:

1) How good am I? or are we?

2) How can I/we do better?

3) Show it

4) Lifelong learning

Teaching QoC; methods

1) Use medical language, no quality slang:-Indicator = a diagnostic instrument for QoC2) Avoid words like “control”,”system”,

“standard”3) Themes connected to medical care:-EBP; safety (side effects, complications)4) Problem oriented themes (patients/

practise)

Teaching: themes

Teaching; framework QoC

Scopes:• Professional: evidence based practise (systematic

reviews; guidelines; decision aids)• Organisational: proces oriented practise

(pathways; multiprofessional collaboration; task delegation); management participation; financial incentives; capacity management

• Patient oriented practise: communication; education; shared decisions; quality of life

Improvement: teaching; cross themes

1) Evaluation: themes; designs; use well described EB interventions, validated methods and measurement techniques; statistics; process evaluation; qualitative evaluation

2) Implementation of improvement: barriers, facilitators, limiting conditions, project management, the quality circle (plan, do, check, act), measurements (indicators) and feedback

What types of undergraduate education?

1) Existing programs

2) Programs that should be developed

3) Teaching methods

4) Examination methods

5) The Dutch (European?) initiative

Undergraduate education in medicine; existing programs; USA

Existing programs:

Mayo Medical School; Ro; MN; USA

Prathiba Varkey, Thomas R Viggiano

Task:

“The curriculum now only focussed on di-seases, should systematically introduce QI”

Undergraduate education in medicine;existing programs; Mayo Clinics

Objectives:1) To define and impart knowledge of QI

sciences that is “developmentally” appropriate to medical students

2) To introduce the skills to assess the gap between existing and optimal practise and to plan and measure change

3) To apply knowledge and skills through QI projects

Mayo; the QI modules (4 wks)

Year 1: orientation introduction to the patient continuity of careYear 2: evaluation skills institutional leadership (panel discussions) clerkship in family medicine (introduction to EBP)

Mayo; the QI modules

Year 3: clerkship survival skills clerkship in internal medicine (application of EBP) QI research projectYear 4: preventive medicine and public health social medicine (evaluation of EBP) clerkship in emergency medicine (application of QI)

Mayo; QI curriculum; the essential

1) Health care as a process/ as a system;

2) QoC measurement and improvement; process analysis

3) Variation; optimal care

4) Leadership and team collaboration

5) Safety and errors

Mayo; QI curriculum; teaching methods

1) Case/ problem based learning2) Exercises3) Simulations4) Interviews5) Video discussions6) Panel discussions7) Project presentations to teach the other students8) Web modules9) Debriefing: clinical rounds; night shift; MPD10) EBP before, during and after clerkship

Mayo; QI curriculum; an example

Year 1; Orientation module (last week)

-Presentation: A case with a medication error

-Small group discussion: what went wrong and suggestions for improvement

-Panel discussion with experts

-Video: The patients view

-Presentation: How to communicate error

-Simulation: Communicating error with a patient/ family

Mayo: QI curriculum; an example

-Debriefing: panel discussion: difficulties; two video examples: do’s and dont’s

-Video of a law suit-Debriefing: panel discussion about the video-Exercise: 5 groups: day 5 presentations: 1)analyze error and its consequences; 2)a medication error improvement plan; 3)a fall prevention plan; 4)a plan to prevent pressure ulcers; 5)a plan to prevent wound infections.

Mayo; QI curriculum; experiences

1) Hostile medical professors

2) Always teach within a medical setting

3) Students: sceptical before; enthusiasm after

4) Extensive evaluation of results by before/ after assessments of attitude; knowledge; skills

5) Permanent improvement on the basis of evaluation

Undergraduate education in medicine;existing programs; Nijmegen

Radboud UMC Nijmegen; Medical Faculty:

Year 1: communication skills (3 hrs; video and patient demo); EBP and guidelines (2 hrs; key lecture and case)

Year 3 and 4: the process of care (4 wks); optimizing clinical skills (4 wks); quality and the law (17 hrs); free choice modules

Undergraduate education in medicine; teaching and exam methods

Teaching methods: active problem based learning1) Care related problem presentation and evaluation2) Evidence or safety as starting points3) Activities:-Evaluating observed skills or simulations-Interviewing key QoC persons or patients4) Examination:-Writing a QI paper-Perform and present a QI research project

Undergraduate education in medicine;the Dutch initiative

Care Research Netherlands (ZonMw):

The development of a national teaching program “quality of care” for (bio)medical schools in the Netherlands

All Dutch Universities:

-exploration of existing programs/ teaching methods

-what should be developed?

Educating QoC: 4 questions

Deliberate with your neighbour; answer the following questions:

1a) What is the domain of QoC?1b) Should it be taught on its own or should it be part of:

clinical subjects; epidemiology, EBP, clinical decision making or management in health care?

2a) What are learning goals for MD’s?2b) Which goal in which phase of study?3) Successful teaching methods?4) Is there a special role for QoC teaching in primary

care?

European collaboration?

Are you experienced with successful programs and teaching methods and willing to exchange?

Mail me: h.wollersheim@medzaken.umcn.nl

The problem; Quality of Care

Attitude: -All day we deal with quality of care; “our”

domain -Are systematic improvement activities

effective and efficient? 10% = the placebo effect

Improvements: to enthuse

Care provider: less problems; more publications; >job satisfaction

Group: better communication/ cooperation/ knowledge exchange/ task delegation:

>team climate inventory

Hospital management: <costs

Public: >honor role

Patient: >satisfaction; >quality of live

Fly wheel effect: other improvement projects

Undergraduate; medicine, RUN

Optimizing clinical skills: 4 wksPractise: 1)Outpatient clinic of Internal Medicine; 2)Department of Geriatrics; 3)General Practise; 4)Determinants of health care.Themes: evidence and guidelines, communication,

collaboration, the patient’s perspective, evaluation of improvement, research

Undergraduate education; Netherlands

Erasmus University Rotterdam:Prof dr Marc Berg; prof dr Jan WalburgiBMG; BaMaSc:-Ba: organisational improvement quality and the law-Ma: integral management of care: management of care ICT; accountability performance management

Undergraduate education; Netherlands

AMC; UvA:Prof Dr Niek KlazingaMedicine: 4th year: Quality of Care: guidelines audit collaboration social and primary care improvement paper

Undergraduate education: Netherlands

Vumc:Prof Dr Gerrit van der WalMedicine: 4th year: Quality of Care: introduction focus on unsafety (mimicing Disciplinary Committee case) writing a QI paper after interviewing key quality persons

Undergraduate education

azM;UM:

Prof dr Frans van Wijmen:

-Medicine: 3th year: surgical audits

5th year: QoC research

-Focus on Health Care research and “Hogescholen” (nursing and allied health care sciences)