Practice Based Learning and Improvement

Education and training in the methods and implementation of Performance Improvement (PI) and Evidenced Based Medicine (EBM) is a vital part of the residency curriculum, no matter which mode of practice or setting the resident chooses after graduation. EBM and PI offer an approach and a set of tools to the physician faced with a process problem in both clinical practice and administrative office issues. Many non-medical industries have embraced PI methodology with impressive results. Learning from the care we have provided and caring for patients are two very integrated and ongoing processes that continue well beyond residency training.

PI may be defined as the body of knowledge, attitudes and skills necessary to efficiently lead and continuously improve the multiple elements of care delivery within a medical practice. EBM has been defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

More and more, physicians are being asked to help improve the quality of health care as a part of a team comprised of non-physician health care providers and non-medical support staff. Training and education in EBM and PI methodology will help physicians be effective members of those teams.

This curriculum complements two other AAFP curricula- Research and Scholarly Activity and Medical Information Technology. Many of the attitudes, knowledge, and competencies in those two documents are integrated into PI and EBM. Medical information systems specifically will greatly enhance the ability of the clinician to measure and improve performance and access the best evidence available for medical decision-making.

Attitudes

The resident should develop attitudes that encompass:

Performance Improvement

A willingness to work on teams tasked with improvement initiatives
An awareness and positive attitude toward improving health care delivery
A belief that PI tools and methods can improve the care deliver

Evidence Based Medicine

An ongoing effort to identify the best evidence available for each clinical issue faced

Knowledge

Performance Improvement:

Understand where Process Improvement theory originated
Be able to define a process and the outcomes produced by processes
1. Type of outcomes
  1. Physical- the measurable physical outcomes of the patient as a result of health care provided
  2. Service- access to care and patient satisfaction with care provided
  3. Cost- appropriate use of resources and subsequent affect on costs in the care provided
Definition of a customer- this can be a patient, office staff, physicians or anyone who plays a role in the delivery of health care
How practice variation affects the cost and quality of health care
1. Random variation
2. Assignable variation
3. Significance of clinical variation in the United States (e.g. Dartmouth Atlas of Health Care, 1999)
Teamwork Concepts and Effects of Teamwork as a Skill
1. How to form a team
2. Effective meeting management
3. Tools for generating ideas- brainstorming, multivoting, nominal group technique
4. Role of team leader and facilitator
Use of Performance Improvement Methodology and Rapid Cycle Improvement including Plan-Do-Study-Act (PDSA)
1. Find, Organize, Clarify, Understand, Select (FOCUS)
  1. Find- Identify a process in need of improvement by talking to customers and owners of clinical and administrative processes
  2. Organize- Select and organize a team and draft a mission statement
  3. Clarify- General goals for the team; what are the key parameters which define the quality of the process
  4. Understand- Understand what the team is trying to improve; how will you know if a change occurs? PI tools (cause and effect diagrams, Pareto charts, tally sheets) can be used to identify the characteristics which define the quality of the process
  5. Select- The items or processes that need to be changed. Select the key improvement outcomes expected and cause and effect relationships that will change
2. Plan, Do, Study, Act
  1. Plan- Identify a process in need of improvement and formulate a plan as to how the process might be improved. Establish a baseline so that any improvements can be measured
  2. Do- Implement the changes
  3. Act- If successful, implement the change on a broader scale. If not, reevaluate the process and changes made and determine whether to try a different approach and start over or move on to a different process
3. Three Questions to ask in any PDSA cycle
  1. What are we trying to accomplish?
  2. What change can we make that will result in improvement?
  3. How will we know that a change is an improvement?
Performance Improvement Tools- flow charting a process
1. Pareto diagrams, run charts, statistical process control (SPC) charts, scatter diagrams, flow charts, cause and effect diagrams, control charts, bar charts
  1. Graphical data presentations and their advantages over tables of data
Medical errors and patient safety issues
1. Medication errors and subsequent adverse drug events (ADE)
2. Resources- Joint Commission on Accreditation of Health Care Organizations (JCAHO), Institute for Clinical Systems Improvement (ICSI), Institute for Health Care Delivery Research (IHC), Institute for Health Care Improvement (IHI), American Academy of Family Physicians (AAFP), Institute of Medicine (IOM), Occupational Safety and Healthcare Administration (OSHA)
Role of information systems and informatics in process improvement
1. Sources of data/information
  1. External organizations- NCQA, Dartmouth Atlas, JCAHO
  2. Patent accounting systems
  3. Health plan reports
  4. Hospital data systems
  5. External sources (e.g., County Health Departments, Peer Review Organizations)
Outcomes management
1. Outcomes management and the various terms used to describe the process
  1. Clinical guidelines/Practice protocols/
  2. Care Process Models
  3. Disease Management
Critical appraisal of the clinical literature
1. External Peer Review Organizations
  1. NCQA Health Plan Employe Data and Information Set (HEDIS) Criteria
  2. JCAHO
  3. Center for Medicare and Medicaid Services (CMS, formerly HCFA) Peer Review Organizations (PRO)

Evidence Based Medicine

Applying the principals of evidence based medicine in clinical practice
1. Identify a problem or area of uncertainty
2. Formulate a relevant, focused, clinically important question that is likely to be answered
3. Find and appraise the evidence
4. Assess the clinical importance of the evidence
5. Assess the clinical applicability of any recommendations or conclusions
6. Decide whether or not to act on the evidence
7. Assess the outcome of your action
8. Summarize and store the record for future reference

Competencies

Performance Improvement:

Learn how to identify clinical processes which might be improved using PI methodology
Be able to analyze past and current clinical practice and improve future care based on previous experience
Participation on at least one team to improve one process or one aspect of health care delivery within the residency
Learn how to identify the individual/group that owns the process and ensure they participate
Learn how to collect and analyze data from a variety of sources
Demonstrate understanding by effective team participation (e.g., communication, conflict resolution, team member and team leader)

Evidence Based Medicine:

Pose a relevant question
Search the literature using both print and internet-based resources
Apply the literature to the pertinent clinical issue
Be familiar with and able to access information from EBM data sources
1. Cochrane Data Base
2. Agency for Healthcare Research and Quality (AGRQ)
Be able to determine the outcome of a given intervention when using as well as not using relevant information
Be familiar with study design and statistical methods in evaluating relevant clinical information

Implementation

The implementation of these core curriculum guidelines should be longitudinal throughout the residents' experience, with increasing emphasis in the latter half of the residency. The core curriculum guidelines should be integrated into the schedule of conferences and other teaching activities. The resident should be given hands-on experience leading at least one performance improvement initiative during the three years of training.

Where possible, additional training such as exposure to local resources and experts should be encouraged. Partnership with outside organizations who might provide additional data is also encouraged.

Printed Resources

"Letting Good Care Drive Out The Bad" Medical Economics Sep. 95
"Quality of Health Care"(6 part series) New England Journal of Medicine Sep.-Oct.
"Users' Guides to the Medical Literature" (Multipart Series) Journal of American Medical Association 1993-2000 (Available online at: http://www.cche.net/principles/main.asp)
Berwick, Donald M. On Quality. Jossey-Bass, Oct 1995
Berwick, Donald M., Roessner, Jane A., Godfrey, Blanton. Curing Health Care: New Strategies for Quality Improvement. Jossey-Bass, Jan 1991
Family Practice Management- numerous PI articles in 1999-2000
Eddy, David M. Clinical Decision Making: From Theory to Practice: A Collection of Essays from JAMA. Sudbury: Jones & Bartlett, Jan 1996
IOM Committee on Quality of Health Care in America, “Crossing the Quality Chasm: A New Health System for the 21st Century”, Institute of Medicine 2000
Kohn, Linda. “To Err Is Human: Building a Safer Health System” Institute of Medicine 1999
Medical Informatics and Computer Applications, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 288 (Available online as a part of the RAP Curriculum Guidelines)
Research and Scholarly Activity, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 280 (Available online as a part of the RAP Curriculum Guidelines)
Sackett, David Evidence-Based Medicine: How to Practice and Teach EBM Philadelphia:Churchill Livingston, 2000
Silverman, William A. and Sackett, David L. Where's the Evidence? Debates in Modern Medicine :Oxford Univ. Press, 1999

Web Resources

AAFP Clinical Quality Improvement: http://www.aafp.org/quality
Agency for Healthcare Research and Quality: http://www.ahrq.gov
Clinical Practice Guidelines: http://www.guidelines.gov
Cochrane Library: http://www.thecochranelibrary.com
Evidence-based Medicine Resource Center (New York Academy of Medicine & Evidence-based Medicine Committee of the American College of Physicians, New York Chapter with funding from the National Institutes of Health): http://www.ebmny.org
Institute for Healthcare Improvement: http://www.ihi.org
Institute of Medicine “Crossing the Quality Chasm: A New Health System for the 21st Century”, http://www.nap.edu/catalog/10027.html
Joint Commission on Accreditation of Health Care Organizations: http://www.jointcommission.org/
MEDLINE PubMed: http://www.ncbi.nlm.nih.gov/PubMed
National Association for Healthcare Quality: http://www.nahq.org
American College of Physicians (ACP) Journal Club: http://www.acpjc.org/ (Requires ACP membership or subscription.)
Centre for Evidenced Based Medicine: http://www.cebm.net/
SCHARR Netting the Evidence: http://www.shef.ac.uk/~scharr/ir/netting
The Leapfrog Group: http://www.leapfroggroup.org
University of Alberta, Introduction to Evidence Based Medicine: http://www.med.ualberta.ca/ebm/ebmintro.htm