MOVING FROM DIDACTIC TO APPLIED LEARNING IN · Include specific measurable targets. (quantity/time) Highlight the improved features using circles or call-outs. Make the changes/improvements

MOVING FROM DIDACTIC

TO APPLIED LEARNING IN

THE ACGME’S CLER

DOMAINS OF QUALITY &

SAFETY

ARTHUR B. RUBIN, DO, FACOP

CHARLESTON AREA MEDICAL CENTER

APRIL 7, 2016

OBJECTIVES

UNDERSTAND HOW RESIDENTS & FELLOWS MOVE FROM DIDACTIC TO APPLIED LEARNING BY MERGING 3 PROCESSES:

1. Annual Program Effectiveness

2. DMAIC

3. QIPS

900 beds – 3 teaching sites

16 Residency Programs

(allopathic and osteopathic)

175 residents and fellows

Regional Campus (100 medical

students):

West Virginia University

West Virginia School of

Osteopathic Medicine

Teaching and non-teaching

physicians

Clinical teaching affiliations – 49



Heart Institute

Hematology/Oncology Center

Outpatient Surgery

Ambulatory Care Clinics

State’s largest Peds/Ob facility

Level 4 NICU, PICU, and Pediatric ER

Special women’s services

Level 1 Trauma Center

Nephrology and Renal Transplantation

Medical Rehab

Neuroscience Center

Behavioral Medicine

Universal Curriculum Timetable Academic Year 2015-2016

Curriculum Q1 2015-2016 Q2 2015-2016 Q3 2015-2016 Q4 2015-2016

July Aug Sept Oct Nov Dec Jan Feb March April May June

Onboarding- New Residents and Faculty

Foundations: Teamwork, Just Culture,

Crucial Conversations – 4.0 hr

Patient Experience - Service Plus/ AIDET

/ HCAHPS – 1.5 hr

Introduction to Sleep Deprivation/ Fatigue Mitigation for PG1 (Orientation) - .5 hr

All Residents and Faculty

Universal Curriculum Booster (Annual Required - All) – 1.0 hr

Sleep Deprivation/ Fatigue Mitigation (Annual Required - All) – 1.0 hr

High Value Cost-Conscious Care Module 2 – Healthcare Costs and payment

Methods - 1.0 hr

High Value Cost-Conscious Care Module 3 – Utilizing Biostatistics in Diagnosis

and Prevention – 1.0 hr

CLER Overview (Online) - .25 hr

Residents Only

Annual Inservices – 2.0 hr - 4.0 hr

DMAIC MODULE

Professionalism Contract*

QIPS Curriculum (Residents and Faculty)

Patient Safety & Quality Improvement Unit 1 – 1.0 hr

Quality Improvement Unit 2 - .2 hour

Quality Improvement Unit 3 - .2 hour

Quality Improvement Unit 4 -.2 hour

Patient Safety Training/Reporting - .5

hr

2016--BEST PLACE TO LEARN GOALS

QIPS Goal Cascade

1. Improve integration of research and academic programs and learners to CAMC Quality and Patient Safety structure, processes and priority projects.

Each program to align 2 projects of institutional priority and 1 to Annual Program Effectiveness

DMAIC Reporting/Project Improvement

Top 5 boards – each program

Improve tracking and monitoring system using NI tool

Universal Curriculum – Extended/Advanced/Onboarding

2. Identify strategies to assess and improve the clinical learning environment for learners and education affiliates (All departments engaged with learners).

Survey Improvements (ACGME/PS Survey/Clinical Learning Environment)

Patient safety reporting and tracking customized to programs.

Complete M&M transition to Patient Safety Conference

7

DMAIC

DEFINE – MEASURE – ANALYZE –

IMPROVE - CONTROL

DMAIC

SIX SIGMA METHODOLOGY FOR PROBLEM SOLVING

REDUCES VARIATION

IMPROVES PRODUCTIVITY

IMPROVES QUALITY

IMPROVES TIME EFFICIENCY

IMPROVES COST ISSUES

DMAIC – 3 PRINCIPLES

RESULTS-FOCUSED: DRIVEN BY DATA, FACTS, & METRICS

WORK IS PROJECT-BASED & STRUCTURED: SHORT-TERM IN NATURE

INHERENT COMBINATION OF TOOLS-TASKS-DELIVERABLES LINKAGE THAT VARIES BY STEP IN THE METHOD

DMAIC – STEP 1

STEP 1. DEFINE THE PROBLEM AND SCOPE THE WORK EFFORT OF THE PROJECT TEAM

IDENTIFY THE CUSTOMER, PROJECT GOALS, TIMEFRAME FOR COMPLETION

PROBLEM SHOULD BE SYSTEMIC/NOT ONE-TIME

DMAIC – STEP 2

STEP 2. MEASURE THE CURRENT PROCESS OR PERFORMANCE

IDENTIFY DATA & ITS SOURCE

DEVELOP A PLAN TO GATHER IT

GATHER & SUMMARIZE THE DATA

UTILIZATION OF GRAPHICAL TOOLS

DMAIC – STEP 3

STEP 3. ANALYZE THE CURRENT

PERFORMANCE TO ISOLATE THE PROBLEM

STATISTICAL & QUALITATIVE

FORMULATE & TEST HYPOTHESES RE: ROOT

CAUSE OF THE PROBLEM

DMAIC – STEP 4

STEP 4. IMPROVE THE PROBLEM BY SELECTING A SOLUTION

ADDRESS THE IDENTIFIED ROOT CAUSE WITH AN IMPROVEMENT

BRAINSTORM POTENTIAL SOLUTIONS, PRIORITIZE, SELECT, & TEST TO SEE IF THE SOLUTION RESOLVES THE PROBLEM

DMAIC – STEP 5

STEP 5. CONTROL THE IMPROVED PROCESS OR PRODUCT PERFORMANCE TO ENSURE THE TARGET(S) ARE MET

IMPROVEMENTS MUST BE STANDARDIZED & SUSTAINED

CONTROL PLAN TO MONITOR ONGOING PERFORMANCE

PROJECT CLOSES

DMAIC - ICON

Define Measure Analyze Improve Control

2015-2016 CAMC QIPS

Merging 3 Processes

Moving from didactic learning to applied learning

Vehicle will be top 5 board with it’s tools

Visible, recognizable, easy

Next step in evolution of QIPS process

• OFI’s identified

Annual Program Effectiveness

• Application: Tools for improvement

DMAIC

• Processes at institutional and Program Level

QIPS

Transforming Care Together

Top 5 Boards / A3 Problem Solving

Topic/Issue:Background/Problem Statement: (when, where, how does it occur)

Improvement Goal Statement: (goal target and date to accomplish)

Ideal Future State Process: (list or draw process if waste & defects removed) D

EFIN

E

Current State Process: (list or draw steps of the process to ID bottlenecks)

Baseline Metrics & Date:

MEA

SU

RE

Analysis (get to the root cause(s) for the problem, update analysis when additional root

causes identified)

AN

ALY

ZE

IMPR

OV

E

Solutions – Short Term (implement 2-4 weeks)

Solutions – Long Term (> 4 weeks to implement)

Implementation Plan

ActionsWho By When Expected Outcome

Sustainment/Follow-up Plan

CO

NT

RO

L

If applicable, Internal Audit #:Date of Completion: Revision Dates:

Team Members:Approvals:

A3 Problem Solving

17-6522 Revised 8-15A3 Problem Solving

Topic/Issue: What is going on? What is the issue through the eyes of the customer/patients?

Background/Problem Statement: Include information for understanding the issue. (when, where, how does it occur? How big is the problem? What is the impact?) Include history and data that is pertinent to the issue.

Improvement Goal Statement:Good problem and goal statements are SMART: Specific, Measurable, Achievable, Relevant, and Time-Bound. Keep it brief, simple, yet specific. Do not assign blame. Do not assume solutions. You may not have enough information at this point to complete the goal statement. Review and update it after the Analyze phase.

Ideal Future State:Draw a diagram of what should be happening: a better way to work.Include specific measurable targets. (quantity/time)Highlight the improved features using circles or call-outs. Make the changes/improvements obvious to anyone reviewing your document. These should address the problems, or storm clouds in the Current State.

DEFIN

E

Current State Process:Draw a diagram of how the work process happens now.Do direct observation of the work process to ensure that reality is reflected.Highlight the specific problems/issues/waste with storm clouds or stars.What specifically about the problem/issue is not defect-free?Can you measure the waste?

Baseline Metrics & Date: Included pertinent current state measurement data that is aligned with the Problem Statement and Goal Statement. Include specific information for the source(s) of data, as well as clear definitions for the metrics.

MEA

SU

RE

AnalysisIdentify problems and waste with the current condition. (as identified by storm clouds above)Get to the root cause(s) for the problem(s).Consider using one or more of the following tools:• 5 Whys• Brainstorming• FMEA (Failure Modes Effects Analysis

Update Improvement Goal Statement: Be sure to update the goal statement based upon the findings of the Measure and Analyze phases of problem solving.

AN

ALY

ZE

IMPR

OV

E

Solutions – Short TermWhat are we going to do in the short term to have immediate impact on the problems.Short term solutions should address any immediate safety or major financial implications.

Solutions – Long TermWhat are we going to do to move us to the Ideal State.Solutions may need to be evaluated and prioritized.Pilots or PDSA tests of change may need to be conducted on solutions.

A cost/savings analysis and summary may be required for solutions.• Supports decision making and prioritization of solutions• Facilitates the effective management of resources

Implementation Plan

ActionsWho By When Expected Outcome

Include specifics of

implementing solutions

Sustainment/Follow-up PlanWhen and how will follow-up be conducted? By whom?What are the results compared to the goals?What are the strategies for sustaining improvements?• Examples: 5S, visual management, single point lessons, standardized work, error proofing, etc.

CO

NT

RO

L

Date: Include the date, or date range, when this A3 was completed.Team Members: Include the names of all participating team members. Identify a key contact.

Approvals:What stakeholders will need to be informed and approve solutions? Remember any related regulatory entities.

A3 Problem Solving Reference Guide

Program Effectiveness Meeting 2015

Attachment A

3.2 PERFORMANCE IMPROVEMENT GOALS AND ACTION PLAN 2015-2016

PERFORMANCE IMPROVEMENT CATEGORY

NOTE: YOU MUST SUBMIT IMPROVEMENT

GOALS IN ALL REQUIRED AREAS BELOW

***

Performance Improvement Goal (Identify the

Goals to be Addressed in the Category. Label as

1.a.; 1.b, etc. ). Note: Goals can address a

concern or be an improvement goal you will plan

to address.

Action Plan (For each goal, describe the activities/plans that

the program will address in 2015-2016 (what/

who/how/when and other helpful comments that describe

your plans)

Measurement/Metric: What is your target goal?

Identify measurement/metric you are trying to reach or

identify how you will measure whether you have

achieved goal. (Note--- not all goals will require a

metric?)

1. Resident Clinical/Educational

Performance (Must include

plans for graduate performance

on certification exam (if

currently not meeting

requirements.)

1. Program Curriculum

Modification or Redesign

(Specify competency-based

goals and objective/procedural

goals/goals related to

milestones). ***

1. Quality and Patient Safety

(Address QIPS, curricula, faculty

or resident engagement as

applicable).***

1. Address CLER address program

level goals with respect to other

CLER domains.***

1. ACGME/AOA/CAMC Resident

Survey Improvement Plan (Plan

for Improvement from previous

survey results).

***

Behavioral Medicine and Psychiatry Quality Improvement

Project

Four-Weeks Blocks Schedule for

Continuity of Care Improvement

Khaled Bowarshi, PGY5

Internal Medicine and Psychiatry Chief Resident

Behavioral Medicine and Psychiatry Co-Chief Resident

WVU-Charleston Division

Charleston Area medical center

March 14, 2016

DMAIC step one: Define

Continuity of care is an important aspect of quality

Better rapport with patients

More availability for patients

for appointments

via phone

for clinic calls

hidden patient care; documentation, prior authorizations

More availability for

learning (attending didactics)

teaching (med students, interns supervision)

admin responsibilities (meeting, research, QI)


The ACGME recognized how important continuity of care is and made it a core requirement for all residency programs including psychiatry.

VI.B.2.

“Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. (Core)”


Patient care need to be provided 24 hours, 7 days a week.

Night Float system provides good solution with some

major problems

1. Can’t always have night float resident because of

Small size of residency program

Residents don’t elect for this rotation

Curriculum doesn’t recognize it as in/pt rotation

2. Not all months are equal (28 days vs 31)

3. The language of the rotation is too fluid 16-20 calls


Pulling residents from outpt to cover nights caused out/pt continuity of care to be jeopardized

In/pt residents covering 24 for overnight shifts means more days post-call causing in/pt continuity of care to be jeopardized

More hands-off and transition of care equals higher risk for misses and near misses.

Random nights of work leads to poor fatigue management

All of the above means less than optimal quality of care.

DMAIC step two: Measure

Two outcomes were observed

A: number of incidents of interruption of care for out/pt services.

B: number of incidents of interruption of care for in/pt services.

Review of records of call schedule and clinic schedule

revealed that between July 1, 2014 until Feb 28, 2015

A = 64

B = 29

Total (near misses*) incidents = 93

DMAIC step three: Analyze



1. Change from month schedule to block schedule, all blocks are

28 days

20 week-days

8 weekends

20 nights to cover without post call time-off

2. Recruit more residents to do night float

A senior PGY4 or PGY5 who takes an block elective of nights won’t have weekend

calls for 6 months

DMAIC step four: Improve

1. We had night float coverage 11 blocks out of 13 blocks

2. Less post call days.

3. Less canceled out/pt clinics

4. Less understaffed days in 6E


Two outcome were followed

A: number of incidents of interruption of care for outpt services.

B: number of incidents of interruption of care for inpt services.

Review of records of call schedule and clinic schedule revealed that between July 1 2015 until Feb 28, 2016

A = 1

B = 2

Total (near misses*) incidents = 3


2014-2015 # 93 2015-2016 # 3

I/P 29 2

O/P 64 1

0102030405060708090

100

Axis

Tit

le

Incidents of Care Interruption

Utilization Report July to Oct

2014

Mean +/-SD

224 +/- 28


Utilization Report July to Oct

2015

Mean +/-SD

240 +/- 24


1. Keep following up with near-misses (Define)

2. Block 9 had the 3 incidents of interruption of care (Measure)

3. Why? Because a resident requested a vacation during night float to do only 16 shifts (Analyze)

4. Change the language of the night float requirements to 20 shifts on and 8 nights off (Improve)

5. And Control again!

DMAIC step five: Control

Concerns for the future;

1. What if we had less residents?

2. What if no PGY4 andPGY5 takes the night float elective?

Suggestions:

1. Night float weeks in in/pt rotation

2. Keep the “no night float months” to the end of the year when PGY1 s are level 3

3. Maybe make it a requirement for PGY4 and PGY5 to do night float “elective”!



Documents

MOVING FROM DIDACTIC TO APPLIED LEARNING IN · Include specific measurable targets. (quantity/time) Highlight the improved features using circles or call-outs. Make the changes/improvements