Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A Matrix Solution • 3:15 pm – 3:25 pm Introduction Berend Mets, MB, Ph.D., Moderator • 3:25 pm – 3:55 pm Embedding the Core Competencies Using the Matrix John Bingham Director, Center for Clinical Improvement Vanderbilt University Medical Center Nashville Tennessee • 3:55 pm – 4:10 pm Question & Answer Session • 4:10 pm – 4:40 pm Practical Examples of the Matrix Doris Quinn, Ph.D. Assistant Professor, Division of Medical Education Vanderbilt University Medical Center Nashville Tennessee • 4:10 pm – 4:55 pm Question & Answer Session
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Vanderbilt University Medical Center Linking Outcomes of Care to the ACGME Core Competencies: A Matrix Solution 3:15 pm – 3:25 pmIntroduction Berend Mets,
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Vanderbilt University Medical Center
Linking Outcomes of Care to the ACGME Core
Competencies: A Matrix Solution• 3:15 pm – 3:25 pm Introduction
Berend Mets, MB, Ph.D., Moderator
• 3:25 pm – 3:55 pm Embedding the Core Competencies Using the MatrixJohn BinghamDirector, Center for Clinical ImprovementVanderbilt University Medical Center Nashville Tennessee
• 3:55 pm – 4:10 pm Question & Answer Session
• 4:10 pm – 4:40 pm Practical Examples of the MatrixDoris Quinn, Ph.D.Assistant Professor, Division of Medical EducationVanderbilt University Medical Center Nashville Tennessee
• 4:10 pm – 4:55 pm Question & Answer Session
Vanderbilt University Medical Center
Linking Outcomes of Care and the ACGME Core Competencies:
A Matrix Solution
John Bingham, MHADirector
Center for Clinical Improvement
SAAC/AAPD Annual MeetingWashington, DC
November 5, 2005
Doris Quinn, PhDAssistant Professor
Division of Medical Education
Vanderbilt University Medical Center
Objectives for today:
1. Discuss the Institute of Medicine (IOM) Aims for Improvement and the ACGME Core Competencies.
2. Describe how the Healthcare Matrix helps link outcomes of care to learning the core competencies.
3. Provide examples of how the Healthcare Matrix is used to improve education and the delivery of care.
Vanderbilt University Medical Center
1999 2001 2002 2003 2004
Emerging public
reporting of
quality
measures
“Hospital Compare”
“Kyros” Events in Healthcare:
Vanderbilt University Medical Center
Extrapolated study results imply that between 44,000-98,000 U. S. hospital patients die each year as
a result of medical errors.March 2000
Vanderbilt University Medical Center
“Five Years After To Err is Human: What Have We Learned?”
Lucian L. Leape, MD; Donald M. Berwick, MD JAMA, May 18, 2005
“If the experience of the past 5 years demonstrates anything, it is that neither strong evidence of ongoing serious harm
nor the activities, examples, and progress of a courageous minority are
sufficient to generate the national commitment needed to rapidly advance
VUMC Observed to Expected Mortality and Actual Number of Mortalities 2003-2005
Vanderbilt University Medical Center
“Reducing waits and sometimes harmful delays for both those who receive and those who give care”
PATIENT CARE that is…
Timely
Safe
Vanderbilt University Medical Center
PATIENT CARE that is…
Timely
Safe
•What is our Anesthesia performance for:
•% Patients with Anesthesia Prep Time < 15 Minutes?
•% Patients with on-time prophylactic antibiotics?
•% Patients with prophylactic antibiotics? discontinued <24 hours after surgery end time?
•% cases completed < 15% of scheduled length?
•% cases with surgical consent before day of surgery?
•Average time between cases (Gap Time)?
•Average time between “room ready” and “in room”?
Vanderbilt University Medical Center
Percentage of Surgery Patients Who Received Preventive
Antibiotic (s) One Hour Before IncisionTop Hospitals:
93%
AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES
AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY HOSPITAL
69%
64%
47%
Top Hospitals represents the top 10% of hospitals nationwide (Data displayed are from data reported July-Dec.04)
Vanderbilt University Medical Center
What is the infection rate for surgical patients (in total, by procedure, by specialty, by surgeon; by site of surgery) ?
Exceptions by procedure, by specialty, by surgeon; by site of surgery ?
Received the appropriate antibiotic?
Received prophylactic antibiotics?
Received within one hour prior to surgical incision?%
% with Infectio
n
No Yes
No
% with Infection
% with Infection
% with Infection
Yes
No Yes
Exceptions
Patients with
Needs
Patients with Needs
Met
Access Diagnosis Treatment Follow-upAssessment
Vanderbilt University Medical Center
Percentage of Surgery Patients Whose Preventive Antibiotics
are stopped Within 24 Hours After Surgery
Top Hospitals:100%
AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES
AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY HOSPITAL
64%
58%
78%
Top Hospitals represents the top 10% of hospitals nationwide
(Data displayed are from data reported July-Dec.04)
Vanderbilt University Medical Center
“Providing services based on scientific knowledge to all who
could benefit and refraining from providing services to those not
likely to benefit”
PATIENT CARE that is…
Timely
Effective
Safe
Vanderbilt University Medical Center
PATIENT CARE that is…
Timely
Effective
Safe
•What is our Anesthesia performance for:
•% Patients that received preoperative prophylaxis for VTE?
•% non-cardiac vascular surgery patient receiving beta-blockers during perioperative period
•% Patients with CAD who received beta blockers during perioperative period?
•% Patients on a ventilator whose post op orders included elevating bed >= 30 degrees?
Vanderbilt University Medical Center
Vanderbilt University Medical Center
“Avoiding waste, including waste of equipment, supplies, ideas, and
energy”
PATIENT CARE that is…
Timely
EfficientEffective
Safe
Vanderbilt University Medical Center
PATIENT CARE that is…
Timely
EfficientEffective
Safe
•What is our Anesthesia performance (over time) for:
•Total cost per case?
•Supply cost per case?
•Supply waste per case?
•OR non-billable time delays due to Anesthesia?
•Rate of increase in revenue vs. expenses?
Vanderbilt University Medical Center
“Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socio-economic status”
PATIENT CARE that is…
Timely
EfficientEffective
Equitable
Safe
Vanderbilt University Medical Center
Is Care Is Care Equitable?Equitable?AHRQ 2004 National Healthcare Disparities
Report Released 2/22/2005•Blacks:
• had worse access than whites for about 40% of access 40% of access measuresmeasures• received poorer quality for about 66% of quality measures66% of quality measures
•Asians:• had worse access than whites for about 33% of access 33% of access measuresmeasures• received poorer quality than whites for about 10% of quality10% of quality measuresmeasures
•Hispanics:• had worse access than non-Hispanic whites for about 90% 90% of access measuresof access measures• received lower quality of care than non-Hispanic whites for 50% of quality measures 50% of quality measures
•Poor people:• had worse access for about 80% of access measures80% of access measures than those with high incomes • received lower quality of care for about 60% of quality 60% of quality measuresmeasures
Vanderbilt University Medical Center
“Providing care that is respectful of, and responsive to:
•individual patient preferences,
•needs and values,
•and ensuring that patient values guide all clinical decisions”
PATIENT CARE that is…
Timely
EfficientEffective
Equitable
Patient Centered
Safe
Vanderbilt University Medical Center
Is Care Is Care Patient Centered?Patient Centered?HCAPS/CMS Patient Perception Surveys
Effective in 2006-Public in 2007
What are our patients’ perceptions of:
•Communications with Nurses? •Communications with Doctors?•Communications about medications?•Nursing services?•Pain management?•The hospital environment?•Adequacy of discharge information?•Our system overall?•Their willingness to recommend us?
Vanderbilt University Medical Center
“…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
PATIENT CARE that is…
Timely
EfficientEffective
Equitable
Patient Centered
Safe
What must we know?
Vanderbilt University Medical Center
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?
Vanderbilt University Medical Center
“…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?
Vanderbilt University Medical Center
“…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
Interpersonal and Communication SkillsProfessionalism
System-Based Practice
PATIENT CARE Timely
EfficientEffective
Equitable
Patient Centered
Safe
What is the Process?On whom do we depend?
Who depends on us?
Vanderbilt University Medical Center
“…involves investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in
patient care.”
Medical Knowledge
Interpersonal and Communication SkillsProfessionalism
System-Based Practice
Practice-Based Learning & Improvement
PATIENT CARE Timely
EfficientEffective
Equitable
Patient Centered
Safe
What have we learned?What will we improve?
Vanderbilt University Medical Center
Patients with
Needs
Patients with Needs Met
Access Diagnosis Treatment Follow-upAssessment
Linking it all together….Linking it all together….
products, staff time) were not utilized in an efficient manner.
NOLanguage was a
problem
NOPatient was not
adequately apprised of her own health
problems and did not participate fully in her
care decisions
MEDICAL KNOWLEDGE(What must we
know)
Priorities in hemorrhagic shock are ABC: ensure oxygen delivery, support BP, aggressive IV resuscitation, treat cause
Hemorrhagic shock is life-threatening emergency: Prompt diagnosis, recognize urgency, initiate therapy, incl. timely transport to OR. Diagnosis was made late. No urgency to treat. Delay in contacting Anesth. Inadequate assistance in transport to OR
D.I.C. in pregnancy: Physiology, diagnosis, causes, treatment. Regional v. General Anesth? Post resuscitation pulmonary edema. Hypocalcemia due to massive transfusion. Invasive monitoring indications. Pharmacology of uterotonic drugs.
Survival in postpartum hemorrhage requires aggressive IV resuscitation: always consider combining procedures (start 2nd IV while drawing blood sample for transfusion cross match).
INTERPERSONAL AND
COMMUNICATION SKILLS
(What must we say)
Safety is jeopardized unless team members are fully apprised of patient’s condition (blood loss following delivery, vital signs, plans for intervention).
Orders (blood cross match) must be prioritized and fully implemented in a timely fashion.
Effectiveness of life-saving intervention depends on effective communication between team members.
Communications of a defensive or argumentative nature are counter-productive to efficient and safe care. The focus should be patient care, with analysis of misunderstandings at a later time.
Must communicate patient’s condition and intended interventions (blood transfusion, emergency hysterectomy), and in a way that is understandable and useful to the patient, respecting patient autonomy.
PROFESSIONALISM(How must we act)
Professional duty to accompany critically ill patient to the OR, to ensure safety, and to expedite therapy.
Patient’s ethnic, socio-economic, “service patient” status should have no effect on quality of care.
Professional duty to attempt to preserve patient autonomy (make sure patient understands situation and interventions)
Vanderbilt University Medical Center
SYSTEM-BASED
PRACTICE(On whom do
we depend and who depends
on us)
System must ensure that appropriate consultants are notified when needed to ensure safety in life-threatening medical condition.
During postpartum bleeding, type & cross match must be drawn, sent, and verified promptly. Failure to do so threatens life.
Failures to draw, send, and verify cross match blood sample jeopardizes effectiveness of life-saving therapy.
Standard of care should not vary due to differences in staffing that result from time of day / night (availability of lab medicine physician, timely transport of blood samples, adequate number & expertise of obstetrics, anesthesiology, & nursing staff)
Improvement
PRACTICE-BASED
LEARNING AND
IMPROVEMENT(How must we
improve)
Policy and Procedures changed for Mother/Baby in trouble
Revise the criteria for and system of communicating urgent / emergent request for Anesthesiology consultation
Departmental Teaching Conference on management of parturient with D.I.C.
Procedure outlined for fastest prep for OR
Increased awareness of need to consider patient centeredness even in emergent or crisis situations. Communication with father / family members when appropriate and possible.
Residents all waitingfor preceptor at sametime, major holdup inschedule
Insufficient room space
One location for labs to be drawn & vitalstaken by nurse for all pts, creates roadblock
Vanderbilt University Medical Center
Improvements From Medicine Residents:
Pat Covington RN, Manager
EMR: We can now text message across departments. Use of pt waiting time: Have Kiosk in exam room to fill in review of systems. Questionnaires being sent to pts ahead of time. Those with email get questionnaire and can return via email. Availability of techs: Modified schedule of techs to improve service. Residents’ schedules were also changed to better utilize staff. Patient visit survey and phone calls will now be done after visit. Patient Letter revised: “Bring old records, come 15 minutes before appt.”
Vanderbilt University Medical Center
Transforming M&M Conferences
into
Practice-based Learning and Improvement
Vanderbilt University Medical Center
Care of Child with Hyperleukocytosis M&M 3/25/04 (Peds Hem/Onc)
IOM ACGME
SAFE1 TIMELY
2 EFFECTIVE
3 EFFICIENT
4 EQUITABLE
5 PATIENT -CENTERED
6
Assessment
I.PATIENT CARE 7
Mostly yes
(Toxicity of chemo needed better monitoring)
Yes
Yes (but variation
exists) WBC dropped from
324K to 37K by midnight
Yes
Yes
Yes
Family told of possible Dx within 2
hours of ED visit.
II. A MEDICAL
KNOWLEDGE 8 (What must I know)
-Hypercalcemia led to hypotension. -Respiratory distress secondary to fluid overload and atelectasis required intubation Complications of Leukopheresis was discussed.
Full dose Chemotherapy started quickly
Management of Hyperleukocytosis: was major discussion for M&M conference.
Discussed lack of benefit and increase cost of cranial irradiation
How to tell family bad news (lecture at VU). Pediatrics Oncologists have a lot of experience and are very family centered. Family was well informed of likely dx and plan of action.
II. B PROFESSIONALIS M 9
(How must I act)
PCP referred child to ED for evaluation very quickly (from community 40 miles away).
Feedback to PCP was done as soon as a concern was voiced.
Some physician variation noted at VU for treatment. Can we standardize with pathway?
Able to talk to family and PCP in professional and evidenced -based manner.
II. C INTERPERSONAL AND
COMMUNICATION SKILLS 10
(What must I say)
Experienced physicians and researchers communicated well.
Hand -offs were smooth and well executed.
Pare nts felt comfortable providing inform consent by 7 PM the same day.
II. D SYSTEM -BASED
PRACTICE11
(On whom do I depend
and who depends on me)
Toxicity was an issue and the team needed to do a better job of recording what was happening.
Quick response by VCH to PCP. hyperleukocytosis 5 hours to Dx 8 hours to start of Tx
Discussed issue of dialysis for treatment. Consulted nephrology and PICU. Dialysis nurse notified early and circuit primed.
Lab results were done quickly from ED. Team worked well to have treatment begin quickly with good results within 10 hours
ED good communication with House Officer. Social worker met with family to explain what was happening.
Improvement
III. PRACTICE -BASED
LEARNING AND IMPROVEMENT
12
(How can I improve)
Be s ure everyone knows the toxicity and complications and document.
Create pathway for hyperleukocytosis to decrease variation
Pt not always safe as evidence by several adverse events
Yes No
Need to find/learn best method.Evidence of Ultrasound for dialysis line placement.
Yes Not Sure
How informed is patient/family? No post procedure instructions.
MEDICAL KNOWLEDGE (What must I
know)
Need additional anatomy lessons for performing this procedure. Need to know what to do with arterial punctures. What to do when patient cannot be still?
No guidelines in literature for Fem. Cannulation.
HCT not efficient way to monitor bleeding
INTERPERSONAL AND
COMMUNICA-TION SKILLS
(What must I say)
Nurses need to know when cannula has been pulled in order to have more observation
Communicating use of Niagra cath that other areas have found less favorable.
Use of patches used on other specialties for punctures not well known.
Better instructions for patient and family.
Nephrology M&M 4/2/04
Vanderbilt University Medical Center
PROFESSIONAL-ISM
(How must I act)
Sharing complications and near misses among all specialties will increase learning.
Sharing expertise from colleagues in surgery, radiology and cardiac cath for most effective and efficient way to do cannulation.
SYSTEM-BASED PRACTICE
(On whom do I depend and
who depends on me)
No nursing orders for post-procedure care. Change of shift dangerous time for patients.
Improvement
PRACTICE-BASED
LEARNING AND IMPROVEMENT
(How can I improve)
Keep QA log on all procedures to detect trends. Need to monitor near misses and complications to learn.
Multidisciplinary Team to decide on orders, policy and procedures for venous cannulation.
To reduce the number of preoperative tests performed so that only those which are important to the medical mgmt of adult surgical pt during pre-op period are ordered.
(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 Stroke
An Oracle Database is being built that will collect
data from each cell and allow analysis and reports
to be generated by:
InstitutionDepartmentDiagnosisIOM Aim
Competency
Vanderbilt University Medical Center
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 often 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
Teamworknegative
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
(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)
Evidence basedOrder sets
MEDICAL
KNOWLEDGE(What must we know)
Pt and family satisfaction data
Outcomes by race, gender, SES
Cost per discharge
Outcomes data
Time Studies
FMEA
EventsPATIENT CARE
(Overall Assessment)Yes/No
Assessment
PATIENT-CENTERED
EQUITABLE
EFFICIENTEFFECTIVETIMELYSAFE AimsCompetencies
Healthcare Matrix: Care of Patient(s) with Stroke
Link to Web based
Education
Vanderbilt University Medical Center
How to Flowchart a Process
• On-line web site for Improvement education
http://mot.vuse.vanderbilt.edu/mt322
(Dr. Quinn’s current course being redesigned for managers and physicians)
Vanderbilt University Medical Center
On Transformation:“And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous
to administer than to introduce a new system of things; for he who introduces it
has all those who profit from the old system as his enemies, and he has only lukewarm allies in all those who might
profit from the new system.”Machiavelli
Vanderbilt University Medical Center
Healthcare Matrix Summary Points:
• Is a framework for integrating competencies into existing educational activities
• Provides a new mental model for Clinicians
analyzing patient care
• Facilitates use of “resident performance data as the basis for improvement”
• Encourages use of “external quality measures to verify resident and program performance levels”
Vanderbilt University Medical Center
Thank You!
Vanderbilt University Medical Center
Implementation of Healthcare Matrix
Vanderbilt University Medical Center
Internal Review QuestionnaireCore Competencies
1. How does your program provide education that develops patient care practice that is
compassionate, appropriate and effective?
How effective is that training?
1Not
effective
2Somewhat effective
3Moderately
Effective
4Effective
5Very
effective
Vanderbilt University Medical Center
ImplementationInternal Review Process:
– Analyze responses to competency questionnaire and discuss with program director; suggest improvements if needed
– Provide information on competencies and use of Matrix
– Offer to assist in the integration of competencies in M&M and case conferences, etc.
Vanderbilt University Medical Center
Implementation• Introduction to Matrix: Program Director or
Dept. Chairs invite us to do lecture or Grand Rounds to introduce competencies and Matrix.
• Using the Matrix: – Attend M&M or case conferences as
observers – Note the discussion on a blank Matrix
showing which cells/competencies were discussed and which were omitted
– Send Matrix to program director and discuss next steps
Vanderbilt University Medical Center
Implementation• Residents and the Matrix:
– Residents fill in Matrix on their own – Best to let them struggle a little with the
competencies as they think about care of their patient
– Get someone (coach) to review Matrix with them – If the situation/case is difficult, Dept Chair,
Program Director and mentors may assist with filling out Matrix and presentation
• Helpful hint: – Find a “coach” to help residents. At the outset,
we work with the residents and faculty. Then Chief residents or interested faculty take the lead. Sometimes nurses can be coaches such as in Psychiatry at VU.