DRAFT: CBC-Quality Improvement
The CBC-Quality Improvement development group included:
Co-Chairs: Peter Carek; Bill Shore
Members: Alec Chessman, Lee Erickson, Julie Sicilia, Jim Schmidt, Deanna Willis, Yar Pye, Gary Reichard, Bruce Schell, Victoria Kaprielian, Bruce Bagley
Quality Improvement is a data-based, team approach designed to increase the quality of goods and services provided. After its incorporation into numerous successful businesses, quality improvement has become central to health care; and every family medicine physician needs to develop competency in using quality improvement. In health care, high quality patient care and medical education is essential.
The goal of this curriculum is to provide family medicine physicians of all levels assistance in the acquisition of knowledge and skills necessary to successfully incorporate the principles and techniques of quality improvement into their professional activities in order to provide improved patient care and develop expertise in this area.
Goals: Promote the importance/significance of performance improvement in health care
(1) Familiarize medical students with the concepts and tools of Quality Improvement.
(2) Train Family Medicine residents to conduct Quality Improvement for patient care and safety.
(3) Assist practicing community family physicians in continuous performance improvement as part of their Lifelong Learning in quality of care and patient safety.
(4) Familiarize all levels of learners with skills to apply quality improvement methods to patients and communities from different cultural and language backgrounds.
Major Learning objectives
(1) The M1/M2 student will be able to explain the key concepts and tools of Quality Improvement, including rationale.Specific Objectives
(2) The M3/M4 student will be able to plan a Quality Improvement project. participate in ongoing improvement work, and identify what measures of quality performance are currently being monitored in their practice site.
(3) The PGY1 resident will be able to describe the key concepts of Quality Improvement practice as part of a team or individually on the resident’s own patient panel
(4) The PGY2/PGY3 resident will be able to plan and conduct a practice-based Quality Improvement project.
(5) The practicing community Family Physician will routinely conduct Quality Improvement projects as part of the maintenance of certification process.
Goal: 1: Describe and apply concepts of Quality Improvement.
Objectives: By the end of this program, participants will be able to:
• 1.1) Contrast structure, process, and outcome measures in clinical performance. ( All learner levels)
• 1.2 Summarize the problems common in health care and cite examples of significant quality improvement programs. (students—limited extent; residents and practicing MD’s)
• 1.3) Describe methods for measuring clinical performance of quality improvement and assessing quality of care. (students, residents and practicing physicians): e.g., Find, Organize, Clarify, Understand, Select ,Plan, Do, Study, Act (FOCUS-PDSA) or "Lean"/Six Sigma" process improvement
• 1.4) Compare and contrast Quality Assurance and Quality Improvement. (residents and practicing physicians)
• 1.5) Distinguish between Quality Improvement projects and research. (residents)
• 1.6) Apply models to analyze and improve a clinical or administrative process. (residents and practicing MD’s) e.g., FOCUS-PDSA, Six Sigma
- Describe and apply rules of work design, standardized process and quality engineering principles to improvement interventions.
• 1.7) Design a prospective chart audit for a quality measure, using certified EHR standards including: (residents-PGY 3 and practicing FP’s)
o topic selection • 1.8) Perform a chart audit and report results in a format useable for quality improvement efforts. (M3/M4—basic; residents and MD’s—more developed)
o identification of a clearly defined performance measure
o identification of target population and sample size
o design of data collection methods and tools, and
o identification of appropriate benchmarks
• 1.9) Describe the components of a chronic disease management system including: (all learners)
o use of patient care registry • 1.10) Develop and implement a chronic disease registry for a practice (or a defined population): (Residents and practicing FP’s))
o role of interdisciplinary care teams and the importance of collaboration (in contrast to working individually)
o all six components of the ICIC model) (residents/practicing FP’s)
Goal 2: Describe issues relating to creation and maintenance of a culture of safety in medical practice with specific mechanisms to assess and minimize medical errors.
Objectives: By the end of this program, participants will be able to:
• 2.1) list reasons why quality and safety are a high priority in healthcare today.(all learners)
• 2.2) define: medical error, active error, and latent error. (M3/M4; residents/MD’s)
• 2.3) discuss the epidemiology of medical errors. (all learners)
• 2.4) identify mechanisms to improve patient safety/ reduce medical errors(all learners) learners
• 2.5) list steps in managing unanticipated outcomes and near miss events (all learners)
• 2.6) define and discuss (all learners)
a. purposes of medical error reporting systems (mandated vs. voluntary)
b. mechanisms for reporting medical errors in your institution
c. sentinel events and root-cause analysis
d. human factors engineering
e. barriers which prevent healthcare professionals from collaborating to optimize patient care safety, and ways to remove these barriers
f. impact of cultural differences and health beliefs on the implementation of medical safety programs
g. ethical, professional and medical-legal issues surrounding medical errors
Teaching and Learning Activities/Instructional Methods for different levels of learners:
Prior to specific, clinical based educational activities, information regarding performance improvement should be provided to the learner. This information can be provided using an interactive web-based curriculum as well as lecture based teaching. The basic principles and tools of quality improvement should be presented and a knowledge assessment should be conducted (pre test).
Brief instructional modules: In order to complete a meaningful educational activity in the limited amount of time provided, patient care registries, chart audits, and/or real-time PDSA exercises should be developed and implemented. Students must see these in practice settings before they are asked to do them and they must be done in conjunction with community preceptor MD’s who are including QI in their practices.
Preclinical students should be introduced to the basic terminology and definitions of Quality improvement. This content could be included in the "Doctoring" or "Introduction to Clinical Medicine (ICM) courses. Ideally, students should be assigned to preceptor offices in which QI strategies are being implemented. QI methodologies should be included in preceptor faculty development sessions that are sponsored by preclinical courses.
Clerkship students can be assigned 2 -4 hours per week to work on a Quality Improvement project. This can be combined with community health or service learning projects that are currently part of required activities on many Family Medicine clerkships. Some initial time for presenting the general concepts of QI is necessary. Projects are best done in pairs or small groups and only in practice settings in which preceptors are actively engaged in the process.
Residency programs will include formal Quality improvement projects in their curriculum. This should span over time, beginning in PGY 2 at the latest, and include time for development and the ability to assess outcomes by the end of PGY 3. Practicing Family Physicians (Preceptors)
Early in PGY 1 residents should have core didactic sessions on Quality Improvement terminology and methodologies. In workshops and lecture discussions, they can begin to design and develop QI projects from their practices that incorporate certified EHR methodologies, implementation strategies, and assessment tools. Examples include: Improving phone and reception services, chronic care management innovations, adding new clinical services, etc
Practicing Family physicians will need educational resources to conduct Quality Improvement projects on a continuous basis in their practice. These should include training sessions at Family Medicine local and national meetings, on-line interactive modules, and information from the maintenance of certification requirements. Mechanisms should be developed for these community physicians to receive CME credit for the trainings, time spent in implementing programs, and incorporation of teaching activities, e.g., with medical students, in the projects
Learner and Program Evaluation should be developed for these community physician to receive CME credit for the trainings, time spent in implementing programs, and incorporation of teaching activities, e.g. with medical students, in the projects. Students by the end of the Family Medicine clerkship:
• Pre and post-tests to assess knowledge and attitudesSample Student Assessment Tools
• Present final reports to clerkship directors, preceptors, and fellow students. These reports can be presented on-line as well as in small group formats.
• Evaluated by clerkship and project site directors, using tools as below
• Complete electronic course and project evaluations
• Focus groups to evaluate perceptions and value of QI projects
Doona Kern, MD, Alec Chessman, MD., MUSC
ratingform.pdf (see attachmentat the top of this page)
ratingform2.pdf (see attachment at the top of this page)
Residents by Graduation:
• Present QI project to peers, clinic management, and facultyPracticing Family Physicians
• Assess QI from the project
• Present recommendations for continuation and assessment of the project
• Assess increased patient satisfaction, increased safety and decreased patient errors
• Results and presentations of QI work can be documented resident portfolios to meet ACGME competency requirements.
• Discuss mechanisms to include QI in future practice
Leenstra, JL, Beckman, TJ, Reed, DA, et al. (2007). Validation of a method for assessing resident physicians' quality improvement proposals. Journal of general internal medicine, 22(9), 1330-4.http://www.springerlink.com/content/u6g61r4q30j74470/
• Improved clinical outcomes in patient satisfaction, safety, and decreased errors
• Meet MOC accreditation goals and standards
• Include and demonstrate to learners QI office procedures
Faculty Development and Lifelong Learning Support Services/ Resources
Pawar M. Getting Beyond Blame. Family Practice Management. May 2007: www.aafp.org/pm
Endsley S, Magill MK, Godfrey MM. Creating a Lean. Family Practice Management. April, 2006:
AAFP/STFM: Practice Improvement-Annual conferences
ABFM: MOC materials
Erickson, LK. CQI for Doctors: A reference for the Rest of Us. West Penn Family Medicine Residency Progam.
Quality Improvement Resources
The Institute for Healthcare Improvement has several quality improvement resources and tools available to members online. Membership is free and can be accessed online.
Information available through the American Academy of Family Physicians for quality improvement and office transformation.
Information of quality improvement, pay for performance, and practice redesign from the American College of Physicians.
Publications from the Commonwealth Fund with various healthcare topics including issues in performance improvement.
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance
Authors: Langley, Nolan, Nolan, Norman, Provost
An introductory text to performance improvement.
Practicing Excellence: A physician's manual to exceptional Health Care
Author: Stephen Beeson, MD
This basic primer is recommended if you are specifically looking to improve a physician practice.
The Deming Management Method
Author: Mary Walton
This introductory book gives basic information and practical applications of quality improvement based on the writing of W. Edwards Deming. The style of writing is practical and readable by those new to quality improvement.
The Red Bead Game
This game was developed by Edward Deming as a teaching tool for quality improvement. It is an interactive game that assists the participants in role playing through the dynamics of a flawed process. The game is described in more detail in “The Deming Management Method”. It is available at www.redbead.com.
Putting Total Quality Management to Work
Authors: Sashkin, Kiser
This book discusses tools for conducting quality improvement such as fishbone diagrams and pareto charts.
Meetings, Bloody Meetings
This Video featuring John Cleese discusses how to conduct effective, time conscious meetings through parody. This and sequels are available at numerous sources online such as http://www.business-marketing.com/store/cleesecoastal.html
This Video helps highlight how individuals and organizations often get distracted on their way to achieving their goals. It is available at www.abileneparadox.com.
Fundamental and concise PI module with pre and post questionnaires available through AFMRD on line.
Good program for a physician leader/manager.
Pittsburgh Regional Health Initiative's "Prefecting Patient Care" course—covers Toyota-style quality improvement and process design.
The Toyota Way
Author: Jeffrey Liker. McGraw-Hill, 2004.
Fixing Healthcare from the Inside, Today
Author: Steven J. Spear. Harvard Business Review, September 2005.
"Time and Motion Regained"
Author: Paul S Adler, Harvard Business Review, January-February 1993.
Measuring Quality Improvement in Healthcare--A Guide to Statistical Process Control Applications
Authors: Raymond G. Carey & Robert C. Loyd, 1995.
This book addresses the critical growing need among health care administrators and practitioners to measure the effectiveness of quality improvement efforts. The authors' straightforward discussions of data collection, variation, and process improvement incorporates the patient as a key element in driving the improvement of processes and outcomes. The core of the book is a set of twelve case studies that show how to apply statistical thinking to health care processes. (You can preview a good portion of the book by entering the title on Google .com.)
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