First Do No Harm: Optimizing Quality and Safety Training STFM May 2017 Lance Fuchs, MD FAAFP Vidush Athyal, MD FAAFP Kaiser Permanente San Diego Family Medicine Residency

Introductions Your Name Where are you from? Your role One goal from this discussion

Goals and Objectives Understand important components of a quality, safety and performance improvement curriculum Understand strategies to integrate quality and safety training into your residency curriculum Understand strategies to implement panel management activities into your residency curriculum Discuss what other programs are doing to achieve the same goals

Our Residency Large HMO community-based program 6 residents per year Level 3 PCMH

What are we discussing? Quality Improvement (QI) Performance Improvement (PI) Patient Safety (PS)

ACGME requirements VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs. (Core) VI.A.4. The learning objectives of the program must: VI.A.4.a) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and, (Core) VI.A.4.b) not be compromised by excessive reliance on residents to fulfill non-physician service obligations. (Core)

ACGME requirements IV.B. Residents’ Scholarly Activities IV.B.1. The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. (Core) IV.B.2. Residents should participate in scholarly activity. (Core) IV.B.2.a) Residents should complete two scholarly activities, at least one of which should be a quality improvement project. (Outcome)

Kaiser Permanente Company culture includes emphasis on quality care and employee/patient safety Advanced systems to support these efforts “Culture of excellence” A high level of expectation of effort by every team member is needed for this work. Successful team: people/relationships, effective processes, results

Kaiser Permanente Coordinating efforts with your hospital, medical group, department or faculty goals What can residents do to help? Is there educational value for the residents? What is required?

The Basics of Quality Work Health Care must be: Safe Effective Patient-Centered Timely Efficient Equitable

An Outline of Our Curriculum Next we will summarize the components of our curriculum.

Teaching Evidence-Based Care USPSTF guidelines Choosing Wisely Campaign KP Regional Clinical Guidelines PICO exercise Monthly journal club to evaluate evidence

Resident Participation in Department Quality Team Over 200 family physicians in our department Quality team = 5 leaders and other physicians rotate through Rate cases Provide education to department All residents participate 1-2 residents attend each month

Reporting Process for Patient Care Cases Involving Residents “Culture of Safety” Recognize/respond/disclose adverse events and near misses Safe reporting Tracking Educating Standardization of clinical processes

Monthly Quality Didactics/Discussions The resident(s) who attended the department quality meeting present the cases Highlight recurrent themes where providers make errors Discuss importance of effective communication between team members

Peer Chart Review Clinic visits, telephone appointment visits and e-mail messages Expectation of high quality documentation in EMR

Safety Net for Clinical Advice In-basket coverage calendar with assigned faculty to call every day/any time

Teaching Safe Habits Hand washing Not recapping needles Wearing goggles/masks for high-risk procedures

Panel Management EMR-based care gap reminders (in-reach) Registries/Report cards Team-based care/defined roles Pod-based efforts Learn processes/best practices for clinical strategic goals Participate in PBM outreach efforts Whole person care as a health care system: flu shot everywhere (even in Ortho), get them where they are

Studying a Process/Changing a Process Experiences in PDSA cycles Using SMART criteria Root-cause analysis/fishbone diagrams From report cards to improved performance Experiencing efforts to reduce errors formal approach to performance analysis and systematic efforts to improve it

Institute of Health Care Improvement (IHI) Open School All of our residents complete IHI Open School Basic Certificate on their own time KP Southern California has an IHI residency network with 6 FM programs – resident led Collaborative QI projects

Late in the first year of residency KP Southern California Regional Resident Performance Improvement Workshop Late in the first year of residency Provide guidance for class-based project

Scholarly Projects Class-based projects Individual projects: Literature review Clinical PI/QI/PS project Publishable/presentable scientific research

What are your expectations of residents’ quality and safety education? Learn the process Experiential is better Those more interested can do more Need to provide them support (time, faculty)

Assessing Our Residents Do residents enter training feeling ill-equipped to handle issues of QI/PS? Does training improve knowledge and skill? What parts are most and least useful?

Discussion Common challenges and strategies to overcome them: Faculty time Faculty interest and expertise Sustainability of projects Others?

References IHI Open School: www.ihi.org Improving Resident Education in Quality Improvement and Patient Safety. Ramon Cancino, MD. STFM 2011. Creating and sustaining a culture of safety in a Family Medicine residency. E. Btkiewicz et al. STFM.

References How Doctors Think: Contributions to Medical Errors. T. Munzing et al. STFM. “How Doctors Think”. Jerome Groopman. 2007. To Err is Human: Building a Safer Health System for the 21st Century, IOM, 2001. Leadership Guide to Patient Safety, Institute of Health Improvement. 2006.

References How to measure quality and improvement of panel manager’s work in the PCMH in a residency practice. D. Yamashita et al. STFM. A Bridge to Safety: A curriculum for creating a safety state of mind. C. Gleit et al. STFM 2016. ACGME Program Requirements for Graduate Medical Education in Family Medicine