Institutionalizing Quality Improvement in a Family Medicine Residency Fred Tudiver, MD East Tennessee State University

BACKGROUND ACGME competencies include quality improvement methods Current QI residency training: – Seminars, lectures, and/or group activities – Most do not use validated measures Systematic review of assessing QI teaching – Few if any validated measures – QIKAT; knowledge; commitment to change; audits

PCMH: Quality Measures Traditional non-PCMH model: – No systematic documentation for chronic disease Low Tech PCMH – Paper-based QI monitoring with flow charts of disease outcomes; feedback to provider & patient High Tech PCMH – Automated QI monitoring with electronic feedback of disease outcomes; feedback to provider & patient

PURPOSE Incorporate QI learning experiences into residents’ training Provide a standardized and reproducible QI curriculum during residency Develop and use validated measures for assessing QI training effectiveness

SETTING 3 College of Medicine affiliated residencies – 6-6-6; 6-6-7; No ongoing QI program at the start Funding: HRSA BHPr 3-year residency training grant

Method:  Six one hour introductory training sessions  Didactic and interactive small groups Training Topics: 1.Efficient Literature Searching 2.Critical Appraisal 3.Health Disparities 4.Rural Health, Prevention & Healthy People Cultural Competency 6.Health Literacy 7.Comprehensive - interactive teaming session METHOD: TRAINING THE FACULTY

METHOD: TRAINING THE RESIDENTS Method:  Formal lesson plan  Training workbook for Residents  Interactive teamwork over year after training workshop Training Topics: 1.Principles of evidence-based medicine 2.Introduction to QI and tools: PDSA Cycle 3.Researching evidence – intro to efficient literature searching 4.Critically Appraising Literature 5.Teaming: How to effectively work as a team 6.Project development: small group sessions

RESULTS – 6 QI Projects 1.Improvement diabetic BP control – Intervention: in-service to all providers; patient education; regular chart reviews 2.Improve throughput time of outpatients – Intervention: decrease longest section to national standard (decrease 35 min to 28min) 3.Improve Pap smear rates and follow-up rates for abnormal Paps Intervention: better/more visible documentation forms; in-service to all providers; disseminate guidelines

RESULTS – 6 QI Projects 4.Reduce the rate of hospital “bounce backs” 5.Identifying/improving patient concerns re: communication among IMGs 6.Implementing a systematic method for proper foot exams on all diabetics

OUTCOME MEASURE-1 Knowledge & skills self-assessment survey Knowledge of current skills to develop and implement a QI project 9-item Likert 5 point scale; score range 9-45 Knowledge of current skills to develop and implement a QI project. 9-item Likert 5 point scale; Range of possible scores was 9-45 Scale ranged from “Not at all comfortable” to “Very comfortable” Conducted face validity for clarity & relevance assessment with 9 faculty Several items were re-worded and order changed due to feedback Two internal consistency estimates of reliability were computed: o Cronbach’s alpha = o Spearman-Brown coefficient = 0.943

Paired t-tests on overall scores: Pre-training = Post-training = p = <.001.

Paired t-tests on overall scores: Pre-training = Post-training = 33.0 p = <.001.

OUTCOME MEASURE-2 QIKAT Knowledge Assessment Tool – 3 clinical case scenarios with 3 questions: What is the aim? What would you measure? What change would you implement? – Scoring based on identifying process and it is patient focused

DISCUSSION POINTS Challenges – Perceived as an “add-on”, not core curriculum – Teaming was a major challenge – QI topic perceived as the faculty’s topic Lessons Learned – Let them choose a leader at the start – Don’t assume they got it at the initial training – Lots of face time is critical