1. Redesigning Residencies: Initial Outcomes of the I 3 Collaborative Libby Baxley, MD Warren Newton, MD MPH Stanley McCloy MD Alfred Reid MA Michele Stanek MHS Sam Weir MD

2. I 3 Rationale Quality chasm across the continuum of care, with disparities of access, process and outcomes Collaboratives a robust method across diverse diseases, and open access Academic settings “orders of magnitude” more difficult than private practice settings Residencies potentially allow “cubic” impact—patients, residents’ practices on departure, faculty support of regional practices

3. I 3 Collaborative Goals Dramatic improvement in quality of care in diabetes and congestive heart failure Exchange of best practices in teaching Participate in scholarship in residency practice redesign Extension to other FM residencies and other primary care specialties

4. I 3 Methods Breakthrough Series Collaborative Model: multidisciplinary teams, learning sessions, data sharing, electronic and telephone reporting, rapid cycle PDSA, regional learning network Additions for Academic Setting – AHC leadership involvement, regional setting – QI / Clinical site visit and ongoing support – Longer time period (2 years) – Support of some direct costs ($10,000 over three years, pay for participation) – Academic collaborative

5. Trajectory of Quality Improvement Quality Time

6. I 3 Mechanics Engagement at each site – Identify and support site Champion and Team – Site visit with clinical and data faculty 5 face to face meetings Monthly call – Share plans, information, trouble shoot – Promote accountability: focus on data and action plans Design Team phone meetings q 2 weeks Academic Collaborative in parallel

7. Timeline Fall/Winter 2005 Summer 2006 Oct 06 Mar 07 Apr 07 Sep 07 Oct 07 Mar 08 Apr 08 Sep 08 Spring 09 Application Startup Site visits Baseline data Charter Capstone 1 Leadership Change Model Collaboratives Collaborative Periods 1 – 4 Learning Session 2 Learning Session 3 Capstone 2 Other residencies Other specialties Learning Session 1 Sharing baseline data Training in registries, self-care management, and PDSAs Sharing educational ideas, plans for improving care and education

8. Recruitment Process Statewide networking/letter + meeting + personal call Formal application process, requiring definition of team, baseline clinical data, and letter of support from institution

9. Recruitment Message How residencies could benefit… Opportunity to improve care Share ideas on care redesign Share best practices about teaching Participate in scholarship about practice redesign Opportunity to develop faculty, staff, infrastructure Pay for Participation--$10,000, distributed in 4 payments in response for participation in meetings and submission of data

10. Results

11. Recruitment AnMed Family Medicine Cabarrus Family Medicine Carolinas Medical Center East Carolina University Hendersonville Mountain Area Health Education Center Medical University of South Carolina Spartanburg Family Medicine University of North Carolina at Chapel Hill University of South Carolina Special Guests

12. Funding/Statewide Alignment Design—$80K, two institutions—Fullerton First three years—$350K—Fullerton Years 2-4--$550K—Duke Endowment Other collaborators: NC AHEC, SC AHEC, CCME (SC QIO), Division of Public Health, IPIP

13. Learnings from enrollement… 16/20 NC/SC residencies submitted applications No clinical incentives available in any place at beginning Of 10 finalists, 9 wanted to do chronic diseases, 1 wanted to do advanced access 9/10 had EHRs, none had registry function; 1 paper based practice had advanced registry function and outperformed EHRs.

14. Process Data Submission: >85% of data submitted Attendance at face to face meetings excellent. 4 residencies sent residents, 1 sent medical students. Two spin-off face to face meetings—nursing, academic Evaluations stellar—”the best CME I have ever had in my life”— director of a major CME Unit. Collaborative succeeded in spreading ideas across residencies, but more mature QI places learned more quickly…

15. CHF Outcomes of I 3

22. NCQA goal

27. Academic Collaborative Requirement: each residency contributes at least one academic product. Charter developed, with formal meetings, joint authorship rules and process for involvement Results so far: all 10 residencies have presented nationally (total of 20 presentations); 2 mss submitted, 5 more in progress, 3 more starting.

28. I 3 Learnings Residencies have great potential impact—700,000 visits, 335 residents, 92 faculty—which merits investment. Great variation in numbers of patients with diseases across sites Residencies are challenging for QI – Informatics, Staff turnover, HR rigidity, Leadership, Culture—but there are some advantages of the setting, such as orientation and openness to data It is possible to improve care significantly with added support.

29. I 3 Teaching Best Practices Challenge is to make learning active and build residents into ongoing practice management Balance of longitudinal and block experiences, lecture and PDSAs best Better later in curriculum—PGY2 and PGY3

30. Improving Quality Improvement in Family Medicine Residencies Leadership, in depth, is critical. PDSAs, small and spread… Focus on key drivers: registry, standing orders, outreach, self-management Minimize toxicities of training setting (faculty/staff turnover, part time physicians, HR/EHR control); take advantage of setting (frequent orientation, openness to data, residents as change agents)

31. I 3 Next Steps Continue collaborative with focus Patient Centered Medical Home, including obtaining NCQA certification Expansion to Other Family Medicine Residencies in SC, NC, Va, Tenn Extension to Primary Care IM, Pediatrics

32. Implications for Residency Redesign Residency collaboratives marshal huge numbers of patients, with high proportion of patients of color, and have impact of residents and faculty themselves later: merit substantial investment from Title VII and foundations Academic settings are challenging, but also have advantages/resources Clinical care should trump curriculum…goal should be to put residencies into practices, rather than practices into residencies New focus requires fundamental innovations innovation in teaching