1. Continuous Quality Improvement (CQI) In a Family Medicine Residency Program: Leveraging Three Missions Sonja Van Hala, MD, MPH Jennifer Leiser, MD Bernadette Kiraly, MD Richard Backman, MD Kyle Jones, MD

2. Objectives At the end of this presentation the participant will:  Describe the key factors that transformed our ineffective CQI process into one that is functional, practical, and productive  Explain how a clinic-wide quality improvement process in a family medicine residency program can leverage success in three missions: clinical, education, and scholarship  Utilize a planning tool to identify next steps in moving participant organizations toward CQI goals

3. In The Beginning…

4. Start with Why  Stagnant quality indicators for our resident/faculty clinics  Resident CQI projects were ineffectual due to poor clinic engagement and institutional support with no protected time for team meetings  Resident and faculty scholarship were wanting  Video Video

5. Set Goals: Start with Why  Start with core values Our identity as clinicians Our identity as educators Our identity as scholars

6. Set Goals: Identify Your Goals  Clinical What processes need to be improved?  Educational How do we integrate this work into a curriculum?  Scholarship How do we translate this work into scholarship?

7. Identify Roles: Change Process SponsorThe individual or group with power to sanction or legitimize change AgentThe individual or group responsible for actually making the change TargetThe individual or group who must actually change AdvocateThe individual or group who wants to achieve a change but lacks the power to sanction it Managing at the Speed of Change Daryl R. Connor

8. Identify Resources: Data  Identify data already collected by institution or outside sources  Determine how to access and utilize available data  Interpretation of data  Statistical analysis of data

9. Identify Resources: Time, Location & Support Personnel  Time  Location/Venue Lecture Hall Multiple small rooms Adequate resources Food  Support Personnel

10. Identify Resources: Content Expertise  Hospital quality group  FM faculty  MPH faculty  Institutional clinical staff  Educational resources (IHI)

11. Identify Resources: Finances  Budget for and mitigate financial losses  Plan that future revenue will be tied to quality

12. Action: Get it Movin’ Clinic Quality Meeting (CQM)  In July 2011 we implemented a monthly 4.5 hour meeting to focus on quality and team building  All faculty, residents, mid-levels, and staff of the clinics participate

13. Clinical: Leadership & Organization  Create agenda to meet goals  Create schedule of topics  Assign staff to support activities  Change management/communication Establish vision Communicate early and often Address resistance “Go Live” date – Clear all schedules Set expectations (attendance)

14. 8:00-8:50 Clinic Quality General Presentation Topic introduction Personalized story Clinic quality data Explanation of metrics EMR tools review 9:00-10:00 Clinic MeetingsClinic greats Organizational goals Safety/environment of care HIPAA Open Forum 10:00- 11:00 Clinical Teams MeetingReview individual provider quality data Create action plan w/assignments Work “exception report” for quality indicators 11:00-12:00 CQI Team Meetings Resident ‐ led & faculty-mentored All faculty, residents and staff participate on a team 12:00-12:30 Ad hoc Resident/Faculty Practice Improvement Groups Clinical issues work groups

15. Education

16. Education: Faculty Development in CQI  Faculty CQI Training Two 1-hour sessions during faculty development  Follow up needs assessment indicated faculty were comfortable mentoring CQI projects

17. Education: Faculty Champions  Determine faculty mentors for CQI projects  Identify faculty champion to oversee residency curriculum and execution

18. Education: CQI Curriculum  Use existing resources (IHI, FOCUS- PDSA model)  Integrate into didactic series, coordinated with team-meeting schedule

19. S elect the process improvement U nderstand causes of process variation C larify current knowledge of the process O rganize a team that knows the process F ind a process to improve Do Stud y Act Plan

20. CQI Curriculum: FOCUS - PDSA IRBF/OCUSPDS July Aug Sept Oct Nov Dec Jan Feb Mar Apr F/OCUSP Problem-solving, Overcoming barriers, Leadership, etc. CQI Team Activities SEMINAR: Theory SS Scholarship Break

21. Education: Assess Process & Outcomes  Formative feedback (coaching) to residents on leadership skills  Residents evaluate the curriculum  Final CQI project presentations

22. Scholarship

23. Scholarship: Preparation  Residents complete IRB training  Submit for IRB approval Standing umbrella IRB approval as “not human subjects research” New resident projects submitted as an addendum to original IRB

24. Scholarship: Translation  Translate work into resident presentations Create awareness for venues to disseminate Support costs Support time away for residents

25. Scholarship: Collaboration  Include faculty in resident scholarship  Explore interdisciplinary collaboration

26. Scholarship: Branding Brand for institutional/national promotion and collaboration  Tie efforts to institutional goals (demonstrate value)  Present and promote program

27. CQI in Action

28. S elect the process improvement U nderstand causes of process variation C larify current knowledge of the process O rganize a team that knows the process F ind a process to improve Do Stud y Act Plan

29. F ind a process to improve  Preselected topics based on data already collected by the organization  Residents wanting a topic outside these areas met with faculty to brainstorm how to get data  Select topic prior to start of R3 year

30. Jones Project  Healthy People 2020 goal of immunizing 80% of children under age 2

31. O rganize a team  MA’s and clinic staff invited to join a team that interests them  All staff participate  Faculty mentor for each project  Creation of aim statement

32. Jones Project Clinic Staff Team  R3 team leader  R1 resident  Faculty mentor  2 medical assistants  LPN  Receptionist Aim: Improve clinic vaccination rate to 90% for children under age 2

33. C larify the current process  Determine baseline data  Tools for systematic assessment of the current process  Flow diagram

35. U nderstand causes of variation  Fishbone diagram Diagram all factors preventing achievement of the goal  Pareto chart Organize factors in order of frequency

37. Jones Project  Family Medicine clinic: 66%  National average: 70% Data provided Utah State Department of Health (USIIS/Webkids)

38. S elect a process to improve  Teams decide on a way to improve the process and plan the implementation  Support from clinic managers and medical directors

39. Jones Project  Intervention: Daily printed report for each pediatric patient scheduled in clinic Distribute report to providers as a reminder  Measures: Frequency of printing reports (process measure) Immunization rate for children under 2 (outcome measure)  Time Frame: Intervention implemented on October 24, 2011 Reviewed immunization rates on December 31, 2011 and March 31, 2012

40. Jones Project  Outcomes Batch report (process measure)  97% compliance by end of project Immunization rates (outcome measure)  Improved from 66% to 92% over the five month intervention (n=91)

41. Bringing It All Together

42. Mission 1: Clinical Quality

43. Mission 2: Education 9 Third year residents each led a CQI clinic team, applying principles learned in longitudinal CQI seminar  Resident empowerment  Skill acquisition  Real-life application  Leadership coaching

44. Mission 3: Scholarship  9 resident projects  1 resident presentation Utah Public Health Association  3 national poster presentations with 4 resident and 5 faculty authors Society of Teachers of Family Medicine  3 faculty posters presented  2 papers underway

45. Conclusion  Patient care outcomes improved  Our real-life curriculum trains residents in CQI methodologies  Scholarship activities naturally flow from the engagement of faculty and residents