1. Shifting Gears: From EBM in Silo to QI and Team-based Care
STFM Annual Conference
Spring 2015
Ben Preyss, MD
Anuj Shah, MD
Mary R. Talen, PhD
Northwestern Family Medicine Residency
Erie Family Health Center
Chicago, IL
Abstract: With the advent of healthcare reform act, family physicians need to be flexible in shifting their focus on how healthcare is delivered. While physicians need to understand one-on-one patient care, they also need to gain experience in understanding healthcare needs from a patient population perspective. The PCMH model calls for shifting gears from individuals to team-based care that incorporates quality improvement processes. This session outlines a residency oriented-PCMH initiative that focuses on quality care from different levels-- individual care to chronic disease management of patient panels to complexity care assessment and intervention. The curriculum incorporates a range of active learning activites using registries, evidenced based practices, and PDSA cycles, and complex patient care reviews.

2. Overview Background and Goals of Curriculum
Continuum of Learning (“Triple Aim”)
Patient Focused: Chart Reviews
Panel-Population Focused: Quality Improvement
System Focused: Team-Based Care Initiatives
Lessons Learned and Future Directions
In this session, we will describe a structured continuum of learning that moves practice-based learning from standard chart reviews to managing patient panels to addressing complex care. We will describe how we have been shifting the focus of training from best practices for individual care to quality improvement practices for patient panels and communities. The goal of this training have been to provide hands-on activities that widen the perspective of healthcare quality individual to populations.
Abstract: With the advent of healthcare reform act, family physicians need to be flexible in shifting their focus on how healthcare is delivered. While physicians need to understand one-on-one patient care, they also need to gain experience in understanding healthcare needs from a patient population perspective. The PCMH model calls for shifting gears from indiviudals to team-based care that incorporates quality improvement processes. This session outlines a residency oriented-PCMH initiative that focuses on quality care from different levels-- individual care to chronic disease management of patient panels to complexity care assessment and intervention. The curriculum incorporates a range of active learning activites using registries , evidenced based practices, and PDSA cycles, and complex patient care reviews.

3. Background and Problem
Population changes → system and workforce challenges.
Primary care tasked with meeting this burden:
Improving patient outcomes/experience
Improving health of larger populations
Managing cost
Current approach is PCMH, team-based care.
The problem: Training in PCMH, team-based care, & QI is often minimal or unintentional.
Health care at a crossroads. Our population is changing → we’re older, sicker, and are accessing health care in record numbers.
Primary care docs, namely FM docs, are charged with leading us into this era by meeting the triple aim → we have to find a way to meet these demands by improving quality outcomes and experience for our patients, managing larger numbers of them in total (population health), and managing the cost of these services.
Currently one of the best ways to do this is PCMH → namely team-based care. We’re going to need interprofessional teams to meet these demands.
Problem is...we don’t get trained in this. It’s not something that is intuitive to a physician and we’re finding that we’re poorly equipped when graduating residency.
ENTER our curriculum. It’s our program’s attempt to begin to internalize how we think of our patients, our panels/populations, and the health care system. It’s also our attempt to internalize the QI process and how we can actually impact our patients/populations/system further upstream in the process. --
Faculty need to find ways to teach a new generation of physicians in PCMH settings about population-based health. Standard forms of patient chart reviews need to be expanded to patient populations and quality improvement processes in clinical care.
This is one residency program’s approach to address this need and advance the goals for quality improvement. The lessons learned from these educational activities and expanding opportunities will be addressed. This curriculum also meets the educational focus for a number of milestones: patient care, systems based practice, team-based care, practice based learning, and communication. These activities provide ample opportunity for direct teaching and observation of resident functioning. In addition, residents will learn how to adapt best practices for chronic disease management not only for individuals but also a panel of patients with hypertension, diabetes, asthma and obesity. Our goal is that residents will gain exposure and experience in how to implement a QI project and use this experience to further patient safety and person-centered care in other settings.
This session will offer ideas on how residency programs can expand their quality improvement teaching opportunities and improve patient care and team-based strategies based on population. With the advent of PCMH and ACO’s, healthcare outcomes, patient safety and quality improvement will be at the heart of our healthcare system. Physicians will need to develop QI strategies for care that meet the needs of groups of patients rather than using a case by case approach.

4. Background ACGME Requirements: ABFM Requirements:
Residents are expected to develop skills to...systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement.
Residents should complete 2 scholarly activities, at least one of which should be a quality improvement project.
ABFM Requirements:
Residents MUST complete one Part IV activity using data from a patient population in order to apply for the ABFM certification examination.
Health care at a crossroads. Our population is changing → we’re older, sicker, and are accessing health care in record numbers.
Primary care docs, namely FM docs, are charged with leading us into this era by meeting the triple aim → we have to find a way to meet these demands by improving quality outcomes and experience for our patients, managing larger numbers of them in total (population health), and managing the cost of these services.
Currently one of the best ways to do this is PCMH → namely team-based care. We’re going to need interprofessional teams to meet these demands.
Problem is...we don’t get trained in this. It’s not something that is intuitive to a physician and we’re finding that we’re poorly equipped when graduating residency.
ENTER our curriculum. It’s our program’s attempt to begin to internalize how we think of our patients, our panels/populations, and the health care system. It’s also our attempt to internalize the QI process and how we can actually impact our patients/populations/system further upstream in the process. --
Faculty need to find ways to teach a new generation of physicians in PCMH settings about population-based health. Standard forms of patient chart reviews need to be expanded to patient populations and quality improvement processes in clinical care.
This is one residency program’s approach to address this need and advance the goals for quality improvement. The lessons learned from these educational activities and expanding opportunities will be addressed. This curriculum also meets the educational focus for a number of milestones: patient care, systems based practice, team-based care, practice based learning, and communication. These activities provide ample opportunity for direct teaching and observation of resident functioning. In addition, residents will learn how to adapt best practices for chronic disease management not only for individuals but also a panel of patients with hypertension, diabetes, asthma and obesity. Our goal is that residents will gain exposure and experience in how to implement a QI project and use this experience to further patient safety and person-centered care in other settings.
This session will offer ideas on how residency programs can expand their quality improvement teaching opportunities and improve patient care and team-based strategies based on population. With the advent of PCMH and ACO’s, healthcare outcomes, patient safety and quality improvement will be at the heart of our healthcare system. Physicians will need to develop QI strategies for care that meet the needs of groups of patients rather than using a case by case approach.

5. Purpose and Goals of Curriculum
Improve patient care
Chart review, EBM, etc.
Faculty evaluation and teaching.
Improve population care
Panel management
QI process and PDSA, etc.
HEDIS measures
Improve care systems
Team-based care and moving care “upstream”
Health care at a crossroads. Our population is changing → we’re older, sicker, and are accessing health care in record numbers.
Primary care docs, namely FM docs, are charged with leading us into this era by meeting the triple aim → we have to find a way to meet these demands by improving quality outcomes and experience for our patients, managing larger numbers of them in total (population health), and managing the cost of these services.
Currently one of the best ways to do this is PCMH → namely team-based care. We’re going to need efficient, adaptable, interprofessional teams to meet these demands.
Problem is...we don’t get trained in this. It’s not something that is intuitive to a physician and we’re finding that we’re poorly equipped when graduating residency.
ENTER our curriculum. It’s our program’s attempt to begin to internalize how we think of our patients, our panels/populations, and the health care system. It’s also our attempt to internalize the QI process and how we can actually impact our patients/populations/system further upstream in the process. --
Faculty need to find ways to teach a new generation of physicians in PCMH settings about population-based health. Standard forms of patient chart reviews need to be expanded to patient populations and quality improvement processes in clinical care.
This is one residency program’s approach to address this need and advance the goals for quality improvement. The lessons learned from these educational activities and expanding opportunities will be addressed. This curriculum also meets the educational focus for a number of milestones: patient care, systems based practice, team-based care, practice based learning, and communication. These activities provide ample opportunity for direct teaching and observation of resident functioning. In addition, residents will learn how to adapt best practices for chronic disease management not only for individuals but also a panel of patients with hypertension, diabetes, asthma and obesity. Our goal is that residents will gain exposure and experience in how to implement a QI project and use this experience to further patient safety and person-centered care in other settings.
This session will offer ideas on how residency programs can expand their quality improvement teaching opportunities and improve patient care and team-based strategies based on population. With the advent of PCMH and ACO’s, healthcare outcomes, patient safety and quality improvement will be at the heart of our healthcare system. Physicians will need to develop QI strategies for care that meet the needs of groups of patients rather than using a case by case approach.

6. Phase I: Patient Chart Reviews
Content
Process
Pulling Team Panels
QI Dept. vs. EMR options
Assessment of Patient Care Quality
Self-assessment
Faculty assessment
Reviewing with Faculty
Feedback
Didactic Session
Residents review patient charts
AAFP METRIC module
ABFM Requirement
Faculty review same patient charts
Milestone-based Evaluations
ACGME Requirement
So for instance, we recently completed an asthma project.
QI pulled patients with asthma diagnosis, recent visit.
Residents completed the AAFP METRIC module based on individual chart reviews.
Faculty reviewed charts for METRIC accuracy and milestone evaluation.
Then met during a dedicated didactic session:
1:1 resident feedback with faculty.
Rest of didactic really gets into the QI, PDSA component and thinking about our individual patients as a panel/population group...

7. Phase I: Patient Chart Reviews AAFP Metric Evaluation
The third component really focuses on bring the QI process to life → the DSA of our PDSA cycle.
It’s an opportunity for residents to be involved and lead interprofessional teams and QI process.
This component of the curriculum requires the most buy-in from leadership of residency and clinic as time and resources are necessary.

8. Phase I: Patient Chart Reviews Milestone-based Evaluation
Asthma Metric
A). Did resident turn in chart review or enter it into AAFP? If Yes- PBL3#2 If No- PLB3#0
B). Did resident complete entire AAPG metric after two months? If Yes- PBL3#3 If No-N/A
Yes No
N/A
Field Note Key
Incorporates disease prevention and health promotion into practice
Was referral made into health promotions?
Reconciles recommendations for health maintenance and screening guidelines developed by various organizations
Is asthma severity documented?
C3#2 PC3#2 PC2#2.5
…if intermittent, SABA prescribed?
…if mild/moderate persistent, ICS for daily use + SABA prescribed?
…if severe, ICS + LABA for daily use + SABA prescribed?
Are the following frequencies documented…
...daily symptoms?
PC2#2
…night time symptoms?
… SABA use?
…yearly exacerbations?
Is it clear from documentation that patient has been counseled on trigger avoidance?
PC2#3
Is there an asthma action plan documented?
PC2#3 C4#2 C3#3
Has patient been appropriately referred to asthma education?
PC3#3 PC2#4 C3#3
Has the resident prescribed medications that are covered by patient's insurance?
SBP1#3
The third component really focuses on bring the QI process to life → the DSA of our PDSA cycle.
It’s an opportunity for residents to be involved and lead interprofessional teams and QI process.
This component of the curriculum requires the most buy-in from leadership of residency and clinic as time and resources are necessary.

9. Phase II: Quality Improvement
Example
Sharing Results from Chart Review
Identifying QI Intervention and Measure
Plan for implementing intervention/measure with Team
Our Asthma Pilot Module:
Inadequate grading of severity.
Use of ACT (Asthma control test)
Role of Providers
Role of MA
Role of EMR Form
The second level focuses on patient panel management and PDSAs. This gives residents the opportunity to implement a PDSA cycle for quality improvement. Residents compile the data from the chart reviews with their other clinic team members using an excel spread sheet and they identify areas for improvement. Residents share the best practices with their healthcare team (MAs, RNs, PBAs, HP, BH). In this PLAN phase, the team brainstorms and drafts an intervention plan during scheduled team meetings to improve patient care using available resources. In the DO phase, the team implements a plan for improvement and measures the process and outcome. The STUDY and ACT phase gives residents the opportunity to review the improvement process and identify success and barriers to change with the whole team.

10. Phase III: Team-based Care
Connecting to Clinic Team-based Initiatives
PDSA = now do, study, act!
Interprofessional.
Resident led when possible.
Key Stakeholders  
Leadership Support
Administrative Time: RN, MA, Residents, Referrals, Front-desk, Case Management
Schedule and Space
The third component really focuses on bring the QI process to life → the DSA of our PDSA cycle.
It’s an opportunity for residents to be involved and lead interprofessional teams and QI process.
This component of the curriculum requires the most buy-in from leadership of residency and clinic as time and resources are necessary.

11. Phase III: Team-Based Care Initiatives
Team-based care Structure and Format:
Proposed monthly PDSA cycles (1x week/45 min)
1st week: Review QI data, identify goal & focus.
2nd week: Identify intervention plan
3rd week:  Evaluate workflow & revise intervention.
4th week:  Further evaluation with QI data.
QI data review at 6 months.
What did this actually look like?  
Our process has narrowed in on monthly PDSA cycles.
1st week: Review QI data, identify goal & focus.
2nd week: Identify intervention plan (workflow, f/u processes, interventions, etc.)
3rd week:  Evaluate workflow and revise intervention.
4th week:  Further evaluation with QI data. QI data review in 6 months as well.

12. Phase III: Team-Based Care Initiatives
Our pilot project:
Meetings (Fridays from 1-1:45pm)
Team: (3 residents, 2 attendings, 1 RN, 2 MAs, referrals)
1st week: Colon cancer screening data
2nd week: RCA, workflow outline
3rd week: Benefit vs. effort analysis
4th week: Intervention design
5th week: Review & modify intervention
6th week: Early data, next steps
So in practice, our pilot looked like this...

13. Lessons Learned Leadership buy-in is critical.
Clinic
Residency
Platform for resident research, leadership
Examples: HPV screening, smoking cessation, etc.
EMR/QI Dept. involvement useful

14. Future Directions
Expanding/shaping curriculum for specific clinical rotations
Promoting opportunities for research, leadership.

15. Discussion and Questions