1. The heatlhcare matrix Erin Hurley, PGY 4 June 16, 2020
Thank you, Dr. Azziz, faculty, and fellow residents for attending my grand rounds presentation on the healthcare matrix.
For the past four years, each month the residents have presented patient cases using the healthcare matrix as a format.
Today, I am going to describe the development of the Heatlhcare matrix and the goals of using this tool.
I also am going to discuss the impact it has on residency training and patient care here at Cedars.
Erin Hurley, PGY 4
June 16, 2020

2. “Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘If not—why not?’ with a view to preventing similar failures in the future.”
Ernest Codman M.D. , 1914
No goals in health care delivery are more critical than keeping patients safe from harm during treatment and improving processes and outcomes of their care.
In 1914, Ernest Codman who was a well-respected Boston physician recognized this and stated: SLIDE.
When he tried to establish a registry to track outcomes of clinical care at Massachusetts General Hospital he was expelled from the medical staff and removed from the Harvard faculty.
Fortunately, he carried on his work and inspired an impressive body of knowledge that now exists about quality improvement and patient safety.

3. Patient Safety Anesthesia coined the term “patient safety”
Institute of Medicine (IOM) of the US Academy of Sciences
1999: “To Err is Human”
2001: “Crossing the Quality Chasm”
In North America, the specialty of anesthesia is credited by many as the discipline in health care that initially published data on safety and coined the term “patient safety”.
Furthermore, the now well-known monograph by the Institute of medicine (IOM)’s , “To Err is Human” and the follow up publication, “ Crossing the Quality Chasm” called attention to how common medical and surgical errors are.

4. Quality Chasm
“Health care we have and the care we could have– represents more than a gap, but rather a chasm”
Medical education chasm
In 2001, the Institute of Medicine presented a compelling case for its claim that the difference between the “SLIDE” and that this quality chasm persists unchecked.
They also found the same deficiency exists between the medical education that we have and that which we could have.

5. IOM
Care of every patient has the potential to improve the care of all patients yet to come
Competencies are integrated into the routine practices of daily care
Decision making regarding care of the patient is guided by the best evidence available
The quality of health care is positively related to the quality of medical education
The IOM identified reform of health professions education as critical to enhancing the quality of health care in the United States.
They sought to create a system in which the following are true: That the “SLIDE”

6. IOM– Aims for Improvement
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
To address this chasm in health care quality, all health care organizations, professional groups, and private and public purchasers are to pursue six Aims for Improvement in health care.
These dimensions of quality describe a health care system that is:

7. ACGME
The content of graduate education is aligned with the changing needs of health systems
Residency programs use sound outcome assessment methods for both residents’ and programs’ achievement of educational outcomes.
At the same time the IOM was developing the six aims for improvement, the Accreditation Council of Graduate Medical Education began to address the shortcomings of Graduate Medical Education and set the following goals.
The ACGME stated that the content of graduate education must be aligned with the changing needs of health systems.
In addition, Residency programs must use sound outcomes to assess methods for both residents and the residency program’s achievement of educational outcomes.

8. ACGME Competencies
“Quality of health care is positively related to quality education”
IOM’s notion that “Quality of health care is positively related to quality education,” provided the impetus for a shift in Graduate medical education-- from a focus on process, to a focus on assuring resident competencies

9. Core Competencies Patient Care Medical Knowledge
Interpersonal and communication skills
Professionalism
Systems-based practice
Practiced-based learning and improvement
The ACGME adopted six core competencies that physicians in training must master if they are to provide quality care.
The American Board of Medical Subspecialties has adopted these same competencies as the basis for the standards of certification and maintenance of certification for all specialty boards– making the framework equally valuable for all practicing physicians.
These core competencies are: SLIDE

10. Core Competencies Teaching Assessment No prescribed formulas
Interpersonal and communication skills
System-based practice
Practice based learning and improvement
Teaching and evaluating core competencies essential for quality health care is an evolutionary process without a prescribed formula.
Teaching and assessing the less formally derived competencies—interpersonal and communication skills, systems-based practice, and practice-based learning and improvement have been problematic.
SBP and PBL have been especially challenging for faculty who do not have experience in quality improvement.

11. Healthcare Matrix A formative approach to the presentation of
core competencies to residents, which in turn is having an effect on the faculty and their patient care
A response to the challenge of linking all six competencies with the realities of the current medical education system– which is focused on acquisition of medical knowledge
Because of that, the healthcare matrix was developed.. Which is SLIDE

12. Healthcare Matrix: Care of Patient (s) with…
AIMS
Competencies
Safe
Timely
Effective
Efficient
Equitable
Patient-Centered
Patient Care
Medical Knowledge
Interpersonal/
Comm. Skills
Professionalism
Systems Based Practice
Practice-Based Learning /Improvement
The matrix is a conceptual framework that projects an ‘episode of care’ as the large and complex picture. It provides a glimpse into the interaction between quality outcomes and the skills, knowledge, and attitudes (competencies) necessary to affect those outcomes.
The matrix is intended to make the linkage between competencies and outcomes readily apparent.
And you can see the X-axis are the Aims of improvement, with the y-axis being the six core competencies.
This format is easily used– and presented by the chief residents to an audience of faculty, residents, medical students, and occasionally other health care providers– including anesthesia, nursing, etc.
IMPROVEMENT
The Healthcare Matrix, 2004, John Bingham & Doris Quinn, Vanderbilt University

13. Patient Care Should Be:
Safe: Avoiding injuries to patients from care intended to help them
Timely: Reducing waits and sometimes harmful delays for those who receive and give care
Effective: Providing services based on scientific knowledge to all who could benefit; refraining from providing services to those likely not to benefit
Efficient: Avoiding waste of equipment, supplies, ideas, energy
Equitable: Providing care that does not vary in quality because of personal characteristics
Patient-Centered: Providing care that is respectful of and responsive to individual patient preferences, needs, values; ensuring that patient values guide all clinical decisions
In completing the aims of improvement portion, the presenter should demonstrate that SLIDE

14. Medical Knowledge: What Must We Know?
Patient care
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Medical Knowledge
“…about established and evolving biomedical, clinical, and cognate sciences, and application of this knowledge to patient care.”
These are answered using the ACGME core competencies as an additional qualifier SLIDE

15. Interpersonal/Communication Skills: What Must We Say?
Patient care
Safe
Timely
Effective
Efficient
Equitable
Patient Centered MK
Interpersonal & Communication Skills
“…that will result in effective information exchange and teaming with patients, their families, & other health professionals.”

16. Professionalism: How Must We Behave?
Patient care
Safe
Timely
Effective
Efficient
Equitable
Patient Centered MK
ICS
Professional-ism
“…as manifested through commitment to carrying out professional responsibilities, adherence to ethical principles, & sensitivity to diverse patient population.”

17. Systems-Based Practice: What is the Process. On Whom Do We Depend
Systems-Based Practice: What is the Process? On Whom Do We Depend? Who Depends On Us?
Patient care
Safe
Timely
Effective
Efficient
Equitable
Patient Centered MK
ICS
Prof
Systems-Based Practice
“…as manifested by actions that demonstrate an awareness of, and responsiveness to, a larger context & system of healthcare and ability to effectively call on system resources to provide care of optimal value.”

18. Practice-Based Learning & Improvement: What Have We Learned
Practice-Based Learning & Improvement: What Have We Learned? What Will We Improve?
Patient care
Safe
Timely
Effective
Efficient
Equitable
Patient Centered MK
ICS
Prof
SBP
Practice-Based Learning & Improvement
“…involves investigation & evaluation of residents’ (program’s, or institution’s) own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.”

19. Value of the Matrix
Healthcare Matrix: Improving Care by Linking Outcomes to Competencies
Over 100 matrix presentations at Vanderbilt
Guide learners in analyzing the care of their own patients by using Core competencies to identify opportunities for improvement
Change the environment of case presentations and MM conferences from one of blame to one of
system analysis and quality improvement
The matrix was initially piloted by DC Quinn and JW Bingham at Vanderbilt University.
Their study, entitled the “HCM- improving care by linking outcomes to competencies provided data on the value of the matrix. They analyzed over 100 presentations.
Through the use of the matrix, they were able to guide learners in SLIDE

20. Effectiveness
Provides a learning format that is part of daily education and delivery of care by residents
Addresses the multidisciplinary culture in which residents practice
Being used by many health professions besides residents
Provides a solution that is standardized so that multiple programs and institutions can have a common framework to teach the competencies and learn from each other
They also showed that the matrix provided a learning format that can be part of the daily education and delivery of care by residents;
It addresses the multidisciplinary culture in which residents practice;
It is a tool that is being used by many health professionals besides residents;
Finally, this tool provides a solution that is standardized so that multiple programs and multiple institutions can have a common framework to teach the competencies and to learn from each other

21. Educational Environment
The matrix allows transformation of the educational environment
Team learning
Patient care– structures and systems
Collaborative decision-making
Collective analysis and improvement
Connections/trends between cases
Their experience with the Matrix also showed the slow transformation of the educational environment to one where learning occurs with other team members, that facts about patient care are structured and displayed systematically, and that decisions are made in a collaborative manner.
By prompting users to consider system issues as well as medical knowledge, communication, and professionalism, the Matrix can change the evaluation of care from an atmosphere of "shame and blame" to an environment of collective analysis and improvement.
When many Matrices are analyzed, they can be sorted, allowing us to determine whether there are connections between certain aspects of the cases.

22. Matrix at Vanderbilt
100 matrices were analyzed to look at safety concerns across institutions
Four major themes identified
Communication
Teamwork
“workarounds” (circumventions of a system)
Inadequate or poor documentation
For instance, almost 100 matrices at Vanderbilt were analyzed to look at safety concerns across the institution.
They identified four major themes across all users of the Matrix which were: communication teamwork, "workarounds" (circumventions of a system), and inadequate or poor documentation.
They concluded that each department and each specialty could benefit from this type of report.
There is no doubt that the greatest gains from this tool are the ability to focus on system-based practice and practice-based learning and improvement.

23. Cedars-Sinai Medical Center
Using the healthcare matrix to teach and improve patient safety culture in an OB/GYN residency training program
Utility of healthcare matrix in teaching about safety and improvement of care
Through the work of Dr. Ogunyemi and several residents, they presented a study at APGO this year that looked at our own Matrix presentations.
The study aimed to assess the utility of the healthcare matrix conference (HCMC) in teaching OB/GYN residents about patient safety and improvement of care.

24. Methods
HCMC is held at least once monthly in our residency education program
The selected resident chooses the case & develops a draft matrix under faculty supervision
A multidisciplinary team is invited based on the case
The matrix is presented at conference and a consensus action plan for implementation is generated after discussion
As described before, the HCMC is held SLIDE

25. Methods
Two years after the initiation of the program, the residents completed an anonymous 15-item survey about their perception of the program using a 5 point Likert scale

26. Case Distribution (n=26) Clinical distribution
Results
26 HCMC were held from 2007 to 2009
PGY-4 residents prepared & conducted 77% sessions
Case Distribution (n=26)
Management concerns
42.3%
Medication errors/concerns
23.1%
Bleeding complications
34.6%
Clinical distribution
Gynecology cases
46.2%
Obstetrical cases
53.8%
The study includes 26 healthcare matrix conferences held from 2007 to 2009.
Fourth year residents conducted 77% of the sessions.
This table shows that there were 3 main reasons for residents’ selection of cases---- management issues being the most common reason.
All cases, except one, were found to have suboptimal patient care by both IOM Aims and ACGME Competencies.

27. Sub-optimal care by IOM Aims
By IOM Aims, the most common reason for suboptimal care was safety with timeliness being second.

28. Sub-optimal care by ACGME Competencies
By ACGME competencies, there were problem based learning and improvement opportunities in all of the cases selected.
Systems issues in about ¾ of cases, closely followed by deficiencies in medical knowledge and communication.

29. Residents perception of the utility of the Healthcare Matrix
Figure 1: *Residents perception of the utility of the Healthcare Matrix (n=21)
90.50%
95.20%
71.40%
28.60%
85.70%
100%
38.10% 0%
47.60%
57.10%
81.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Fosters learning
Helped assess errors
Review errors in blame free environment
Felt awkward presenting errors of my superiors
Changed my practice
Helped analyze a complex situation
Useful for quality improvement
Improved my communication skills
Improved ability debrief
Should be canceled
Great, continue to use
Preparation is time consuming
Would use in my clinical practice in future
Effective for teaching ACGME competencies & IOM Aims
Should be interdisciplinary
This figure shows that most residents agreed that the program was useful.
No resident thought that the program should be cancelled.
Also, every resident believed that the program should be interdisciplinary and that it helped in analyzing a complex situation.

30. Results- Residents’ Survey
Effective, fosters learning, and should be continued
Improved their ability to debrief, was useful for quality improvement, helped analyze a complex situation, changed their practice, and helped assess errors
Some felt awkward presenting medical errors made by their superiors, but the majority felt that the HCMC provided them with a blame free environment to discuss errors
The resident survey also showed that respondents thought the matrix was effective, that it fostered learning, and should be continued.
They believed that it improved their ability to debrief, was useful for QI, helped analyze a complex situation, changed their practice, and helped assess errors
Some felt awkward..

31. Conclusion
Residents can use the healthcare matrix in a multidisciplinary setting to evaluate and improve patient care.
HCMC allows the IOM Aims to become a framework for reviewing patient safety culture.
Allows residents to integrate the ACGME Competencies as part of their routine clinical practice.
This study concluded that the residents SLIDE

32. Conclusion
Timeliness, medical knowledge, & communication issues were major contributors to patient safety concerns.
Residents’ survey highlights areas that need more attention.
Healthcare matrix provides a foundation for systematic transformation in patient care, medical education, and team dynamics that could be useful for residency training programs.

33. Matrix 2007
Healthcare Matrix: Care of Patient with uterine atony after D+E with DIC
Aims
Competencies
SAFE
(Avoiding injury from care intended to help)
TIMELY
(Reducing delays for pts and providers)
EFFECTIVE
(Evidence-based medicine, avoiding underuse and overuse)
EFFICIENT
(Avoiding waste of equipment, supplies, ideas, and energy)
EQUITABLE
(Care does not vary based on race, ethnicity, gender, SES)
PATIENT-CENTERED
(Care with respect for preference, needs, values)
Assessment of Care
PATIENT CARE
(Overall Assessment)
Yes/No
No - patient nearly died from hemorrhagic shock
No - Life saving treatment was delayed at several levels
No – intrauterine ballon, uterotonics and fluid resuscitation ineffective.
No – resources such a blood products, mobilization of staff not utilized in efficient manner.
Yes
Yes – Patient and family informed at all times. Patient desired to avoid hysterectomy at all costs.
MEDICAL KNOWLEDGE and SKILLS
(What must we know?)
 Ensure oxygen delivery, support BP, aggressive IV rescuscitation, treat cause
 Prompt diagnosis, recognize urgency, initiate therapy, timely transport to OR.
Urgency to treat delayed.
 Treatment of uterine atony – uterotonics, intrauterine ballon used. Delayed decision to hysterectomy.
 Aggressive IV resuscitation, repletion of blood products, correction of DIC
 N/A
INTERPERSONAL AND COMMUNICATION SKILLS
(What must we say?)
 Debriefing of all teams involved even if ICU is closed
Blood results – stat should be available sooner than 3 hrs. Crossmatched blood should be available sooner.
 More effective communication between team members. Better communication better ICU and gyn residents.
 Private MD patient involve faculty MD
 Good communication with patient and family for intended intervention.
PROFESSIONALISM
(How must we behave?)
 Do no harm
 Professional duty to accompany critically ill patient to the OR, to ensure safety and to expedite therapy.
 Mobilize team members to collect blood products.
 Preserve patient autonomy
SYSTEM-BASED PRACTICE
(What is the process?
On whom do we depend? Who depends on us?)
 System should ensure that appropriate consultants notified such as anaethestiologist for intubation,
 D+E should be done in a tertiary facility so that blood can be mobilized as soon as possible.
 Crossmatch in life-threatening situations should be a priority.
 Availability of lab medicine, physician, timely transport of blood, expertise of gyn, anesthesiology should not vary from time of day/night
For those of you who remember Winnie Mak, she presented this case in 2007.
Of note --in this matrix, which describes a patient who underwent hemorrhagic shock as a result of uterine atony after D&E, complicated by DIC– was the unfamiliarity with the hemorrhage protocol, and the communication gap between the ICU and the OB residents.
If you ask any resident- OB or anesthesia, nurse or midwife today, they not only are very familiar with the hemorrhage protocol, but feel very comfortable in activating it.
The action plan that was created as a result of this matrix identified flaws in a system which were then addressed.

34. Summary--Creating and Reinforcing a Culture of Learning
The matrix is intended to help consider patient care in terms of the IOM Aims and the ACGME Core Competencies
Enhance learning for every resident
Team learning/ team dynamics
Collaborative decision
Resident– part of a system of care
Common framework for evaluating and improving patient care across disciplines
Integrate the ACGME Competencies as part of their routine clinical practice
Improve quality of care
In summary, the matrix is intended to help consider patient care in terms of IOM aims and the ACGME core competencies rather than make these dimensions add on to an already compressed duty-hour week.
The matrix is used to enhance the learning experience for every resident.
The matrix will create an environment where learning can occur with other members of the team, where team dynamics are recognized, where data is gathered and reviewed, and where decisions are made in a collaborative manner rather than in an environment characterized by embarrassment, blame and shame.
This new learning environment represents a shift in culture and acknowledges the resident as part of a system of care, in which he or she learns in and about the system of care. It also allows a common framework for evaluating and improving patient care across discipline.
It seamlessly integrates ACGME competencies as part of their routine clinical practice.
And most importantly it improves the quality of care we provide our patients
The residents will continue to present patient episodes in this framework and I encourage every member of the department to participate in the future and use this valuable tool for quality improvement

35. The End Erin Hurley, PGY 4 June 16, 2020
THANK YOU
The End
Erin Hurley, PGY 4
June 16, 2020

36. References
Institute of Medicine: Crossing the Quality Chasm. Washington D.C.: National Academy Press, 2001
Using a Healthcare Matrix to Assess Patient Care in Terms of Aims of Improvement and Core Competencies. Journal on Quality and Patient Safety, February 2005
Quinn D , The Healthcare Matrix: Improving Care by Linking Outcomes to Competencies. MedEdPORTAL; 2007.
Using the Healthcare Matrix to teach and improve patient safety culture in an OB/GYN residency training program Steven Rad, Connie Chung, Jessica Y. Hsu, Carolyn Alexander, and Dotun Ogunyemi. APGO 2010
Shine, K.: Crossing the quality chasm: The role of postgraduate training Am J Med113: 265–267, Aug. 15, 2002