1.  2006 Vanderbilt University Medical Center Linking Outcomes of Care and the ACGME Core Competencies: A Matrix Solution John Bingham, MHA Director Center for Clinical Improvement Competencies Working Group January 5, 2007 Doris Quinn, PhD Assistant Professor Division of Medical Education

2.  2006 Vanderbilt University Medical Center 2 Objectives for today: 1.Review the link between: Outcomes of Care (IOM Aims for Improvement) The ACGME Core Competencies 2.Demonstrate how the Healthcare Matrix is used to improve the delivery of care and education

3.  2006 Vanderbilt University Medical Center 3 1999200120022003 Emerging public reporting and awareness of quality measures Drivers of Change in Healthcare:

4.  2006 Vanderbilt University Medical Center 4 Patient Care should be: Safe, Timely, Effective, Efficient, Equitable, Patient-Centered (STEEEP)

5.  2006 Vanderbilt University Medical Center 5 Phase IPhase IIPhase IIIPhase IV 7/20016/20027/20027/20116/20067/20066/2011Beyond Improve the evaluation processes for all six of the Competencies. Provide aggregated resident performance data for Internal Review Process. Use resident performance data as the basis for improvement. Begin to use external quality measures to verify resident and program performance levels. Identify benchmark programs. Involve community in building knowledge about good GME. Define specific objectives for residents to demonstrate learning of the competencies. Begin integrating the teaching and learning of competencies into residents’ didactic and clinical experiences.

6.  2006 Vanderbilt University Medical Center 6 Public Reporting of Quality CMS Quality Measures (CMS Compare) Accreditation Bodies (JCAHO) Statewide Organizations (QIOs) Business Coalitions (Leapfrog) Employers (Annual Enrollment Process) Commercial Health Care Scorecards –(www.healthgrades.com)

7.  2006 Vanderbilt University Medical Center 7 The future…. in a few words: Transparency Process Reliability

8.  2006 Vanderbilt University Medical Center 8 So…what should we do? 1.Define the measures that matter 2.Measure our performance 3.Utilize the results of measurements to improve: The education of residents and allied professionals The quality of care that we provide Patients with Needs Patients with Needs Met AccessDiagnosisTreatmentFollow-upAssessment

9.  2006 Vanderbilt University Medical Center 9 Patient Care should be: Safe, Timely, Effective, Efficient, Equitable, Patient-Centered (STEEEP)

10.  2006 Vanderbilt University Medical Center 10 PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with…. © 2004 Bingham, Quinn Vanderbilt University

11.  2006 Vanderbilt University Medical Center 11 “Avoiding injuries to patients from the care that is intended to help them” PATIENT CARE that is…Safe

12.  2006 Vanderbilt University Medical Center 12 Percent of Surgeries with appropriate “timeout” Prophylactic Antibiotics for all surgeries Use of Central-line Bundle Use of Ventilator Acquired Pneumonia Bundle Glycemic Control Hand Hygiene Leapfrog’s 30 Safe Practices PATIENT CARE that is…Safe

13.  2006 Vanderbilt University Medical Center 13 “Reducing waits and sometimes harmful delays for both those who receive and those who give care” PATIENT CARE that is…TimelySafe

14.  2006 Vanderbilt University Medical Center 14 “Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit” PATIENT CARE that is…TimelyEffectiveSafe

15.  2006 Vanderbilt University Medical Center 15 “Avoiding waste, including waste of equipment, supplies, ideas, and energy” PATIENT CARE that is…TimelyEfficientEffectiveSafe

16.  2006 Vanderbilt University Medical Center 16 “Providing care that does not vary in quality because of personal characteristics such as: gender, ethnicity, geographic location, and socio-economic status” PATIENT CARE that is…TimelyEfficientEffectiveEquitableSafe

17.  2006 Vanderbilt University Medical Center 17 “Providing care that is respectful of, and responsive to: individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” PATIENT CARE that is… TimelyEfficientEffectiveEquitablePatient CenteredSafe

18.  2006 Vanderbilt University Medical Center 18 “…about established and evolving biomedical, clinical, and cognate sciences, (e.g. epidemiological and social-behavior) and the application of this knowledge to patient care” Medical Knowledge PATIENT CARE that is… TimelyEfficientEffectiveEquitablePatient CenteredSafe What must we know?

19.  2006 Vanderbilt University Medical Center 19 Medical Knowledge Interpersonal and Communication Skills PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe “…that result in effective information exchange and teaming with patients, their families, and other health professionals.” What must we say?

20.  2006 Vanderbilt University Medical Center 20 “…as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” Medical Knowledge Interpersonal and Communication Skills Professionalism PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe How must we behave?

21.  2006 Vanderbilt University Medical Center 21 “…as manifested by actions that demonstrate an awareness of, and responsiveness to, a larger context and system of healthcare and the ability to effectively call on system resources to provide care that is of optimal value.” Medical Knowledge Interpersonal and Communication Skills Professionalism System-Based Practice PATIENT CARETimelyEfficientEffectiveEquitablePatient CenteredSafe What is the Process? On whom do we depend? Who depends on us?

22.  2006 Vanderbilt University Medical Center 22 “…involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.” Medical Knowledge Interpersonal and Communication Skills Professionalism System-Based Practice Practice-Based Learning & Improvement PATIENT CARE TimelyEfficientEffectiveEquitablePatient CenteredSafe What have we learned? What will we improve?

23.  2006 Vanderbilt University Medical Center 23 Patients with Needs Patients with Needs Met AccessDiagnosisTreatmentFollow-upAssessment Linking it all together…. -Medical Knowledge -Interpersonal and Communication Skills -Professionalism -Practice-Based Learning & Improvement TimelyEfficientEffectiveEquitablePatient CenteredSafe -System-Based Practice Clinicians competent in: Patient Care that is…

24.  2006 Vanderbilt University Medical Center 24 PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with…. © 2004 Bingham, Quinn Vanderbilt University

25.  2006 Vanderbilt University Medical Center 25 Applications of the Matrix I.Individual Resident Learning II.Case Presentations III.M & M Conference IV.Linking to External Quality Metrics V.Curriculum Framework VI.Medical Students

26.  2006 Vanderbilt University Medical Center 26  History  Physical Exam  Labs  Tests  Consults  Etc. Diagnosis Care of Patient (Matrix) Using the Matrix

27.  2006 Vanderbilt University Medical Center 27 IOM ACGME SAFETYTIMELINESS EFFECTIVE- NESS EFFICIENCY EQUITA- BILITY PATIENT CENTERED- NESS PATIENT CARE MEDICAL KNOWLEDGE & APPLICATION X X PROFESSIONALISM INTERPERSONAL & COMMUNICATION SKILLS SYSTEMS- & TEAMS-BASED PRACTICE X PRACTICE-BASED LEARNING & IMPROVEMENT (Process to Improve) Anesthesia: One resident’s learning A resident prepared for a case presentation and addressed the following cells. No

28.  2006 Vanderbilt University Medical Center 28 IOM ACGME SAFETY TIMELINESS EFFECTIVE- NESS EFFICIENCY EQUITA- BILITY PATIENT CENTERED- NESS PATIENT CARE MEDICAL KNOWLEDGE X X X X PROFESSIONALISM XX XX INTERPERSONAL & COMMUNICATION SKILLS X X XX X SYSTEMS- & TEAMS-BASED PRACTICE X XXXX PRACTICE-BASED LEARNING & IMPROVEMENT (Process to Improve) P and P changed for Mom/Child in trouble Changed STAT pages to Anes. From OB Class on care of Mom with DIC Procedure outlined for fastest prep for OR Assure Mom aware of what is happening. Communication with father.. After a dialogue with faculty and using the Matrix, she then addressed all of the following cells in her presentation. The presentation resulted in the improvements outlined below.

29.  2006 Vanderbilt University Medical Center 29 Simple Matrix Not all cells need to be filled in, but it’s important to address those cells pertinent to the case. One or more cells may be critical or significant to the case (hot cells).

30.  2006 Vanderbilt University Medical Center 30

31.  2006 Vanderbilt University Medical Center 31 Usual Morbidity and Mortality Conferences

32.  2006 Vanderbilt University Medical Center 32 Major focus on Medical Knowledge

33.  2006 Vanderbilt University Medical Center 33 With All Competencies Reviewed

34.  2006 Vanderbilt University Medical Center 34

35.  2006 Vanderbilt University Medical Center 35 Analyzing Data from Multiple Matrices

36.  2006 Vanderbilt University Medical Center 36

37.  2006 Vanderbilt University Medical Center 37 PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with…. © 2004 Bingham, Quinn Vanderbilt University

38.  2006 Vanderbilt University Medical Center 38 Key Safety Issues Identified for VUMC COMMUNICATION TEAMWORK (especially relationship between specialties) WORKAROUNDS (time stealer) DOCUMENTATION Unnecessary Variation Complexity of patients and limited clinic time Updated medication and problem lists critical for optimal care Getting lab values quickly and alerts for abnormal ones Interpreters for growing number of non-English speaking patients (system not based on solely on people)

39.  2006 Vanderbilt University Medical Center 39 Closing the Patient Care Loop Start with diagnosis as basis for assessment Identify issues of care related to Aims and Competencies Identify lessons learned and improvement needed Complete action plan for improvements with accountabilities and timeline

40.  2006 Vanderbilt University Medical Center 40

41.  2006 Vanderbilt University Medical Center 41

42.  2006 Vanderbilt University Medical Center 42 © 2004 Bingham, Quinn Vanderbilt University PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with Stroke An Oracle Database is being built that will collect data from each cell and allow analysis and reports to be generated by: Institution Department Diagnosis IOM Aim Competency

43.  2006 Vanderbilt University Medical Center 43