1. CHAMP Teaching on Today’s Wards Session 3 – Systems Based Practice and Practice Based Learning and Improvement Chad Whelan, MD Julie Johnson, PhD Paula Podrazik, MD

2. Learning Objectives Describe the importance of teaching systems based practice (SBP) and practice based learning and improvement (PBLI)Describe the importance of teaching systems based practice (SBP) and practice based learning and improvement (PBLI) Improve comfort and skills in teaching and evaluating SBP and PBLIImprove comfort and skills in teaching and evaluating SBP and PBLI –Define systems-based practice Demonstrate how solutions to problems affect the systemDemonstrate how solutions to problems affect the system –Define practice-based learning and improvement Demonstrate teaching and evaluation of this ACGME competencyDemonstrate teaching and evaluation of this ACGME competency

3. Learning Objectives Develop strategies for teaching these core competencies in clinical settingsDevelop strategies for teaching these core competencies in clinical settings –Practice identifying triggers for teaching systems based practice –Learn about one model for improvement –Choose an improvement topic

4. Agenda 10:00 – 10:25Introduction to systems based practice and practice based learning and improvement 10:25 – 10:50Small group exercise – identifying teaching triggers 10:50 – 11:00Debriefing 11:00 – 11:25Introduction to practice based learning and improvement and the PDSA Improvement Model 11:25 – 11:45Group exercise – Selecting a topic for improvement 11:45 – 11:55Debriefing 11:55 – 12:00Final Comments and Take Home Points

5. ACGME/ABMS Core Competencies Patient CarePatient Care Medical KnowledgeMedical Knowledge Interpersonal & Communication SkillsInterpersonal & Communication Skills ProfessionalismProfessionalism Practice-based Learning & Improvement Practice-based Learning & Improvement Systems-based Practice Systems-based Practice

6. What comes to mind when I say “system”? Name a system that you are part of now, or one you’ve been part of in the pastName a system that you are part of now, or one you’ve been part of in the past What word comes to mind when you think of that system?What word comes to mind when you think of that system?

7. System: A Definition A set of interacting, interrelated, or independent elements that work together in a particular environment to perform the functions that are required to achieve a specific aimA set of interacting, interrelated, or independent elements that work together in a particular environment to perform the functions that are required to achieve a specific aim Bertalanffy, 1968

8. ACGME Elements Systems-Based Practice Understand inter-relatedness of system componentsUnderstand inter-relatedness of system components Know how types of medical practice & delivery systems differ regarding costs & resource allocationKnow how types of medical practice & delivery systems differ regarding costs & resource allocation Practice cost-effective health carePractice cost-effective health care Advocate for quality patient careAdvocate for quality patient care Work with others to improve patient careWork with others to improve patient care

9. ACGME Elements Practice Based Learning and Improvement Analyze practice and perform improvement activitiesAnalyze practice and perform improvement activities Find and assimilate evidence related to patient needsFind and assimilate evidence related to patient needs Use information about own patients to design improvements for a population of patientsUse information about own patients to design improvements for a population of patients Use information technology to manage informationUse information technology to manage information Facilitate the learning of students and other health care professionalsFacilitate the learning of students and other health care professionals

10. How are SBP and PBLI different? Systems-based practiceSystems-based practice –Analytic tool, way of viewing the world that makes our care- giving and change efforts more successful –Focus is understanding the interdependencies of a system or series of systems –Changes can be made and measured on the system Practice-based learning and improvementPractice-based learning and improvement –Focus is on reflection and change at the level of the provider or group of providers and what they do in caring for their patients –Goal is measurement as an aid to learning about and improving practice –Some changes can be made by provider, others require system- level intervention

11. How are SBP and PBLI different? SBP is like a villageSBP is like a village –“A physician must work together with a community of providers to deliver optimal patient care” PBLI is like a mirrorPBLI is like a mirror –“Holding up a mirror to ourselves to document, assess, and improve our practice” Source: Ziegelstein & Fiebach, Acad. Med. 2004;79:83.

12. Sometimes it’s hard to separate the two How can I improve care for my patients or my team’s patients?How can I improve care for my patients or my team’s patients? –e.g., do a daily census audit of foley catheters to reduce the inappropriate use How can I improve the system?How can I improve the system? –e.g., build in a reminder so that all foley catheters are automatically discontinued after 2 days, unless specific criteria are met

13. We Can Focus on the System at Different Levels Community, Market, Social Policy System Macro- organization System Microsystem Individual care-giver & patient System Self-care System

14. Method of Teaching SBP and PBLI Needs to Address the Level of the Learner Dreyfus ModelDreyfus Model Method of teaching has to be relevant to the learner and grounded in the daily work of caring for patientsMethod of teaching has to be relevant to the learner and grounded in the daily work of caring for patients Novice Advanced Beginner CompetentProficientExpert

15. Recognizing the Opportunity to Teach

16. Systems-based Practice in Residency Training There are multiple opportunities to tease out the system issues and talk about them, once we recognize themThere are multiple opportunities to tease out the system issues and talk about them, once we recognize them This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be requiredThis can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required –Organizational support –Feedback on what is being done to address the issues Faculty are looking for methods, teaching tools, etc. to make this easierFaculty are looking for methods, teaching tools, etc. to make this easier

17. How Can We Identify Opportunities for Teaching SBP? What are the triggers for teaching?What are the triggers for teaching? –Topics –Transitions –Failures Where do the triggers occur?Where do the triggers occur? –Everywhere!!!

18. Triggers for Teaching about Systems LocationTopicTransitionFailures

19. Example Imagine this scenarioImagine this scenario –Your team is post call, in conference room getting a run-down on patients: –67 year-old male with chronic renal insufficiency secondary to poorly controlled hypertension admitted to initiate dialysis and to get placed with a dialysis center

20. Triggers for Teaching about Systems LocationTopicTransitionFailures Conference Room Process of initiating dialysis Cost, burden of uncontrolled hypertension Cost, burden of hypertension

21. Patient With ESRD (cont.) Bedside Presentation:Bedside Presentation: –Patient is admitted from ER for initiation of dialysis –Although he has known he will need dialysis soon (he already has access), he did not always show up for his renal clinic appointments –His blood pressure has been poorly controlled and he does not always take his medications –His social history is notable for his current IVDA. His nephrologist was surprised at how quickly he progressed over the past 6 months to the point where he requires dialysis, although not emergently –The patient was essentially admitted electively to facilitate initiation of dialysis

22. Triggers for Teaching for Systems LocationTopicTransitionFailures Conference Room Cost, burden of uncontrolled hypertension Bedside Cost, burden of drug rehab Compliance, patient preference in initiating dialysis Process of initiating dialysis Admission process through ER as a “workaround” to getting a dialysis chair Cost, burden of hypertension

23. Patient with ESRD (cont.) Post-Bedside Discussion:Post-Bedside Discussion: –You agree with the team that there were no urgent indications for dialysis –Your team tells you that his nephrologist had a difficult time getting the patient a chair as an outpatient as he is poorly compliant and uses IV drugs –The nephrologist told the patient it would be easier to go to the ER to get admitted to start dialysis, –At this point your team is obviously frustrated by the events that got this patient admitted through the ER to an acute hospital bed for something that medically could have been done as an outpatient

24. Triggers for Teaching for Systems LocationTopicTransitionFailures Conference Room Bedside Post-bedside Cost, burden of drug rehab Contra- indications for dialysis PCP communication Compliance, patient preference in initiating dialysis Process of initiating dialysis Cost, burden of uncontrolled hypertension Admission process through ER as a “workaround” to getting a dialysis chair Cost, burden of dialysis Cost, burden of hypertension

25. Small Group Exercise #1 What are the triggers for teaching about systems based practice in the case?What are the triggers for teaching about systems based practice in the case? –Work in small groups –Complete the Triggers for Teaching Matrix

26. Small Group Exercise #1 DebriefingDebriefing See handout on teaching systems based practiceSee handout on teaching systems based practice

27. Take Home Points Systems issues are prevalentSystems issues are prevalent We tend to create elaborate processes to “work around” the most problematic system issuesWe tend to create elaborate processes to “work around” the most problematic system issues There are multiple opportunities to tease out the system issues and talk about them, once we recognize themThere are multiple opportunities to tease out the system issues and talk about them, once we recognize them

28. Take Home Points This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be requiredThis can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required Faculty are looking for methods, teaching tools, etc. to make this easierFaculty are looking for methods, teaching tools, etc. to make this easier Observation is important -- what are the system issues you have seen?Observation is important -- what are the system issues you have seen?

29. Practice Based Learning and Improvement A more indepth look...A more indepth look...

30. What Do We Need to Improve Care? Improvement Knowledge Professional Knowledge Subject Discipline Values System Variation Psychology Theory of Knowledge Traditional Improvement of Health Care Continual Improvement of Health Care +

31. If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead give them a tool, the use of which will lead to new ways of thinking - Buckminster Fuller

32. Plan, Do, Study, Act Cycle A Model for Improvement The plan, do, study, act or PDSA cycle links ideas to action and then makes the connection to continuous learningThe plan, do, study, act or PDSA cycle links ideas to action and then makes the connection to continuous learning –It can be done at the individual level (e.g., changes you want to make to your teaching process) –It can be done at the team level (e.g., small improvement pilots that you can guide your team through in a 2-4 week timeframe)

33. Plan, Do, Study, Act Cycle A Model for Improvement The PDSA cycle provides framework for efficient trial-and-error learning methodologyThe PDSA cycle provides framework for efficient trial-and-error learning methodology –Small changes can have a big impact (thing about the effect on the system) –Choose carefully –Pilot test

34. Plan, Do, Study, Act Cycle A Model for Improvement Aim,who, what, when & data collection plan Execute, collect & analyze data, note unexpecteds Analyze, compare to prediction, ID lessons learned Plan DoStudy Act What changes to make, spread, & next cycle

35. Plan, Do, Study, Act Cycle A Model for Improvement PlanPlan –Describe objective and specific change –Specify where it fits into the process flow –Who, does what, when, with what tools and training –Data collection plan: who measures what and displays how and where DoDo –Carry out the change

36. Plan, Do, Study, Act Cycle A Model for Improvement StudyStudy –Make sure that you leave time for reflection about your test –Use the data and the experience of those carrying out the test to –Discuss what happened –Did you get the results you expected? If not, why not? –Did anything unexpected happen during the test?

37. Plan, Do, Study, Act Cycle A Model for Improvement ActAct –Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?

38. PDSA Worksheet This worksheet for tracking PDSA cycles that has been developed by the Institute for Healthcare Improvement (IHI)This worksheet for tracking PDSA cycles that has been developed by the Institute for Healthcare Improvement (IHI) See handoutSee handout

40. Group Exercise Selecting a topic for improvementSelecting a topic for improvement –The work before the work...

41. Draft an initial list of priority improvements Consider these questions:Consider these questions: The clinical areas that really need to be improved are __________________________The clinical areas that really need to be improved are __________________________ The reason things don’t work right around here is _________________________The reason things don’t work right around here is _________________________ There’s one thing that we do all the time that accomplishes very little and that’s _______________There’s one thing that we do all the time that accomplishes very little and that’s _______________ –How would different people answer those questions? (e.g., nurses, physicians, patients/family, pharmacists, secretaries, etc.)

42. Draft an initial list of priority improvements (cont.) Prioritize your listPrioritize your list –in order of descending achievable benefit not yet achieved (ABNA) (1=highest ABNA) –least cost to change (1=least costly) –shortest time to get started (1=can get started with a small test next week) –greatest importance to inpatient medicine wards (1=most important)

43. Finally, consider the “ramp of complexity” Time Complexity P D C A P D C A P D C A

44. Based on the exercise, what are the priorities? Improvement Priorities:Improvement Priorities: – – – – – – –

45. Homework Think about the topic(s) identifiedThink about the topic(s) identified –How would you assess the magnitude of the problem? –What data will you need?