1. CHAMP Teaching on Today’s Wards Session 4 – Systems Based Practice and Practice Based Learning and Improvement Chad Whelan, MD Julie Johnson, PhD Julie Johnson, PhD Paula Podrazik, MD

2. Learning Objectives Improve comfort and skills in teaching and evaluating PBLIImprove comfort and skills in teaching and evaluating PBLI –Demonstrate teaching and evaluation of this ACGME competency Develop strategies for teaching these PBLI in clinical settingsDevelop strategies for teaching these PBLI in clinical settings –Demonstrate case and census audits

3. Agenda 10:00 – 10:15Review Homework from Session 3 10:15 – 10:25Introduction to Case Audit 10:25 – 11:00Videos and Conversation 11:00 – 11:15Introduction to Census Audit 11:15 – 11:45Small group exercise – create a census audit tool 11:45 – 11:55Debriefing 11:55 – 12:00Final Comments and Take Home Points

4. Review from Session 3 Homework Review of the improvement area we selectedReview of the improvement area we selected –How would you assess the magnitude of the problem? –What data will you need?

5. Is there a way to bring this to the bedside? Case Audits and Census AuditsCase Audits and Census Audits –Teach about the clinical topic –Teach about PBLI –Collect data for improvement

6. Toolbox: Case Audit A structured review of clinical care across a single patient’s hospital stayA structured review of clinical care across a single patient’s hospital stay –Relevant Clinical Care Issue –Accepted Quality Measures Exist –Performed by the Team Caring for the Patient –Fits PBLI Construct

7. Why a Case Audit? Incorporates PBLI into formal teaching roundsIncorporates PBLI into formal teaching rounds Objectively review care of patient in high- risk situationsObjectively review care of patient in high- risk situations Develops skills in self-assessment and improvementDevelops skills in self-assessment and improvement Provides rich opportunities for in-depth teachingProvides rich opportunities for in-depth teaching

8. Case Audit: Picking the Topic Something You Care AboutSomething You Care About Something that is “Difficult” to TeachSomething that is “Difficult” to Teach High-Risk IssuesHigh-Risk Issues Explicit Quality Measures Exist that Chart Review Can DetermineExplicit Quality Measures Exist that Chart Review Can Determine ExamplesExamples –PCP Communication, Polypharmacy, Discharge Process

9. Case Audit VideoVideo –Part 1: Dr. Sims Pay attention to:Pay attention to: –Learning Climate –Control of Session –Communication of Goals –Promoting Understanding and Retention –Evaluation –Feedback –Promoting Self Directed Learning

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11. Discussion from Part 1, Dr. Sims What did you notice?What did you notice? –Learning Climate –Control of Session –Communication of Goals –Promoting Understanding and Retention –Evaluation –Feedback –Promoting Self Directed Learning

12. Case Audit: Operationalize it Formal Teaching Rounds (Hour long)Formal Teaching Rounds (Hour long) Choose your Patient Based on RiskChoose your Patient Based on Risk Explain Purpose ExplicitlyExplain Purpose Explicitly Assign RolesAssign Roles Save Time to Teach and DiscussSave Time to Teach and Discuss Discuss Plan for ImprovementDiscuss Plan for Improvement Label it as Practice Based LearningLabel it as Practice Based Learning

13. Case Audit: Keys to Success Create an Environment that:Create an Environment that: –Is Blame Free –Nurtures Self-reflection –Focuses on Self-improvement –Emphasizes Team Based not Individual Based Care –Encourages Systems Thinking

14. Case Audit VideoVideo –Part 1, Dr. Quinn Pay attention to:Pay attention to: –Learning Climate –Control of Session –Communication of Goals –Promoting Understanding and Retention –Evaluation –Feedback –Promoting Self Directed Learning

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16. Discussion from Part 1, Dr. Quinn What did you notice?What did you notice? –Learning Climate –Control of Session –Communication of Goals –Promoting Understanding and Retention –Evaluation –Feedback –Promoting Self Directed Learning What are barriers to conducting a case audit?What are barriers to conducting a case audit?

17. Case Audit Video Parts 2 and 3, Dr. QuinnVideo Parts 2 and 3, Dr. Quinn

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19. Discussion Comments?Comments? Other barriers?Other barriers?

20. Case Audit Take Home Points Incorporates PBLI into formal teaching roundsIncorporates PBLI into formal teaching rounds Objectively review care of patient in high- risk situationsObjectively review care of patient in high- risk situations Develops skills in self-assessment and improvementDevelops skills in self-assessment and improvement Provides rich opportunities for in-depth teachingProvides rich opportunities for in-depth teaching

21. Case Audit Limitations TimeTime –Preparation –Teaching Only looks at care of one patientOnly looks at care of one patient Difficult to assemble the entire teamDifficult to assemble the entire team Medical culture of blame and shameMedical culture of blame and shame

22. Toolbox: Census Audit A review of clinical care across patients A review of clinical care across patients –Focused Clinical Care Issue –Simple Quality Measures –Performed by the Team –Fits PBLI Construct

23. Why a Census Audit?  Simple method of using PBLI  Objectively review team’s clinical care across multiple patients  Develops skills in self-assessment and improvement  Easy to incorporate into work-flow  Can be used to create a teachable moment

24. Census Audit: Picking the Topic Something you care aboutSomething you care about Something that is “difficult” to teachSomething that is “difficult” to teach Common issueCommon issue High-risk problemHigh-risk problem Simple explicit quality measures existSimple explicit quality measures exist

25. Census Audit: Operationalize It Inform teamInform team Incorporate into work-roundsIncorporate into work-rounds Save time to discuss/teachSave time to discuss/teach Discuss plan for improvementDiscuss plan for improvement Consider re-auditConsider re-audit Label it as practice based learningLabel it as practice based learning

26. Census Audit: Keys to Success Create an Environment that:Create an Environment that: –Is blame free –Nurtures of self-reflection –Focuses on self-improvement –Emphasizes team based not individual based care –Encourages systems based thinking

27. Census Audit: Create the Tool Choose topic and quality measuresChoose topic and quality measures Keep it short and simpleKeep it short and simple Incorporate key problem areasIncorporate key problem areas Consider summary sectionConsider summary section Include a plan for improvementInclude a plan for improvement

28. CENSUS AUDIT: STRESS ULCER PROPHYLAXIS CENSUS AUDIT: STRESS ULCER PROPHYLAXIS Ulcer Prevention Agent (PPI, H2, Sulcrafate):YesNoUlcer Prevention Agent (PPI, H2, Sulcrafate):YesNo If Yes, then:Where was it started? _____________________If Yes, then:Where was it started? _____________________ If in hospital, was it for: TREATMENT PROPHYLAXISIf in hospital, was it for: TREATMENT PROPHYLAXIS If Prophylaxis, Indication?If Prophylaxis, Indication? Mechanical VentilationCoagulapathyMechanical VentilationCoagulapathy If None, then DCIf None, then DC If Yes, Plan for DC upon discharge?Yes NoIf Yes, Plan for DC upon discharge?Yes No Patient Safety Issues/Systems Issues?Patient Safety Issues/Systems Issues? SummarySummary Proportion of Patients with Stress Ulcer Prophylaxis (SUP) ________Proportion of Patients with Stress Ulcer Prophylaxis (SUP) ________ Proportion of Patients with SUP with appropriate indication _______Proportion of Patients with SUP with appropriate indication _______ Patient Safety Issues/Systems Issues ThemesPatient Safety Issues/Systems Issues Themes __________________________________________________________________________________________________________________________________________ Plan for Change: _______________________________________________________Plan for Change: _______________________________________________________ ____________________________________________________________________________________________________________________________________________ Plan to Re-Measure: __________________________________________________Plan to Re-Measure: __________________________________________________

29. Small Group Exercise Create a Census Audit ToolCreate a Census Audit Tool –Divide into three groups –Each group choose a different one of the improvement areas

30. Small Group Exercise #2 DebriefingDebriefing

31. Final Comments and Take Home Points By recognizing the triggers, we can teach systems based practice in real time clinical teachingBy recognizing the triggers, we can teach systems based practice in real time clinical teaching We can teach and practice an improvement method as a way to teach practice based learning and improvementWe can teach and practice an improvement method as a way to teach practice based learning and improvement It’s possible to make small scale improvements during a short time periodIt’s possible to make small scale improvements during a short time period