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Unit Orientation and Expectations Admitting Clinical Practice
Continuous Quality Improvement: An Educational Tool for the Training of Medical Professionals
Review by Debra L. Bynum, MD
CQI and Medical Education: Background
Traditionally, medical education has revolved around a curriculum based upon content and examinations. Key curriculum components thus included the learning methods, educational strategies, and “aims and objectives.” The current focus has shifted to “outcome based education,” emphasizing the product rather than the process. The essential question becomes, “what kind of doctor is being produced?” “Competency” replaces “learning objective” – not just “what will the student learn”, but what will the doctor be able to do? What skills and capabilities will the doctor possess? [1, Harden 1999].
The ACGME at its 1999 meeting endorsed the following six competencies for residents in the areas of
1. Patient care
2. Medical knowledge
3. Practice-based learning and improvement
4. Interpersonal and communication skills
6. Systems-based practice
Two of these core competencies, practice- based learning and improvement (PBL) and systems based practice (SBP), have received special attention as areas that focus on a physician’s ability to utilize the processes of Continuous Quality Improvement (CQI) to improve care. Without the ability to reflect and analyze one’s own practice and to work within a larger system in order to improve the quality of care delivered at all levels, even the most knowledgeable and professional doctor will be of limited value.
ACGME : Competency in Practice-Based Learning and Improvement
“Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:
-analyze practice experience and perform practice-based improvement activities using a systemic methodology
-locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
-obtain and use information about their own population of patients and the larger population from which their patients are drawn
-apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
-use information technology to manage information, access on-line medical information; and support their own education
-facilitate the learning of students and other health care professionals”
ACGME: Competency in Systems-Based Practice
“Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
-understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
-know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
-practice cost-effective health care and resource allocation that does not compromise quality of care
-advocate for quality patient care and assist patients in dealing with system complexities
-know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance”
[2, ACGME Outcome Project 1999].
The Push for Quality Improvement
In short, the issue of Quality Improvement is a current reality in medical practice and education. Complicating this though are multiple forces, multiple agendas, and multiple perspectives. Patients, third-party payers, purchasers of health plans, administrators, and evaluators of health care systems are all actively interested in the “quality” of care provided. But multiple questions remain, including what is quality, who defines quality, how is quality measured, how is good quality compensated, is bad quality penalized, how is quality reported?
It is important to understand several of the major forces behind incorporating Quality Improvement into medical care and education. Below are some of the major players:
1. Institute of Medicine (IOM): a current main goal is to improve patient safety after releasing in 2001 a report, “Crossing the Quality Chasm.” Well known and often cited report, “To Err is Human – Building a Safer Health System,” states that over 90,000 deaths each year are due to preventable medical errors.
2. Center for Medicare and Medicaid Services (CMS): CMS has had an active role with the Department of Health and Human Services (HHS) to develop “quality indicators” with the goal of improving the quality of health care by requiring accountability and public disclosure. The other key is the goal of CMS to tie reimbursement to performance based upon these specific quality-of-care indicators.
3. Department of Health and Human Services (HHS): Quality Initiative program started in 2001.
a. Nursing Home Quality Initiative (NHQI) 2002
e. Physician Voluntary Reporting Program 2005
4. National Committee for Quality Assurance (NCQA): An independent, non-profit organization that essentially serves as the “watchdog” of managed care. The organization provides information about quality of managed care plans, and gives “accreditation” to those agencies that meet their standards. Their reviews of various Preferred Provider Organizations (PPOs) and HMOs provides data that is often used by employers and patients to make decisions about health plans. They manage a large data set, known as the Health Plan Employer and Data Set (HEDIS), that is being used to follow performance measures. The NCQA has been in support of the CMS efforts to tie reimbursement and quality.
5. ACGME: Incorporation of PBLI and SBP into core competencies (see above).
6. American Board of Internal Medicine (ABIM): The ABIM has now incorporated a Practice Performance Requirement and Practice Improvement Module (PIM) into the Maintenance of Certification Program (10-year recertification). “The short term goal for implementing this requirement in ABIM’s maintenance of Certification program is to introduce certified physicians to the competencies of Practice-Based Learning and Improvement and Systems Based Practice… The long term goal for the requirement is that physicians will be competent in improvement science and will have the information systems needed to meet the quality reporting requirements of patients, purchasers and payers.” Each Practice Assessment Pathway includes a Practice Improvement Module to be completed online, surveys of peers/patients/staff that must be completed (25 required), and a self-directed quality measurement and improvement project that usually consists of chart and patient reviews.
Several studies have demonstrated positive methods of teaching CQI techniques and processes to resident physicians. The best programs involve residents in the projects – just teaching about CQI does not work, residents need to have hands on experience with how to actually perform CQI [3, 4,5,6,7,8,9,10,11,12,13,14,15, 16]. Involving residents in active CQI projects is essential; without resident involvement, the likelihood of having significant impact with any hospital wide policy change is low [17, 14]
What is CQI and How Do We “Teach” it? A Primer on CQI Processes and Measurements:
Continuous Quality Improvement, as originally outlined and described by W. Edwards Deming and Joseph Juran, is basically a collection of principles and methods aimed at letting individuals improve the systems in which they work with a scientific approach of testing changes to demonstrate improvement .
Key Concepts of CQI:
Basic Method of CQI Process:
CQI: Terms and Definitions
4. Near Miss: as an occurrence of an error that did not result in harm.
5. Adverse Event: an injury resulting from a medical intervention.
6. Preventable Adverse Event: harm that could be avoided through reasonable planning or proper execution of an action.
(Taken from Pronovost, “Defining and measuring patient safety,” 19, and AHRQ and IOM definitions of terms).
Measuring Quality and Safety:
How can we measure patient safety?
[Adapted from Pronovost 2005, 19]
How to Use the Methods and Principles of CQI for the Education of Resident Physicians: Meeting the Core Competencies of Practice-Based Learning and Improvement and Systems-Based Practice
10. Suggest a Solution. Create a focused plan of intervention.
11. Implement the Solution. Advertise the change, get active participation from all involved.
CQI: How Effective Is It in Improving Care?
CQI has a strong foundation in the worlds of business and aviation safety, but is it effective at improving the quality of medical care? Despite the push for CQI in practice and education, it might be surprising to many that there is actually very little data to support that CQI interventions have a significant, lasting, consistent impact on patient care. What is the data?
Multiple studies and reviews have demonstrated that it is difficult to change physician behavior. Passive approaches with an emphasis upon provider feedback do not work to change physician behavior. A multi-faceted approach with provider feedback, reminders, compensation plans and guidelines are required to demonstrate any significant change in behavior, and the long lasting effect after these systems are gone is not known .
In addition, many changes in quality of care do not rely upon the physician alone but require the system to be effective. In a study by Halm in 2004, a multicenter intervention including treatment guidelines, critical pathways, education sessions, pocket reminders, standardized orders and patient education materials had essentially no significant impact on the overall care of patients with pneumonia. Despite an increased use of guideline recommendations, outcomes such as time to receive antibiotics rely upon much more than education [21, 22].
Even in large projects (that report success), such as the Cooperative Cardiovascular Project supported by Medicare/CMS, the sustained improvements in care are modest . In a 2004 review of Quality Improvement Programs and their impact after 2 years, there was essentially little to no consistent association between QI projects and quality of health plans [24, 25].
In summary, the effectiveness is not clear. There are multiple reasons why CQI initiatives in medicine are complicated and multiple unanswered questions:
So, why bother with CQI? Several main reasons include:
CQI: Beyond Meeting Core Competencies.
We have shifted our focus in medical education from the process of teaching to the outcome of the education. This emphasis on “Outcome Based Education” has led to the development of “competencies” – what should a competent physician be able to do? With multiple forces including the public, third-party payers, Medicare/Medicaid, hospital administration, the ABIM/ABFM, and mandate statements from the IOM, IHI, and NCQA emphasizing the need to improve the quality and safety of medical care delivered, core competencies for medical training now include practice- and system-based improvements. Much focus is now being made on how to “teach” CQI and how to incorporate these competencies and methods of CQI into the curriculum of resident education.
Upon further review, using the methods of quality improvement may have much more to offer than meeting core requirements. It may even have another outcome equal in improving the quality of patient care. It may serve as an educational tool in and of itself – utilizing the methods of quality improvement to teach core topics of internal medicine. Review of our individual practice and errors in addition to review of system-based problems can serve as a very powerful and lasting educational tool. The processes of quality improvement work well as a structure and foundation upon which to build upon, layering bricks of knowledge and core topics, creating a framework for the other core competencies to be taught. In a recent survey, physicians viewed as “high performing” in real practice reported several important keys to their ongoing education – namely a practice-based learning approach based upon questions that arose from specific cases and problems .
Future Directions: Will using the methods of CQI and structuring educational programs to meet the needs of instruction in Practice-Based Learning and Improvement and Systems-Based Practice serve as a useful educational tool? Will residents benefit with improved knowledge skills if taught core topics in such a format compared to the traditional method of didactic lectures? Will residents be more competent in other proficiencies such as professionalism and communication if they learn to work with an interdisciplinary team in identifying system based problems and means for improvement? Will overall patient care be improved by physicians who learn within a framework of identifying and creating opportunities for change and improvement? Ziegelstein and Fiebach summarized this process of education well by describing it as teaching the importance of “the mirror” and “the village” in learning how to care for patients – looking into the mirror to improve individual practice, and looking at the village to improve our systems of care . Will the “mirror” and the “village” serve as new frameworks for medical education, a truly outcomes-based educational directive aimed at creating physicians who are prepared to optimally provide quality care?
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This page last updated 9/12/2007.
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