CHAMP Teaching on Today's Wards

CHAMPCHAMPTeaching on Today’s WardsTeaching on Today’s WardsSession 3 – Systems Based Practice Session 3 – Systems Based Practice and and Practice Based Learning and Practice Based Learning and ImprovementImprovement

Chad Whelan, MDChad Whelan, MD

Julie Johnson, PhDJulie Johnson, PhD

Paula Podrazik, MDPaula Podrazik, MD

Learning ObjectivesLearning Objectives

• Describe the importance of teaching Describe the importance of teaching systems based practice (SBP) and practice systems based practice (SBP) and practice based learning and improvement (PBLI)based learning and improvement (PBLI)

• Improve comfort and skills in teaching and Improve comfort and skills in teaching and evaluating SBP and PBLIevaluating SBP and PBLI– Define Define systems-based practicesystems-based practice

• Demonstrate how solutions to problems affect the Demonstrate how solutions to problems affect the systemsystem

– Define Define practice-based learning and practice-based learning and improvement improvement • Demonstrate teaching and evaluation of this ACGME Demonstrate teaching and evaluation of this ACGME

competencycompetency

Learning ObjectivesLearning Objectives

• Develop strategies for teaching these Develop strategies for teaching these core competencies in clinical settingscore competencies in clinical settings– Practice identifying triggers for teaching Practice identifying triggers for teaching

systems based practice systems based practice – Learn about one model for improvementLearn about one model for improvement– Choose an improvement topic Choose an improvement topic

AgendaAgenda

10:00 – 10:2510:00 – 10:25 Introduction to systems based practice and Introduction to systems based practice and practice based learning and improvementpractice based learning and improvement

10:25 – 10:5010:25 – 10:50 Small group exercise – identifying teaching Small group exercise – identifying teaching triggerstriggers

10:50 – 11:0010:50 – 11:00 DebriefingDebriefing

11:00 – 11:2511:00 – 11:25 Introduction to practice based learning and Introduction to practice based learning and improvement and the PDSA Improvement improvement and the PDSA Improvement ModelModel

11:25 – 11:4511:25 – 11:45 Group exercise – Selecting a topic for Group exercise – Selecting a topic for improvementimprovement

11:45 – 11:5511:45 – 11:55 DebriefingDebriefing

11:55 – 12:0011:55 – 12:00 Final Comments and Take Home Points Final Comments and Take Home Points

ACGME/ABMS Core ACGME/ABMS Core CompetenciesCompetencies

• Patient CarePatient Care• Medical KnowledgeMedical Knowledge• Interpersonal & Communication SkillsInterpersonal & Communication Skills• ProfessionalismProfessionalism• Practice-based Learning & Practice-based Learning &

ImprovementImprovement• Systems-based PracticeSystems-based Practice

What comes to mind What comes to mind when I say “system”? when I say “system”?

• Name a system that you are part of Name a system that you are part of now, or one you’ve been part of in now, or one you’ve been part of in the pastthe past

• What word comes to mind when you What word comes to mind when you think of that system?think of that system?

System: A DefinitionSystem: A Definition

• A set of interacting, interrelated, or A set of interacting, interrelated, or independent elements that work independent elements that work together in a particular environment together in a particular environment to perform the functions that are to perform the functions that are required to achieve a specific aimrequired to achieve a specific aim

Bertalanffy, 1968

ACGME ElementsACGME Elements Systems-Based PracticeSystems-Based Practice

• Understand inter-relatedness of Understand inter-relatedness of system componentssystem components

• Know how types of medical practice & Know how types of medical practice & delivery systems differ regarding costs delivery systems differ regarding costs & resource allocation& resource allocation

• Practice cost-effective health care Practice cost-effective health care • Advocate for quality patient care Advocate for quality patient care • Work with others to improve patient Work with others to improve patient

care care

ACGME ElementsACGME Elements Practice Based Learning and Practice Based Learning and ImprovementImprovement

• Analyze practice and perform Analyze practice and perform improvement activitiesimprovement activities

• Find and assimilate evidence related to Find and assimilate evidence related to patient needspatient needs

• Use information about own patients to Use information about own patients to design improvements for a population of design improvements for a population of patientspatients

• Use information technology to manage Use information technology to manage informationinformation

• Facilitate the learning of students and Facilitate the learning of students and other health care professionalsother health care professionals

How are SBP and PBLI different?How are SBP and PBLI different?

• Systems-based practiceSystems-based practice– Analytic tool, way of viewing the world that makes our Analytic tool, way of viewing the world that makes our

care-giving and change efforts more successfulcare-giving and change efforts more successful– Focus is understanding the interdependencies of a Focus is understanding the interdependencies of a

system or series of systemssystem or series of systems– Changes can be made and measured on the systemChanges 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 Focus is on reflection and change at the level of the

provider or group of providers and what they do in provider or group of providers and what they do in caring for their patientscaring for their patients

– Goal is measurement as an aid to learning about and Goal is measurement as an aid to learning about and improving practiceimproving practice

– Some changes can be made by provider, others require Some changes can be made by provider, others require system-level interventionsystem-level intervention

How are SBP and PBLI different?How are SBP and PBLI different?

• SBP is like a villageSBP is like a village– ““A physician must work together with a A physician must work together with a

community of providers to deliver community of providers to deliver optimal patient care”optimal patient care”

• PBLI is like a mirrorPBLI is like a mirror– ““Holding up a mirror to ourselves to Holding up a mirror to ourselves to

document, assess, and improve our document, assess, and improve our practice”practice”

Source: Ziegelstein & Fiebach, Acad. Med. 2004;79:83.

Sometimes it’s hard to separate Sometimes it’s hard to separate the twothe two

• How can I improve care for my How can I improve care for my patients or my team’s patients?patients or my team’s patients?– e.g., do a daily census audit of foley e.g., do a daily census audit of foley

catheters to reduce the inappropriate usecatheters 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 e.g., build in a reminder so that all foley

catheters are automatically discontinued catheters are automatically discontinued after 2 days, unless specific criteria are after 2 days, unless specific criteria are metmet

We Can Focus on the We Can Focus on the System at Different System at Different LevelsLevels

Community, Market, Social Policy System

Macro-organization

System

Microsystem

Individual care-giver &

patient System

Self-care System

Method of Teaching SBP and PBLI Method of Teaching SBP and PBLI Needs to Address the Level of the Needs to Address the Level of the LearnerLearner

• Dreyfus ModelDreyfus Model

• Method of teaching has to be relevant Method of teaching has to be relevant to the learner and grounded in the to the learner and grounded in the daily work of caring for patientsdaily work of caring for patients

NoviceAdvance

d Beginner

Competent

Proficient

Expert

Recognizing the Opportunity to Recognizing the Opportunity to TeachTeach

Systems-based Practice in Systems-based Practice in Residency TrainingResidency Training

• There are multiple opportunities to tease There are multiple opportunities to tease out the system issues and talk about out the system issues and talk about them, once we recognize themthem, once we recognize them

• This can be a Pandora’s Box – we need to This can be a Pandora’s Box – we need to assure that the organization can support assure that the organization can support the improvement work that will be the improvement work that will be requiredrequired– Organizational supportOrganizational support– Feedback on what is being done to address the Feedback on what is being done to address the

issuesissues• Faculty are looking for methods, teaching Faculty are looking for methods, teaching

tools, etc. to make this easiertools, etc. to make this easier

How Can We Identify How Can We Identify Opportunities for Teaching SBP?Opportunities for Teaching SBP?

• What are the triggers for teaching?What are the triggers for teaching?– TopicsTopics– TransitionsTransitions– FailuresFailures

• Where do the triggers occur?Where do the triggers occur?– Everywhere!!!Everywhere!!!

Triggers for Teaching about Triggers for Teaching about SystemsSystems

LocationLocation TopicTopic TransitionTransition FailuresFailures

ExampleExample

• Imagine this scenarioImagine this scenario– Your team is post call, in conference Your team is post call, in conference

room getting a run-down on patients:room getting a run-down on patients:– 67 year-old male with chronic renal 67 year-old male with chronic renal

insufficiency secondary to poorly insufficiency secondary to poorly controlled hypertension admitted to controlled hypertension admitted to initiate dialysis and to get placed with a initiate dialysis and to get placed with a dialysis centerdialysis center

Triggers for Teaching about Triggers for Teaching about SystemsSystems


Conference Conference RoomRoom

Process of initiating dialysis

Cost, burden of uncontrolled hypertension

Cost, burden of hypertension

Patient With ESRD (cont.)Patient With ESRD (cont.)

• Bedside Presentation:Bedside Presentation:– Patient is admitted from ER for initiation of Patient is admitted from ER for initiation of

dialysisdialysis– Although he has known he will need dialysis soon Although he has known he will need dialysis soon

(he already has access), he did not always show (he already has access), he did not always show up for his renal clinic appointmentsup for his renal clinic appointments

– His blood pressure has been poorly controlled His blood pressure has been poorly controlled and he does not always take his medicationsand he does not always take his medications

– His social history is notable for his current IVDA. His social history is notable for his current IVDA. His nephrologist was surprised at how quickly he His nephrologist was surprised at how quickly he progressed over the past 6 months to the point progressed over the past 6 months to the point where he requires dialysis, although not where he requires dialysis, although not emergentlyemergently

– The patient was essentially admitted electively to The patient was essentially admitted electively to facilitate initiation of dialysisfacilitate initiation of dialysis

Triggers for Teaching for SystemsTriggers for Teaching for Systems



Cost, burden of Cost, burden of uncontrolled uncontrolled hypertensionhypertension

BedsideBedside Cost, burden of drug rehab

Compliance, patient preference in initiating dialysis


Admission process through ER as a “workaround” to getting a dialysis chair


Patient with ESRD (cont.)Patient with ESRD (cont.)

• Post-Bedside Discussion: Post-Bedside Discussion: – You agree with the team that there were no urgent You agree with the team that there were no urgent

indications for dialysisindications for dialysis– Your team tells you that his nephrologist had a Your team tells you that his nephrologist had a

difficult time getting the patient a chair as an difficult time getting the patient a chair as an outpatient as he is poorly compliant and uses IV outpatient as he is poorly compliant and uses IV drugsdrugs

– The nephrologist told the patient it would be easier The nephrologist told the patient it would be easier to go to the ER to get admitted to start dialysis, to go to the ER to get admitted to start dialysis,

– At this point your team is obviously frustrated by At this point your team is obviously frustrated by the events that got this patient admitted through the events that got this patient admitted through the ER to an acute hospital bed for something that the ER to an acute hospital bed for something that medically could have been done as an outpatientmedically could have been done as an outpatient

Triggers for Teaching for SystemsTriggers for Teaching for Systems



BedsideBedside

Post-Post-bedsidebedside

Cost, burden of drug rehab

Contra-indications for dialysis

PCP communication

Compliance, patient preference in initiating dialysis


Cost, burden of uncontrolled hypertension

Admission process through ER as a “workaround” to getting a dialysis chair

Cost, burden of dialysis


Small Group Exercise #1Small Group Exercise #1

• What are the triggers for teaching What are the triggers for teaching about systems based practice in the about systems based practice in the case? case? – Work in small groupsWork in small groups– Complete the Triggers for Teaching Complete the Triggers for Teaching

MatrixMatrix

Small Group Exercise #1Small Group Exercise #1

• DebriefingDebriefing

• See handout on teaching systems See handout on teaching systems based practice based practice

Take Home PointsTake Home Points

• Systems issues are prevalentSystems issues are prevalent• We tend to create elaborate We tend to create elaborate

processes to “work around” the most processes to “work around” the most problematic system issuesproblematic system issues

• There are multiple opportunities to There are multiple opportunities to tease out the system issues and talk tease out the system issues and talk about them, once we recognize themabout them, once we recognize them

Take Home PointsTake Home Points

• This can be a Pandora’s Box – we This can be a Pandora’s Box – we need to assure that the organization need to assure that the organization can support the improvement work can support the improvement work that will be requiredthat will be required

• Faculty are looking for methods, Faculty are looking for methods, teaching tools, etc. to make this teaching tools, etc. to make this easiereasier

• Observation is important -- what are Observation is important -- what are the system issues you have seen?the system issues you have seen?

Practice Based Learning and Practice Based Learning and ImprovementImprovement

• A more indepth look . . .A more indepth look . . .

What Do We Need to Improve Care?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

+

If you want to teach people a If you want to teach people a new way of thinking, don’t new way of thinking, don’t

bother trying to teach them. bother trying to teach them. Instead give them a tool, Instead give them a tool,

the use of which will lead to new the use of which will lead to new ways of thinkingways of thinking

- - Buckminster FullerBuckminster Fuller

Plan, Do, Study, Act CyclePlan, Do, Study, Act CycleA Model for ImprovementA Model for Improvement

• The plan, do, study, act or PDSA cycle links The plan, do, study, act or PDSA cycle links ideas to action and then makes the ideas to action and then makes the connection to continuous learningconnection to continuous learning– It can be done at the individual level (e.g., It can be done at the individual level (e.g.,

changes you want to make to your teaching changes you want to make to your teaching process)process)

– It can be done at the team level (e.g., small It can be done at the team level (e.g., small improvement pilots that you can guide your improvement pilots that you can guide your team through in a 2-4 week timeframe)team through in a 2-4 week timeframe)


• The PDSA cycle provides framework The PDSA cycle provides framework for efficient trial-and-error learning for efficient trial-and-error learning methodologymethodology– Small changes can have a big impact Small changes can have a big impact

(thing about the effect on the system)(thing about the effect on the system)– Choose carefullyChoose carefully– Pilot test Pilot test


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


• PlanPlan– Describe objective and specific changeDescribe objective and specific change– Specify where it fits into the process flowSpecify where it fits into the process flow– Who, does what, when, with what tools and Who, does what, when, with what tools and

trainingtraining– Data collection plan: who measures what and Data collection plan: who measures what and

displays how and wheredisplays how and where

• DoDo– Carry out the changeCarry out the change


• StudyStudy– Make sure that you leave time for reflection Make sure that you leave time for reflection

about your testabout your test– Use the data and the experience of those Use the data and the experience of those

carrying out the test tocarrying out the test to– Discuss what happenedDiscuss what happened– Did you get the results you expected? If not, Did you get the results you expected? If not,

why not?why not?– Did anything unexpected happen during the Did anything unexpected happen during the

test?test?


• ActAct– Given what you learned during the test, Given what you learned during the test,

what will your next test be? Will you what will your next test be? Will you make refinements to the change? make refinements to the change? Abandon it? Keep the change and try it Abandon it? Keep the change and try it on a larger scale?on a larger scale?

PDSA WorksheetPDSA Worksheet

• This worksheet for tracking PDSA This worksheet for tracking PDSA cycles that has been developed by cycles that has been developed by the Institute for Healthcare the Institute for Healthcare Improvement (IHI)Improvement (IHI)

• See handoutSee handout

Group ExerciseGroup Exercise

• Selecting a topic for improvementSelecting a topic for improvement– The work before the work . . .The work before the work . . .

Draft an initial list of priority Draft an initial list of priority improvementsimprovements

• Consider these questions:Consider these questions:• The clinical areas that really need The clinical areas that really need

to be improved are __________________________to be improved are __________________________• The reason things don’t work The reason things don’t work

right around here is _________________________right around here is _________________________• There’s one thing that we do all the time that There’s one thing that we do all the time that

accomplishes very little and that’s _______________accomplishes very little and that’s _______________

– How would different people answer those How would different people answer those questions? (e.g., nurses, physicians, questions? (e.g., nurses, physicians, patients/family, pharmacists, secretaries, etc.)patients/family, pharmacists, secretaries, etc.)

Draft an initial list of priority Draft an initial list of priority improvements (cont.)improvements (cont.)

• Prioritize your listPrioritize your list– in order of descending achievable in order of descending achievable

benefit not yet achieved (ABNA) benefit not yet achieved (ABNA) (1=highest ABNA)(1=highest ABNA)

– least cost to change (1=least costly)least cost to change (1=least costly)– shortest time to get started (1=can get shortest time to get started (1=can get

started with a small test next week)started with a small test next week)– greatest importance to inpatient greatest importance to inpatient

medicine wards (1=most important)medicine wards (1=most important)

Finally, consider the Finally, consider the “ramp of complexity”“ramp of complexity”

Time

Complexity

P

D

C

A

P

D

C

A

P

D

C

A

Based on the exercise, what Based on the exercise, what are the priorities?are the priorities?

• Improvement Priorities:Improvement Priorities:– – – – – – –

HomeworkHomework

• Think about the topic(s) identifiedThink about the topic(s) identified– How would you assess the magnitude of How would you assess the magnitude of

the problem?the problem?– What data will you need?What data will you need?

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