Institutionalizing Quality Improvement in a Family Medicine Residency

Fred Tudiver, MDEast Tennessee State University

BACKGROUND

• ACGME competencies include quality improvement methods

• Current QI residency training:– Seminars, lectures, and/or group activities– Most do not use validated measures

• Systematic review of assessing QI teaching– Few if any validated measures– QIKAT; knowledge; commitment to change; audits

PCMH: Quality Measures

• Traditional non-PCMH model:– No systematic documentation for chronic disease

• Low Tech PCMH– Paper-based QI monitoring with flow charts of

disease outcomes; feedback to provider & patient

• High Tech PCMH– Automated QI monitoring with electronic

feedback of disease outcomes; feedback to provider & patient

PURPOSE

• Incorporate QI learning experiences into residents’ training

• Provide a standardized and reproducible QI curriculum during residency

• Develop and use validated measures for assessing QI training effectiveness

SETTING

• 3 College of Medicine affiliated residencies– 6-6-6; 6-6-7; 8-8-8

• No ongoing QI program at the start• Funding: HRSA BHPr 3-year residency training

grant

Method: Six one hour introductory training sessions Didactic and interactive small groups

Training Topics:1. Efficient Literature Searching2. Critical Appraisal3. Health Disparities4. Rural Health, Prevention & Healthy People 20105. Cultural Competency 6. Health Literacy7. Comprehensive - interactive teaming session

METHOD: TRAINING THE FACULTY

METHOD: TRAINING THE RESIDENTS

Method: Formal lesson plan Training workbook for Residents Interactive teamwork over year after training

workshop

Training Topics:1. Principles of evidence-based medicine2. Introduction to QI and tools: PDSA Cycle3. Researching evidence – intro to efficient literature

searching 4. Critically Appraising Literature5. Teaming: How to effectively work as a team6. Project development: small group sessions

RESULTS – 6 QI Projects1. Improvement diabetic BP control

– Intervention: in-service to all providers; patient education; regular chart reviews

2. Improve throughput time of outpatients– Intervention: decrease longest section to national

standard (decrease 35 min to 28min)

3. Improve Pap smear rates and follow-up rates for abnormal Paps

• Intervention: better/more visible documentation forms; in-service to all providers; disseminate guidelines

RESULTS – 6 QI Projects

4. Reduce the rate of hospital “bounce backs”5. Identifying/improving patient concerns re:

communication among IMGs6. Implementing a systematic method for

proper foot exams on all diabetics

OUTCOME MEASURE-1Knowledge & skills self-assessment survey

• Knowledge of current skills to develop and implement a QI project

• 9-item Likert 5 point scale; score range 9-45

Paired t-tests on overall scores:Pre-training = 26.20Post-training = 33.53 p = <.001.

Paired t-tests on overall scores:Pre-training = 24.72Post-training = 33.0 p = <.001.

OUTCOME MEASURE-2

• QIKAT Knowledge Assessment Tool– 3 clinical case scenarios with 3 questions:

• What is the aim?• What would you measure?• What change would you implement?

– Scoring based on identifying process and it is patient focused

DISCUSSION POINTS

• Challenges– Perceived as an “add-on”, not core curriculum– Teaming was a major challenge– QI topic perceived as the faculty’s topic

• Lessons Learned– Let them choose a leader at the start– Don’t assume they got it at the initial training– Lots of face time is critical