The Role of Education inThe Role of Education inSystems of CareSystems of Care

Malcolm Cox, M.D.Chief Academic Affiliations Officer

Veterans Health AdministrationCarl W. Walter Distinguished Professor of Medicine

Harvard Medical School

10th Annual Forum on Health Care EffectivenessBaton Rouge, LAJanuary 16, 2007

If you don’t knowwhere you’re

going,any road

will get you there.

Victor R. Fuchs

Fuchs VR. What Every Philosopher Should Know About Health Economics.Proceedings of the American Philosophical Society, Volume 140, No. 2, June 1996.

Health Care QualityHealth Care Quality

Health care is plagued today by a serious quality gap. The current health care system is not robust enough to apply medical knowledge and technology consistently in ways that are safe, effective, patient- centered, timely, efficient and equitable.

Institute of Medicine. Crossing the Quality Chasm:A New Health Care System for the 21st Century (2001).

Dimensions of a High Dimensions of a High Performance Health SystemPerformance Health System

67

51

71

66

71

69

0 100

Long, Healthy,Productive Lives

Quality

Access

Efficiency

Equity

OVERALLSCORE

7Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Quality ImprovementQuality ImprovementAction LevelsAction Levels

• Health care system as a whole– Health policy formulation

• Institutions and systems of care– Systems redesign

• Practice patterns of individual providers– Evidence-based medical practice

Quality ImprovementQuality ImprovementPrerequisitesPrerequisites

• Emphasize health not disease• Convert quality into value• Translate science into improved

health

Emphasize Health not Emphasize Health not DiseaseDisease

TertiaryCare

Hospital Care

Primary Care

Community Care

Self Care

Health Maintenance

Adapted from the Third Report of the Pew Health Professions Commission.Critical Challenges: Revitalizing the Health Professions for the Twenty-First

Century (1995).

IncreasingResources

Convert Quality into ValueConvert Quality into Value

Adapted from Kissick WL. Medicine’s Dilemmas: Infinite Needs Versus Finite Resources.Yale Univ Press, 1994

Access Quality

CostContainment

Translate Science intoTranslate Science intoImproved HealthImproved Health

Basic Biomedical Research

Clinical Science and Knowledge

Improved Health

TranslationalResearch

MedicalEducation

OUTCOMESRESEARCH

Clinical Decision MakingClinical Decision Making

CLINICALDECISION

PATHOPHYSIOLOGY

BASIC SCIENCE

RESOURCEALLOCATION

Clinical Decision MakingClinical Decision Making

OUTCOMESRESEARCH

CLINICALDECISION

PATHOPHYSIOLOGY

BASIC SCIENCE

RESOURCEALLOCATION

Patient-Centered CarePatient-Centered CareEssential ElementsEssential Elements

• Timely access to care• Open and clear communication• Coordination of care

High Performance Health High Performance Health SystemSystem

Quality DimensionsQuality Dimensions

69

72

71

70

71

0 100

Getting the rightcare

Coordinated care

Safe care

Patient-centered,timely care

OVERALLSCORE

16Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

58 5649 45

3023

2313

1716

17

13

0

50

100

NZ GER AUS UK US CAN

Next day

Same day

Percent of adults

3

13 1015

23

36

NZ GER AUS UK US CAN

6 days or more

Waiting Times in Six Countries, 2005Waiting Times in Six Countries, 2005Last time you were sick or needed medical attention,

how quickly could you get an appointment to see a doctor?

17Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Primary Care PerformancePrimary Care PerformanceQuality of Physician-Patient Quality of Physician-Patient

InteractionInteractionQuality Elements

1998 2000 ∆ (CI) P

Communication 80.3 77.3

-3.0 (-3.7 to -2.3)

<0.001

Interpersonal Treatment 75.8 73.5

-2.3 (-3.2 to -1.6)

<0.001

Physical Exam Thoroughness

76.6 74.0-2.6 (-3.5 to -

1.7)<0.001

Trust 79.8 80.50.7 (-0.07 to

1.5)NS

Knowledge of Patient 68.9 71.4 2.5 (1.6 to 3.3) <0.001

Montgomery JE et al. Primary care experiences of Medicare beneficiaries, 1998-2000.J Gen Intern Med 2004; 19:991-8

Continuity of CareContinuity of Care

• Continuity has been shown to enhance patient and clinician satisfaction, the delivery of preventive care and the management of chronic disease

• Continuity provides an environment in which the utilization of services can be best matched with patients’ needs and expectations

Advanced Clinic AccessAdvanced Clinic Access

• Goal: same day appointments• Core Components

– Balancing supply and demand– Reducing backlog– Reducing the variety of appointment types– Developing contingency plans– Working to adjust demand profiles– Increasing availability of bottleneck

resourcesMurray M, Berwick DM. Advanced access: reducing waiting and delays in primary care.

JAMA 2003; 289:1035-40.

Veterans Health Veterans Health AdministrationAdministration

• World’s largest integrated health care system– 156 Hospitals, 876 OPCs, 136 NHCUs – 7.8 million enrollees– 4.9 million patients treated annually

• 44 million outpatient visits• 423,000 admissions, 3.5 million BDOC

– 197,000 full-time employees– 92,000 health professional trainees

• Acclaimed as a leader in system redesign, quality improvement and patient safety

VA Clinical WorkloadVA Clinical WorkloadM

illio

ns o

f Uni

que

Pat

ient

s an

d In

patie

nt E

piso

des

0

1

2

3

4

5

1994 1996 1998 2000 2002 2004 2006

0

10

20

30

40

50

60

70

80

90

Outpatient Visits

Inpatient Episodes

Unique Patients

Outpatient Visits

(millions)

Unique Patients and Inpatient

Episodes (millions)

FY 2006 and FY 2007 are projections

Implementation of ACA in Implementation of ACA in VAVA

Selected Components Staff

ClinicsTeaching Clinics

Open Scheduling and Recalls 49% 17%

Leave Coverage 55% 29%

Planning for Contingencies 51% 29%

Prediction of Patient Needs 50% 29%

Optimizing Patient Involvement 60% 31%

Optimizing Team Care 60% 33%

Mean±SD Implementation (n=19)

59±12% 32±9%

Chang BK et al. Resident education in ambulatory settings:advanced access in VA physician resident continuity clinics. Fed Prac (in press, 2007).

Resident Participation in Resident Participation in ACAACA

Barriers to ImplementationBarriers to Implementation• Regulatory Issues

– Insufficient continuity clinic requirement– Duty hour restrictions

• Organizational Issues– Rotational structure– Curriculum governance

• Cultural Issues– Conflict with inpatient responsibilities– Perceptions of relevance

Ambulatory Care ModelsAmbulatory Care ModelsRotational StructureRotational Structure

SEQUENTIALLONGITUDINAL AMBULATORY

SEQUENTIALBLOCK

AMBULATORY

SEQUENTIALRECURRING

AMBULATORY

Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity” as an Organizing Principle for Clinical Clerkships. New Engl J

Med (in press, 2007)

Cambridge Integrated Cambridge Integrated ClerkshipClerkship

A fundamental restructuring of clinical education, integrating all the “traditional” clerkships into one year-long clerkship, focused on longitudinal patient care, close mentoring, and collaborative learning in accordance with adult educational theory.

Ogur B, Hirsch DA, Krupat E, Bor D. The Harvard Medical School- Cambridge integrated clerkship: A pilot, multidisciplinary, longitudinal, integrated clerkship. Acad Med (in press, 2007).

Clinical ClerkshipsClinical ClerkshipsIntegrated ModelIntegrated Model

LONGITUDINALINTEGRATED

SEQUENTIALDISCIPLINE SPECIFIC

Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity” as an Organizing Principle for Clinical Clerkships. New Engl J

Med (in press, 2007)

Continuity of CareContinuity of Care

• Goal– Enhanced patient connection, caring

and advocacy• Educational Prerequisites

– Contact with patients at the site and time of initial medical decision making

– Ability to follow patients across care venues

• Operational Requirements– Longitudinal patient care experiences

Continuity of CurriculumContinuity of Curriculum

• Goal– Enhanced knowledge acquisition,

transfer and meta-cognition• Educational Prerequisites

– Developmentally appropriate acquisition of relevant core competencies and competency-based assessment

• Operational Requirements– Interdisciplinary/interprofessional

curriculum organization and management

Continuity of SupervisionContinuity of Supervision

• Goal– Enhanced role modeling, coaching and

mentoring

• Educational Prerequisites– Community of learners, educators and

caregivers

• Operational Requirements– Longitudinal learner oversight

Core

Facu

lty

Oth

er

Care

giv

ers

Stu

den

t P

racti

ce

Team Learning

Individualized Learning

Patients

OR

IEN

TA

TIO

N

Inpatient/Acute

Outpatient

Core

Facu

lty

Oth

er

Care

giv

ers

Stu

den

t P

racti

ce

OR

IEN

TA

TIO

N

Team Learning

Individualized Learning

Other Faculty and Consultants

Core

Facu

lty

Oth

er

Care

giv

ers

Stu

den

t P

racti

ce

OR

IEN

TA

TIO

N

Team Learning

Individualized Learning

Cambridge Integrated Cambridge Integrated ClerkshipClerkship

Continuity of CareContinuity of CareCIC CON

Chi-Square

Seen hospital patients before diagnosis and decision for admission?

Very Often/Often 100 90.000

Sometimes/Rarely/Never 0 90

Seen hospital patients you have treated after their discharge?

Very Often/Often 100 00.000

Sometimes/Rarely/Never 0 100

Been involved in establishing meaningful relationships with patients?

Very Often/Often 100 450.012

Sometimes/Rarely/Never 0 55

Cambridge Integrated Cambridge Integrated ClerkshipClerkship

Student OutcomesStudent OutcomesCIC CON ALL P

Combined NBMEShelf Exams (%)

78.0 71.5 71.0 <0.001

4th Year OSCE (%) 70.0 63.9 60.8 < 0.01

Communication (%) 75.2 53.5 47.8 <0.001

NBME CCSSA*513.

8398.9 nt <0.05

Tasks of Medicine Scale

pre 3.93 3.35 nt NS

post 4.22 3.12 nt <0.01*Comprehensive Clinical Science Self-Assessment Examination

Cambridge Integrated Cambridge Integrated ClerkshipClerkship

Self AwarenessSelf Awareness

48.13

163.33

0

50

100

150

200CIC

CON

Mean Difference Between Predicted and Actual Scores

P < 0.05

Cambridge Integrated Cambridge Integrated ClerkshipClerkship

“Continuity of Idealism”“Continuity of Idealism”Extent to Which Experiences Have Prepared You To…?

(Mean scores:1=Very Poorly / 6=Very Well) CIC CONP-

value

Be truly caring in dealing with patients 5.63 4.00 0.000

Deal with ethical dilemmas 4.63 2.73 0.000

See how the social context affects patients

5.75 3.45 0.000

Relate well to a diverse patient population

5.63 4.09 0.015

Know your strengths and limitations 4.75 3.55 0.028

Medical EducationMedical Education

Among all of the Academic Health Center roles, education will require the greatest changes in the coming decade…. We regard education as one of the primary mechanisms for initiating a cultural shift toward an emphasis on the needs of patients and populations and a focus on improving health, using the best of science and the best of caring.

Institute of Medicine. Academic Health Centers:Leading Change in the 21st Century (2003).

Traditional New

FrameworkBiological Bio-Psycho-Social

Autonomy Cooperation

Profession-Specific Inter-Professional

PedagogyKnowledge Discovery

Individual Expertise Collective Expertise

Discontinuous Developmental

Assessment

Knowledge Performance

Individual Excellence Team Excellence

Progression

Time-DependentCompetency-Dependent

Health Professions Health Professions EducationEducation

Paradigm ShiftsParadigm Shifts

When you come to

a fork in the road…

Take It!

Yogi Berra