“Teaching on Today’s Wards” User’s Guide:
Systems Based Practice and
Practice Based Learning and Improvement
Session #3: Systems Based Core Competencies
(Intro. 10 minutes)
The core competencies should be thought of as what goes into making a good clinical doctor providing comprehensive, up-to-date clinical care. We should be practicing across the 6 competencies areas for any individual patient case. Some of competencies are intuitive to practice and teach e.g., medical knowledge, patient care, professionalism, communication. Further, we are often most comfortable with evaluating a learners “clinical expertise.” The core competences of practice based learning and improvement (PBLI) and systems based practice (SBP),have been more difficult to teach and evaluate in clinical practice largely because most teaching faculty don’t feel they are enough of a “content” expert to teach PBLI or SBP with skill or comfort. In fact, most places that have made formal efforts at teaching PBLI and SBP have made them a stand-alone curriculum. We hope to demonstrate how PBLI and SBP can and should be a part of our practice of teaching in the clinical setting. When you walk away from here, you will have a toolbox that will allow you to teach and evaluate your learners in these areas.
Learning Objectives:
By the end of this session, the learner will be able to:
- Describe the key components of the systems based practice competency
- Evaluate learners’ abilities to work within the existing system of care
- Teach the basic model of Plan, Do, Study, Act
- Teach and evaluate inpatient teams in how their actions and care practices affect other systems within the hospital.
- Using the PDSA model, identify and outline conceptual QI projects with their inpatient team that address systems level issues that arise during the care of patients.
Introduction to Systems Based Practice (20 minutes):
What is it? ACGME Definition
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
We are going to focus on three areas that can be taught in the traditional inpatient setting (see italics above).
Taking advantage of the systems that are in place within the care setting
Critically thinking about how to improve those systems
Pre-comfort level—discussion
Why is it important?
General Introduction into the QI model (Plan Do Study (Check) Act) and the key components
It’s the system
Don’t blame
Process
Introduction to Toolbox Concept
There are specific concrete tools that you can use in clinical teaching practice to both teach and evaluate Systems Based Practice. In the following breakout session, you will re-visit the case of our elderly patient with apathetic delirium. We will focus our discussion today on evaluating and teaching Systems Based Practice. The facilitator will make sure that key points are discussed.
Breakout session (40 mins.) with Regroup discussion (25 mins.)
See Teaching Matrix on Systems of Care tutorial and exercise sheet
The major teaching points for the faculty learners include the realization that one can teach about systems on any case topic and/or care in transition from one system to another and/or system failure. There are some topical areas in which you may be a content expert and can describe the system with regard to a more detailed demographic, cost, entry criteria and give an expert opinion about what works in the system and what needs to be improved. But even if we are not a content expert on a particular system of care after this course, we should be able to describe what a system is and at the very least try to map some part of the system’s process. We can all usually describe most of a patient’s and our hospitals systems of care and discuss the workarounds within the systems that are closest to our immediate clinical care experience. Labeling these as systems of care and pointing out the strengths and weaknesses of these systems is teaching.
Optional Breakout Session on Teaching about Systems of Care (40 minutes)
Remember the case of the elderly gentleman admitted with apathetic delirium. He has done better when taken off some of his medications. The team is presenting him on the next day thinking he will be ready to go. He is not quite back to his baseline, but when they saw him that morning, he was significantly better than on admission. There were no calls from cross cover and his vitals were ok. His labs were not drawn and the senior resident feels the team should complete the dementia work-up before the patient is discharged. She tells the intern to make sure the TSH is done this morning. The intern replies that it will be fine, he will just order it stat and it will be back in a few hours, it’s frustrating but he often has to do this because his orders get lost all of the time. Although the patient is some better, you are not quite sure about his readiness for discharge.
Question #1: How would you teach or evaluate Systems Based Practice after hearing this discussion in rounds? (OPEN ENDED)
KEY POINT #1: Talk about what systems based resources need to be tapped to properly assure that this patient is safe to be discharged. How could you assess if the team is working within the available resources efficiently?
Cues if needed: Ancillary services, PT/OT, rehab, social work, case management, nursing, etc.
KEY POINT #2: Identify a broken system as an opportunity to teach and evaluate. Talk about the lab ordering issue. How does this relate to systems based care?
Cues:
- Recognize that this is a systems problem, and not due to “lazy or incompetent people”
- Talk about the interns work around. Is that effective? What effects might that have on other’s in this system of care? Emphasize that any change to the system one creates, will likely have far reaching effects.
- How could you talk with your team about fixing this problem?
- What would they need to know to solve the problem?
- Who would be key players involved in the change process?
REGROUP (25 Minutes):
Emphasize Take Home Points:
Systems Based Practice can be taught and evaluated in real time clinical teaching
2 Major Components:
- Working within the present system
- Identifying methods of improvement
- Identifying the problem
- Identifying how individuals’ actions affect others within the health care setting
- Outline key issues in classic QI model to address problem
Practical Toolbox Items can be used to:
- Teach in real time clinical practice
- Label the teaching as systems based so that learners can understand what they are learning and why it is important
- You do not need to know the answer to the systems problem to teach and evaluate the thinking about the problem.
Homework:
- Identify one systems based issue in your own practice that you have not previously spent much time thinking about
- In a teaching situation, try to identify and use a tool
EVALUATION IDEAS:
Pre and Post
Comfort with Teaching Systems Based Practice
Comfort with Evaluating Systems Based Practice
Knowledge about two components of systems based practice teaching
Knowledge about Plan Do Check Act Model of QI
Comfort with Discussing Plan Do Check Act
Knowledge about roles of ancillary services in caring for patients
Comfort in evaluating effective use of ancillary services
Ability to identify the systems based teachable moment
Ability to identify key stakeholders in systems based problems
Session #4: Practice Based Learning and Improvement
PBLI is also one of the newly added core competencies that has primarily been taught and evaluated in separate educational sessions or conferences. However, we are asked to teach and evaluate students and residents during our months on the inpatient service. In order to do this effectively, it is important to understand what the key components of the competency and have strategies to effectively teach and evaluate learners. In this session, we will focus on areas of the PBLI competency not adequately taught in other areas of the residency curriculum and the competency many of the teaching faculty are least comfortable in evaluating.
Learning Objectives:
By the End of this session, the learner will be able to:
- Describe the key components of the practice based learning competency
- Feel comfortable in teaching and evaluating aspects about this competency
- Incorporate Case and Census Audits into their inpatient teaching activities
- Advocate for the teaching and practice of these skills during actual clinical practice
Introduction and Debriefing (30 Minutes):
First, debrief about experience with homework assignment (5 minutes)
We have gone over several key areas of teaching on the wards today. The sessions have consistently tried to emphasize that our teaching activity is a process that tries to maximize educational opportunities, outstanding clinical care, and practical efficiency. Today we are going to use that same approach to thinking about the other new core competency, Practice Based Learning and Improvement. Similar to the other days, we will start with an introductory discussion, followed by a breakout session, and end by re-grouping with discussion.
Introductory Discussion:
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 systematic 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
We are going to focus on two of these areas in this session for two reasons. First, students already receive formal training in many of the other areas outside of their traditional clinical training. Second, the next session will focus on issues about life long learning skills. Third, for faculty interested in learning more about information retrieval or evidence-based methods, there are existing opportunities through existing general medicine faculty development courses that cover these in some detail. Finally, these are the components of the competency that may be most foreign to most faculty teachers.
Pre-comfort level—discussion
Why is it important?
Toolbox Model: Again, we hope to provide two methods that you can be used to teach and evaluate practice based learning concepts. Each of our examples provided, highlight geriatric content, but they can be used conceptually for any topic.
CASE AUDIT: The case audit is used to review your inpatient team’s care of a patient throughout the entire hospital stay. For this to be effective, you need specific measures of quality of care. You also need to create an environment in which self-reflection is encouraged and expected. It is key that the attending sets the example for providing a blame-free, self-improvement based arena when performing the case audit. When a problem area is discovered, the team will be responsible for not only identifying the area, but also determining why it happened and how to prevent it in the future. We recommend focusing these case audits on a select few processes of care during any one audit or a particular clinical topic e.g., delirium, polypharmacy to reinforce through this “teaching” case audit model-- topic review, accepted process of care measures and personal/team improvement in a focused clinical area.
CENSUS AUDIT: The census audit looks not at an individual patient in depth, but across all of the patients under your care. To do this effectively, pick a specific (probably single) measure of quality. Then review your entire patient census to see how your team is doing in meeting that measure of quality. Key parts to this tool: 1.When the results are not satisfactory, discuss reasons and come up with solutions. 2. Consider doing an early month and late month to assess change. 3. Consider doing this when work rounding as it builds this type of teaching and evaluating into the practice of patient care. 4. Label it as practice based learning.
BREAKOUT SESSION: CENSUS AUDITS (45mins.)
See census audit tutorial and sample census audits to be handed out at the end of the exercise.
Please refer to the slide presentation discussion using a sample census audit before starting the census audit tutorial. Have the faculty work through the tutorial in diads and finish as much of the tutorial as possible. Regroup with discussion and hand out the remainder of the sample finished census audits.
OPTIONAL BREAKOUT SESSION on Case Audits (45 Minutes):
During this breakout session, you will be role playing a team. One member is the attending, one is the resident, one the intern, and one is the medical student. Spend five minutes briefly reviewing the case on your own and then begin. The attending will be responsible for setting up the discussion for a case audit. She will use one or more of the tools provided to go through the care of the patient. Remember, to explore the how and why of those areas in which optimal care was not given in a way that is about improvement and not blame.
Case # 1
82 y/o WF with an ischemic cardiomyopathy (ej fx 20%), CRI, HTN, DM type II, admitted for with rapid afib and CHF exacerbation. Came in on digoxin 0.125 qd, coumadin 5 qhs, glucotrol 5 q AM, diovan 160 qd, lasix 80 BID, EC ASA81 qd, lipitor 10 q AM.
Long hospital course. Pt has been in the hospital for 3 weeks in and out of the ICU. Did not tolerate diltiazem, beta-blocker--poor rate control, more CHF.
D/C’d home on above meds and Amiodarone 200 q AM with HR in 60s in NSR. Hgb at baseline of 10.2, Cr of 2.4 baseline and K+ of 5.1. Fasting glc #s in the 160s.
Current exam with clear lungs, trace-1+ pedal edema, pulse ox 94% RA. Can ambulate to the bathroom with walker with mild SOB and 94% RA sat.
Practice-Based Learning and Improvement Review Tools
Geriatric Discharge Case Audit
A. Discharge Planning
Answer Yes or No or N/A, unless otherwise indicated.
1. Was the patient able to make his/her own decisions during hospitalization?
2. If not, had the next of kin been identified?
3. Had discharge planning been discussed with the patient and/or the next of kin?
4. Had the social worker been involved in the discharge planning?
5. Had the case manager been involved in the discharge planning?
6. Had the patient’s attending physician been involved in the discharge planning?
7. On which hospital day did discussion of discharge planning first occur? (Note: hospital day, #1, etc.)
8. If applicable, had the patient been assessed for rehab?
9. If applicable, had the patient been assessed for skilled nursing?
10. If applicable, had the patient been assessed for home nursing and home PT?
11. Were end-of-life wishes discussed with the patient or surrogate decision-maker?
12. If applicable, had hospice been explained and offered to the patient or surrogate decision-maker?
B. Transitioning Care
Answer Yes/No or N/A, unless otherwise noted
1. Was the patient’s attending physician notified of the patient’s admission to the hospital? If so when? (Hospital day #1, etc.)
2. Was the patient’s attending physician notified of the diagnoses, time, place and circumstances of the patient’s discharge?