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Quality of Care (QoC) problems in medicine?

Quality of Care problems in medicine? A role for early educational intervention? Dr Hub Wollersheim, internist Centre for Quality of Care Research (WOK) Radboud University Medical Centre Nijmegen; the Netherlands. Quality of Care (QoC) problems in medicine?. A problem? What problem?

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Quality of Care (QoC) problems in medicine?

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  1. Quality of Care problems in medicine?A role for early educational intervention?Dr Hub Wollersheim, internistCentre for Quality of Care Research (WOK)Radboud University Medical CentreNijmegen; the Netherlands

  2. Quality of Care (QoC) problems in medicine? • A problem? • What problem? • The consequences? • Is early undergraduate education a solution? • And if: How and what?

  3. QoC in medicine; the problems • 1) General: resistance to change • external pressure: loss of autonomy • (BMJ 2001: Why are MD’s so unhappy?) • Quality Management/ Systems: standardisation: • negative attitude: a threat to creativity and • livelong learning; innovation • Quality of Care: • insufficient knowledge/ skills • improvement/ evaluation

  4. QoC; the problem; skills • Insufficient knowledge and skills: • -Quality of Care = guideline development • -Methods: • how to find/ judge evidence? • how to implement improvement? • -Research: • how to design/ evaluate?

  5. QoC: the problem; attitude • Not accustomed to transparancy or accountability: • Training/ working in: • - One to one situations (patient(s) and supervisors) • - A patriarchal culture; professional code: keep the problems inside • - University system: competition instead of cooperation

  6. QoC: real problems • 1) Bureaucracy: 30% paper, 20% meetings • 2) Juridi(culi)sation: VS: 1980/1990/2000: 20X • The guideline as law: 30% deviation • No evidence: SR q-systems: minor effects (n=2) • Managers task, the move from patient care (5-45%)

  7. The consequences • MD’s do not collaborate in QI projects (15%) despite that there participation is fundamental (37% more successfull) • Variation in care: prostatectomy (40x) • Suboptimal care: • -under/ over/ mis use: 30-60%; • -misjudgement (with consequences): 50%; • -unsafety: 50-90.000 (?) deaths US

  8. Improving QoC in medicine • Make QoC attractive: • -Problem in stead of system oriented • -Support in stead of demands • -Internal drive in stead of external pressure • -Publish results of innovative improvements • -No quality slang

  9. QoC: teaching • Teaching programs and methods: • Attitude, • Knowledge, • >SKILLS; • Experience and evidence: • not much to guide us

  10. QoC: competences • 60% QoC goals in competences CanMeds: • Canada> Denmark> Australia> Netherlands (2005): • >deliverance of effective and patient centered care • >communicative, cooperative and management skills

  11. Teaching; baseline principles of QoC • A) Astonishment: • Why? How? • B) Reflection: • 1) How good am I? or are we? • 2) How can I/we do better? • 3) Show it • 4) Lifelong learning

  12. Teaching QoC; methods • 1) Use medical language, no quality slang: • -Indicator = a diagnostic instrument for QoC • 2) Avoid words like “control”,”system”, “standard” • 3) Themes connected to medical care: • -EBP; safety (side effects, complications) • 4) Problem oriented themes (patients/ practise)

  13. Teaching: themes

  14. Teaching; framework QoC • Scopes: • Professional: evidence based practise (systematic reviews; guidelines; decision aids) • Organisational: proces oriented practise (pathways; multiprofessional collaboration; task delegation); management participation; financial incentives; capacity management • Patient oriented practise: communication; education; shared decisions; quality of life

  15. Improvement: teaching; cross themes • Evaluation: themes; designs; use well described EB interventions, validated methods and measurement techniques; statistics; process evaluation; qualitative evaluation • Implementation of improvement: barriers, facilitators, limiting conditions, project management, the quality circle (plan, do, check, act), measurements (indicators) and feedback

  16. What types of undergraduate education? • Existing programs • Programs that should be developed • Teaching methods • Examination methods • The Dutch (European?) initiative

  17. Undergraduate education in medicine; existing programs; USA • Existing programs: • Mayo Medical School; Ro; MN; USA • Prathiba Varkey, Thomas R Viggiano • Task: • “The curriculum now only focussed on di-seases, should systematically introduce QI”

  18. Undergraduate education in medicine;existing programs; Mayo Clinics • Objectives: • To define and impart knowledge of QI sciences that is “developmentally” appropriate to medical students • To introduce the skills to assess the gap between existing and optimal practise and to plan and measure change • To apply knowledge and skills through QI projects

  19. Mayo; the QI modules (4 wks) • Year 1: orientation • introduction to the patient • continuity of care • Year 2: evaluation skills • institutional leadership • (panel discussions) • clerkship in family medicine • (introduction to EBP)

  20. Mayo; the QI modules • Year 3: clerkship survival skills • clerkship in internal medicine • (application of EBP) • QI research project • Year 4: preventive medicine and public health • social medicine • (evaluation of EBP) • clerkship in emergency medicine • (application of QI)

  21. Mayo; QI curriculum; the essential • Health care as a process/ as a system; • QoC measurement and improvement; process analysis • Variation; optimal care • Leadership and team collaboration • Safety and errors

  22. Mayo; QI curriculum; teaching methods • Case/ problem based learning • Exercises • Simulations • Interviews • Video discussions • Panel discussions • Project presentations to teach the other students • Web modules • Debriefing: clinical rounds; night shift; MPD • EBP before, during and after clerkship

  23. Mayo; QI curriculum; an example • Year 1; Orientation module (last week) • -Presentation: A case with a medication error • -Small group discussion: what went wrong and suggestions for improvement • -Panel discussion with experts • -Video: The patients view • -Presentation: How to communicate error • -Simulation: Communicating error with a patient/ family

  24. Mayo: QI curriculum; an example • -Debriefing: panel discussion: difficulties; two video examples: do’s and dont’s • -Video of a law suit • -Debriefing: panel discussion about the video • -Exercise: 5 groups: day 5 presentations: • 1)analyze error and its consequences; • 2)a medication error improvement plan; • 3)a fall prevention plan; • 4)a plan to prevent pressure ulcers; • 5)a plan to prevent wound infections.

  25. Mayo; QI curriculum; experiences • Hostile medical professors • Always teach within a medical setting • Students: sceptical before; enthusiasm after • Extensive evaluation of results by before/ after assessments of attitude; knowledge; skills • Permanent improvement on the basis of evaluation

  26. Undergraduate education in medicine;existing programs; Nijmegen • Radboud UMC Nijmegen; Medical Faculty: • Year 1: communication skills (3 hrs; video and patient demo); EBP and guidelines (2 hrs; key lecture and case) • Year 3 and 4: the process of care (4 wks); optimizing clinical skills (4 wks); quality and the law (17 hrs); free choice modules

  27. Undergraduate education in medicine; teaching and exam methods • Teaching methods: active problem based learning • Care related problem presentation and evaluation • Evidence or safety as starting points • Activities: • -Evaluating observed skills or simulations • -Interviewing key QoC persons or patients • 4) Examination: • -Writing a QI paper • -Perform and present a QI research project

  28. Undergraduate education in medicine;the Dutch initiative • Care Research Netherlands (ZonMw): • The development of a national teaching program “quality of care” for (bio)medical schools in the Netherlands • All Dutch Universities: • -exploration of existing programs/ teaching methods • -what should be developed?

  29. Educating QoC: 4 questions • Deliberate with your neighbour; answer the following questions: • 1a) What is the domain of QoC? • 1b) Should it be taught on its own or should it be part of: clinical subjects; epidemiology, EBP, clinical decision making or management in health care? • 2a) What are learning goals for MD’s? • 2b) Which goal in which phase of study? • 3) Successful teaching methods? • 4) Is there a special role for QoC teaching in primary care?

  30. European collaboration? • Are you experienced with successful programs and teaching methods and willing to exchange? • Mail me: h.wollersheim@medzaken.umcn.nl

  31. The problem; Quality of Care • Attitude: • -All day we deal with quality of care; “our” domain • -Are systematic improvement activities effective and efficient? • 10% = the placebo effect

  32. Improvements: to enthuse • Care provider: less problems; more publications; >job satisfaction • Group: better communication/ cooperation/ knowledge exchange/ task delegation: • >team climate inventory • Hospital management: <costs • Public: >honor role • Patient: >satisfaction; >quality of live • Fly wheel effect: other improvement projects

  33. Undergraduate; medicine, RUN • Optimizing clinical skills: 4 wks • Practise: • 1)Outpatient clinic of Internal Medicine; • 2)Department of Geriatrics; • 3)General Practise; • 4)Determinants of health care. • Themes: evidence and guidelines, communication, collaboration, the patient’s perspective, • evaluation of improvement, research

  34. Undergraduate education; Netherlands • Erasmus University Rotterdam: • Prof dr Marc Berg; prof dr Jan Walburg • iBMG; BaMaSc: • -Ba: organisational improvement • quality and the law • -Ma: integral management of care: • management of care • ICT; accountability • performance management

  35. Undergraduate education; Netherlands • AMC; UvA: • Prof Dr Niek Klazinga • Medicine: 4th year: • Quality of Care: guidelines • audit • collaboration • social and primary care • improvement paper

  36. Undergraduate education: Netherlands • Vumc: • Prof Dr Gerrit van der Wal • Medicine: 4th year: • Quality of Care: • introduction • focus on unsafety (mimicing Disciplinary • Committee case) • writing a QI paper after interviewing key • quality persons

  37. Undergraduate education • azM;UM: • Prof dr Frans van Wijmen: • -Medicine: 3th year: surgical audits • 5th year: QoC research • -Focus on Health Care research and “Hogescholen” (nursing and allied health care sciences)

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