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Institutionalizing Quality Improvement in a Family Medicine Residency

Institutionalizing Quality Improvement in a Family Medicine Residency. Fred Tudiver, MD East Tennessee State University. BACKGROUND. ACGME competencies include quality improvement methods Current QI residency training: Seminars, lectures, and/or group activities

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Institutionalizing Quality Improvement in a Family Medicine Residency

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  1. Institutionalizing Quality Improvement in a Family Medicine Residency Fred Tudiver, MD East Tennessee State University

  2. 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

  3. 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

  4. 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

  5. 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

  6. METHOD: TRAINING THE FACULTY • Method: • Six one hour introductory training sessions • Didactic and interactive small groups • Training Topics: • Efficient Literature Searching • Critical Appraisal • Health Disparities • Rural Health, Prevention & Healthy People 2010 • Cultural Competency • Health Literacy • Comprehensive - interactive teaming session

  7. METHOD: TRAINING THE RESIDENTS • Method: • Formal lesson plan • Training workbook for Residents • Interactive teamwork over year after training workshop • Training Topics: • Principles of evidence-based medicine • Introduction to QI and tools: PDSA Cycle • Researching evidence – intro to efficient literature searching • Critically Appraising Literature • Teaming: How to effectively work as a team • Project development: small group sessions

  8. RESULTS – 6 QI Projects • Improvement diabetic BP control • Intervention: in-service to all providers; patient education; regular chart reviews • Improve throughput time of outpatients • Intervention: decrease longest section to national standard (decrease 35 min to 28min) • Improve Pap smear rates and follow-up rates for abnormal Paps • Intervention: better/more visible documentation forms; in-service to all providers; disseminate guidelines

  9. RESULTS – 6 QI Projects • Reduce the rate of hospital “bounce backs” • Identifying/improving patient concerns re: communication among IMGs • Implementing a systematic method for proper foot exams on all diabetics

  10. OUTCOME MEASURE-1 Knowledge & 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 • Knowledge of current skills to develop and implement a QI project. • 9-item Likert 5 point scale; Range of possible scores was 9-45 • Scale ranged from “Not at all comfortable” to “Very comfortable” • Conducted face validity for clarity & relevance assessment with 9 faculty • Several items were re-worded and order changed due to feedback • Two internal consistency estimates of reliability were computed: • Cronbach’s alpha = 0.876 • Spearman-Brown coefficient = 0.943

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

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

  13. 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

  14. 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

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