Systems-Based Care and Practice Based Learning and Improvement

The Problem The American healthcare delivery system is in need of fundamental change The American healthcare delivery system is in need of fundamental change The current systems cannot do the job The current systems cannot do the job Trying harder will not work Trying harder will not work Changing systems is necessary Changing systems is necessary

Were Driving a Powerful Vehicle, but it has no: Map Map Compass Compass Speedometer Speedometer Odometer, or Odometer, or Clock Clock Yet the pedals to the floor

Aims for Improving Healthcare Safe Safe Effective Effective Patient-centered Patient-centered Timely Timely Efficient Efficient Equitable Equitable

To Err is Human: Building a Safer Health System Why start with errors? Burden of injury Burden of injury Understandable to providers and consumers Understandable to providers and consumers Avoidable Avoidable Experience in other industries Experience in other industries

Many People are Harmed Adverse event – an injury caused by medical management Adverse event – an injury caused by medical management Adverse events occur among 3-4% of hospitalized patients Adverse events occur among 3-4% of hospitalized patients About 1 in 10 results in death About 1 in 10 results in death Over half are preventable Over half are preventable

Key Findings Errors occur because of system failures Errors occur because of system failures Preventing errors means designing a safer system of care Preventing errors means designing a safer system of care

Few newly qualified physicians have the necessary skills to improve health care and safety. These include the ability to perceive and work effectively in interdependencies, the ability to understand work as a process, skill in collecting, aggregating, analyzing, and displaying data on the processes and outcomes of care, skills in designing health care processes, an ability to work in teams and collaboration with managers and patients, and the willingness to examine honesty and learn from mistakes

Professional Competence: a definition The habitual and judicious use of communication, knowledge, technical skills, evidence-based decision-making, emotions, values and reflection to improve the health of the individual patient and the community

Systems-Based Practice 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.

Why Systems-Based Practice? Prepare physicians to work in the current system Prepare physicians to work in the current system Optimize cost and outcomes Optimize cost and outcomes Improve the system Improve the system Transform the health care system Transform the health care system

Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it -- Relman, Acad Med, 73, 1998

Why Systems-Based Care? A systems view is critical to understanding patient outcomes, safety, values and quality A systems view is critical to understanding patient outcomes, safety, values and quality

What are the components of Systems-Based Care? For your Residency Program? For your Residency Program? For your institution/hospital? For your institution/hospital?

Some components of Systems- Based Practice System resources System resources Patient advocacy Patient advocacy Health care economics Health care economics Teamwork Teamwork Cost-benefit considerations Cost-benefit considerations Healthcare economics Healthcare economics Healthcare Financing Healthcare Financing Practice management Practice management Insurance Types Insurance Types Medical-Legal Issues Medical-Legal Issues Coordination of health care Coordination of health care Documentation Issues Documentation Issues Social and political history of US health care system Social and political history of US health care system

Elements of Systems: The Resident-System Interface Within the hospital/clinic Admitting/scheduling Admitting/scheduling Documentation Documentation Other clinical services Other clinical services Ancillary services Ancillary services Nursing Nursing Pharmacy Pharmacy Outside the hospital/clinic Referring physicians Referring physicians Insurers, HMOs Insurers, HMOs Community services Community services External laboratory and radiological services External laboratory and radiological services Legal system Legal system

Systems Thinking Principles and Concepts Interdependence Interdependence Structure drives behavior Structure drives behavior Cause and effect are separated by time and place Cause and effect are separated by time and place Any change in a system has unintended consequences Any change in a system has unintended consequences

The prominence of physicians in highly interdependent medical systems confers tremendous power on them, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about medical systems. --Nolan, Annals Intern Med, 1998

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.

Practice-Based Learning and Improvement Analyze practice and improve using systematic methodology Analyze practice and improve using systematic methodology Locate, appraise and apply scientific evidence Locate, appraise and apply scientific evidence Apply knowledge of study designs and statistics Apply knowledge of study designs and statistics Obtain and use patient population data Obtain and use patient population data Use information technology Use information technology Facilitate the learning of others Facilitate the learning of others

Practice-Based Learning and Improvement Residents must internalize the value of on-going, self-directed learning and improvement of practice Reflect on and analyze practice experience Reflect on and analyze practice experience Locate and apply scientific evidence Locate and apply scientific evidence Take steps to improve practice Take steps to improve practice Demonstrate improvement Demonstrate improvement

Whatever we measure we tend to improve.

We measure what we value.

Practice-Based Learning and Improvement

Where should we start? Begin with what you have in place – your resident interactions with their patients Begin with what you have in place – your resident interactions with their patients

What data can be gathered about a residents knowledge of Systems-Based Practice and Practice Based Learning through a patient encounter? Questions from the attending? Was the care based on a healing relationship? Was the care based on a healing relationship? Was the care customized based on patients needs? Was the care customized based on patients needs? Was evidence-based decision making used? Was evidence-based decision making used? Was safety a system property of the care? Was safety a system property of the care? How did you anticipate the needs of the patient? How did you anticipate the needs of the patient? How could waste be diminished? How could waste be diminished?

Other venues for SBP and PBL Teaching and Evaluation Case analysis – focus on processes of care Case analysis – focus on processes of care Construction of a flow chart of a hospitalized patient to analyze systems of care Construction of a flow chart of a hospitalized patient to analyze systems of care Root cause analysis of an adverse event Root cause analysis of an adverse event Activity based cost analysis of a hospital bill Activity based cost analysis of a hospital bill

Reasons this is hard Competence is a habit Competence is a habit Medicine is a cooperative not a productive art Medicine is a cooperative not a productive art The important things are hard to measure The important things are hard to measure Residents seek practical wisdom Residents seek practical wisdom To become competent you have to feel bad To become competent you have to feel bad Learning occurs in microsystems Learning occurs in microsystems Becoming competent is a complex process Becoming competent is a complex process

Helpful Hints for Program Directors Use current activities already in place (rounds, conferences, grand rounds, discharge planning rounds) to teach and evaluate SBP and PBL Use current activities already in place (rounds, conferences, grand rounds, discharge planning rounds) to teach and evaluate SBP and PBL Issues related to SBP and PBL abound in resident experiences Issues related to SBP and PBL abound in resident experiences Involve the residents in the process of deciding how to incorporate these competencies into your curriculum Involve the residents in the process of deciding how to incorporate these competencies into your curriculum Faculty development is a key to success Faculty development is a key to success