The UCSF ambulatory practice improvement (PI) curriculum was augmented in 2009 with the addition of American Board of Internal Medicine (ABIM) Practice Improvement Modules (PIMs). All residents learn basic PI principles in our PI Ambulatory Didactics held during our R2/R3 biweekly ambulatory conferences.

Claire Horton works with a team of providers at the SFGH medical clinic

The addition of the PIMs enabled incorporating systems-based practice and practice-based learning and improvement into our residents' clinical setting with support from clinic preceptors. The PIMs provide step-by-step guidance for developing a PI project and further supported residents' and clinic preceptors' attainment of knowledge and skills needed to conduct and complete PI projects. The PIM sessions provide protected time for residents to work on their projects. The residents complete the PI curriculum during their 6 months of ambulatory block in postgraduate years 2 and 3.

The PIMs include a patient survey, an examination of the clinic microsystem, a practice analysis and a guide to develop a practice improvement plan. Once the patient survey and systems evaluation are complete, the ABIM web-based software produces a practice analysis. The program guides the resident team through the development of an improvement plan, providing step-by-step prompts and information about setting a performance goal and developing plans for re-measurement.

In the last several years many successful PI projects have been completed. For example, one project at the San Francisco Veterans Affairs Medical Center was to improve compliance with ordered labs and imaging tests. Residents infrequently used an existing discharge planning handout so they designed and implemented a new handout that included an improved checklist of instructions for their patients. Residents added clinic information and tips for good communication with physicians. Subsequently, the resident PI team distributed the handout clinic-wide and it is now broadly used by faculty, resident and nurse practitioner providers.

There have been additional projects involving the creation of templates, including one where residents designed a patient notification one. Providers inform patients of their test results by letters generated in the electronic medical record or by phone call; however our practice analysis showed that only 56% of patients reported they consistently received the results of their diagnostic tests. Residents developed templates within the electronic medical record to streamline the notification process. The templates included simple explanations of basic labs and patient education content and are easily imported into patient letters. Many providers now use these templates daily. Other templates included antihypertensive medication protocols for nurses. Residents chose this project to address a deficiency in the use of algorithms for the management of common problems and to improve resident-nurse communication.

Please see attached table for overview of performance improvement didactic.

For additional information or questions about the Ambulatory PIMs, please contact:

Rebecca Shunk, MD
Associate Clinical Professor of Medicine
Director, Center of Excellence in Primary Care Education
Associate Director of the PRIME Program
UCSF Internal Medicine Residency
San Francisco VA Medical Center
Rebecca.Shunk@va.gov
(415) 221-4810 ext. 4878

Katherine Julian, MD
Associate Clinical Professor of Medicine
Associate Program Director, Department of Medicine
Kathy.julian@ucsf.edu
415-514-8655

Claire Horton, MD, MPH
Assistant Clinical Professor of Medicine
Associate Medical Director
General Medicine Clinic
San Francisco General Hospital
hortonck@medsfgh.ucsf.edu
415-206-6782; Box #1364