Improving Clinics and Patient Care

reprinted from Issue 13, Fall 2011 of Frontiers of Medicine (PDF)

Rebecca Shunk, MD, helped introduce the Practice Improvement Modules to trainees.

As a resident, you don't have a lot of control over your life, or how things work," says Denise Connor, MD, who recently finished a year as chief resident at the San Francisco Veteran Affairs Medical Center (SFVAMC) and now cares for hospitalized patients as a faculty member. "Yet residents are in the trenches and often have a sense of what the biggest problems are that are causing their patients to be unhappy or not get the care they need. They know what the holdups are, because they experience them every day."

Connor was among the first UCSF residents to use a new tool to improve patient care and the clinics in which they practiced. The Practice Improvement Modules (PIMs) are interactive, web-based tutorials that guide the user through the process of collecting patient data to identify gaps in care, and then design and implement a plan to address those shortcomings. The PIMs focus on topics such as asthma, cancer screening and care of vulnerable elderly patients. They were originally designed by the American Board of Internal Medicine as a continuing education tool for physicians who are recertifying their credentials.

UCSF was one of the first residency programs to use PIMs to teach residents and prepare them to maintain their certification as physicians later in their careers. This innovative use of the PIMs is made possible by the UCSF Department of Medicine's participation in the Educational Innovation Project (EIP) of the Accreditation Council for Graduate Medical Education (ACGME). The ACGME has granted the 21 programs selected for the EIP some flexibility in meeting residency accreditation requirements, allowing these programs to pilot creative new approaches to learning.

Quality Improvement in Action

Denise Connor, MD, was one of the first residents to use these web-based quality improvement tools.

"A lot of people of my generation didn't learn about quality, and now we are expected to teach it and be experts in it," says Associate Professor Rebecca Shunk, MD. She completed a PIM during her own recertification process, then helped lead UCSF in using PIMs to teach residents how to improve care in the clinics where they work. "Before, we had taught a lot of the principles of quality improvement, but hadn't done hands-on projects," she says. "The PIMs are very basic online tutorials that give you all the basics you need to know."

A few years ago, she led Connor and other residents in examining their clinic systems. The residents used a PIM-designed questionnaire to assess how well things like their electronic medical records system were functioning, and identified communi-cation as an area of weakness.

"Both the patients and the residents felt frustrated, because we would tell patients, 'Go get your labs and an X-ray and come back next month,'" says Connor. Often these instructions were given verbally, or were scribbled on a piece of scratch paper. "The patient would come back, but wouldn't have done these things because they didn't remember, or they weren't sure how to do them," says Connor.

The checklist that Connor and other residents developed to help communicate follow-up tasks to patients.

The residents brainstormed solutions. They developed a checklist indicating if a patient needed lab tests, prescriptions or X-rays. The sheet also provided special instructions, such as whether patients needed to fast before a lab test, as well as space for doctors to summarize medication changes.

For the back side of the handout, residents developed a summary of other VA services, such as the suicide hotline, smoking cessation and nutrition services. "There were all these resources at the VA that our patients weren't really utilizing, but as individual residents we didn't know all the right contact numbers and how to best refer them," says Connor.

Time to Reflect

"We can't just layer on things that we think would be great educational activities, without carving out the time for residents to do this," says Harry Hollander, MD, program director of the Internal Medicine Residency Program. UCSF now makes a financial investment to cover this time; in Connor's case, she and her peers were released from clinic duties for about 10 hours to work on their PIMs project.

"That gave us time to leave our little cocoon and meet other people on campus and learn from them," says Connor. "Usually you are so busy in clinic that you never really leave your office." For example, social workers told her that patients could call them directly without a referral, and that they could also help patients develop living wills.

"If you can give patients some piece of information that shows you actually know something about it, it's much more convincing than saying, 'There's this place – I think it's pretty nice, but I've never been there,'" says Connor. The handout was so successful that it is now used by many residents, faculty and nurse practitioners at the SFVAMC.

"Having time and space to think about these things is a great idea," says Connor. "It was empowering to say, 'This is something we think is important, and it's easy to fix, so we're just going to fix it.'"

Building Better Systems

Shunk says the computer-based PIMs allow residents to complete projects in a relatively short amount of time. The interactive web programs provide patient questionnaire forms and crunch the numbers, speeding data collection and analysis. "It doesn't require an MPH or major statistical skills, and helps facilitate quality improvement projects," says Shunk.

The PIMs are now used by all medical residents at UCSF to help them improve practices in their outpatient clinics. "We believe the PIMs have an important yield, not only in terms of resident education and performance improve-ment, but also in the care of patients," says Associate Chair for Education Patricia Cornett, MD. "Linking those together has been transformative."

For example, in another recent project at the SFVAMC, residents created a form letter to notify diabetic patients that their hemoglobin A1c level was elevated, what the health consequences could be, and requesting that they schedule an appointment to improve their diabetes control. Another project at San Francisco General Hospital (SFGH) found that about one in six patients seen by a resident did not receive a needed follow-up appointment, and involved physicians, scheduling staff and clinic leaders in developing a simple intervention that lowered the proportion of "dropped" appointments by more than one-third.

In addition to Shunk, other faculty members who are now leading the implementation of the PIMs as a teaching tool include Maya Dulay, MD, at the SFVAMC, Katherine Julian, MD, at UCSF Medical Center, and Claire Horton, MD, at SFGH, along with the ambulatory chief residents at each site.

"Your systems can really help you a lot," says Shunk. "We want residents to realize that if they go into a practice that's not functioning well, they can make changes that will improve their practice and the lives of their patients."

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