Ambulatory Quality Improvement

The UCSF ambulatory QI curriculum spans all three clinic sites (VA, SFGH, Mt. Zion) and allows residents to learn and practice principles of QI. The goal of the curriculum is to equip residents with the skills necessary to incorporate systems-based practice within their outpatient clinic experience. By teaching these skills and then utilizing them in a year-long QI project, we hope residents develop the foundation needed to continuously improve the system in which they deliver care.

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

In addition to the appropriate medical knowledge, competency in systems-based practice and practice-based learning are increasingly important to the physician of the future. The ambulatory QI curriculum establishes a foundation that is necessary to perform clinic-based QI projects with the appropriate mentorship. All first-year residents receive an introduction to QI during their intern rotation, but during the ambulatory blocks of second and third year, they are provided an opportunity to put these concepts into action.

Based on the Institute for Healthcare Improvement's Model for Improvement and selected online learning modules, faculty at each site teach QI concepts during ambulatory conferences, often using the QI Knowledge Assessment Tool (QIKAT) to guide the focus of the didactics. In order to determine the needs of each clinic system and help residents choose a relevant QI project, residents are asked to review performance data and perform root-cause analyses on real patient cases.

Residents receive specific performance feedback at least quarterly at each clinic site. The performance measures include compliance with preventive care guidelines such as annual diabetes screening, mammography, colon cancer screening and vaccinations. They also include disease management measures such as the percentage of patients in a clinic panel with an A1C >9% or BP >140. These individual performance metrics are reviewed with the residents and certain goals (i.e. personal QI projects) are encouraged to improve individual practices. In reviewing overall clinic performance data, if specific problems are recognized, residents are encouraged to brainstorm potential solutions and QI projects. During the two-year curriculum, residents are also asked to identify cases within their own patient panel where an error or adverse outcome occurred and perform a root-cause analysis (RCA). The errors identified during the RCA are used to spearhead QI projects as well. In the process of creating and implementing their QI projects, residents learn about microsystem tools such as process-mapping, fishbone diagrams and run charts.

In the past few years, there have been many successful QI projects at each site. At the San Francisco VA Medical Center, the residents have worked with their interprofessional trainee partners to develop projects such as improving the rates of annual LDL screens in patients with diabetes, which taught residents and nurse practitioner students panel management tools. Other projects at the VA have included improving patient care coordination via a 48-hour post discharge phone call, increasing timeliness of responses to medication refill requests, and implementing a health care maintenance template in the electronic health record. Projects at SFGH have included creating a new complex care management program at General Medicine Clinic for high-risk patients and improving the prior authorization process in clinic. At Mt. Zion last year, the residents focused their efforts on building up an interdisciplinary care team to address chronic diseases.

For additional information or questions about the Ambulatory QI curriculum and projects, 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