Advanced Curriculum Development: Creating Education Models in Practice Based Learning and Improvement and

Systems Based Practice to “Geriatricize” Your Environment

Kathryn E. Callahan, MDHelen M. Fernandez, MD, MPHKirsten Feiereisel, MDWilliam P. Moran, MD, MSPaula M. Podrazik, MDPatty J. Iverson, MA

Objectives• Identify the resources, strengths, and needs in your home institution’s

educational environment to support the design of a PBLI/SBP curriculum with a geriatric focus

• List at least 2 strengths and 2 weaknesses of differing curricular approaches to teaching PBLI and SBP

• Generate at least 1 goal and 3 objectives for a curriculum in PBLI/SBP at your home institution

• Operationalize the needs, goals, objectives, strengths, and weaknesses of your institution’s educational environment to craft the basics of a curriculum in PBLI or SBP using geriatric content.

QI in Ambulatory Geriatrics

Implementation of the Practice Improvement Module for Care of the Vulnerable Elderly: CoVE PIM

Wake Forest School of Medicine

Care of the Vulnerable Elderly Practice Improvement Module (CoVE PIM)

Wake Forest School of Medicine

Piedmont Plaza (FM)OPD Clinic (IM)

Downtown Health Plaza (IM)

CoVE Sites

Wake Forest School of Medicine

Implementing the CoVE PIM

Phase 1: Collect practice data to evaluate performance measures

All PGY-2’s perform a medical record audit on at least 5 older patients in their continuity clinic panel

• Family Medicine- incorporated into clinic experience

• Internal Medicine- incorporated into inpatient geriatrics

At least 25 patient surveys per practice

Submit 1 practice site survey

Wake Forest School of Medicine

Phase 2: Implement Quality Improvement Project

All PGY-3’s review ABIM aggregate data report

Develop, implement and evaluate a quality improvement project to target deficiencies

One project per site

Implementing the CoVE PIM

Wake Forest School of Medicine

CoVE PIM: Internal and Family Medicine

• 2009 Cohort:

• 35 residents completed Phase Two.

• OPD: 12 residents; 60 charts audited; 25 patient surveys.

• DHP: 13 residents; 65 charts audited; 30 patient surveys.

• FM: 10 residents; 60 charts audited; 56 patient surveys.

• 2010 Cohort:

• 38 residents completed Phase One (10 FM/28 IM).

• Phase Two starting Fall 2011.

• 2011 Cohort:

• 38 residents, beginning Phase One.

Wake Forest School of Medicine

CoVE PIM, operationalized:

• IM: Two teams (OPD and DHP), each with:

• 2 faculty mentors

• 3 Resident Leaders: Team Leader, Communication Czar, Interdisciplinary/Staff Liaison

• Additional roles defined as project develops (e.g., Information Technology Liaison, Literature Reviewer)

• FM: Two teams, each with:

• 1 faculty mentor

• 1 Chief Resident

Wake Forest School of Medicine

CoVE PIM: IM 2009 Cohort Impact• Leadership roles inspire Geriatrics interest:

• Team Leaders presented at Grand Rounds

• Team Leaders plan Geriatrics fellowship

• Systems-Based Practice Outcomes:

• Resident-designed Geriatrics Screening Template in hospital-wide EMR

• Interdisciplinary team leadership experience

• Practice-Based Learning Outcomes:

• “I didn’t realize there were guidelines for older adults!”

• “I laminated the Falls Algorithm and posted it…”

Experiential and Longitudinal QI Curriculum for Geriatrics Fellows

• Didactic: QI Curriculum• Application: Practice Improvement Module for

Care of the Vulnerable Elderly (CoVE-PIM)• Assessment:

– Pre- and Post-Test with the Quality Improvement Knowledge Application Tool (QIKAT)

– Structured Interview with fellows– Audit and Feedback with mentored QI project

QI Curriculum• Institute of Healthcare Improvement

– Courses designed by IHI: self-paced• QI 101: Fundamentals of improvement• QI 102: The Model of Improvement• QI 103: Measuring for improvement• QI 104: Putting It All Together• QI 105: Human side of QI• QI 106: Level 100 tools

– Each session duration time is from 30 minutes to 1 hour

QIKAT

• Assesses prior experience with QI

• Three scenarios reflecting quality of care problem:– Identify aim of improvement project– Appropriate measures– Desired outcome for scenario

• Assesses attitudes:– Does learner feel QI is essential to future career?

– Does learner possess confidence in his/her ability to bring about change?

Practice Improvement Module

Holmboe et al. JCEHP 2006; 26: 109-19.

Curriculum, continued

• Fellows reviewed the needs assessment• Three small groups (clinic day); presented

ideas for QI projects• Single project identified (cognitive screening)

and implemented• Outcomes:

– Re-measure process indicator– QIKAT post-test– Qualitative interview with fellows

Curriculum for the Hospitalized Aging PatientCurriculum for the Hospitalized Aging Patient

CHAMPCHAMP

Teaching PBLI/SBP: Teaching PBLI/SBP: Incorporating CHAMP Teaching Tools into your CurriculumIncorporating CHAMP Teaching Tools into your Curriculum

Paula Podrazik, MDPaula Podrazik, MDProgram Director, Geriatrics FellowshipProgram Director, Geriatrics Fellowship

University of Arkansas for Medical Sciences University of Arkansas for Medical Sciences

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CHAMP developed at the University of ChicagoSupported by a D.W. Reynolds Foundation educational grant

17

http://champ.bsd.uchicago.edu

Process Mapping as a teaching Process Mapping as a teaching tooltool

A A process map process map or flowchart is a picture of the sequence of steps in a process as or flowchart is a picture of the sequence of steps in a process as it it

actually occurs. Can be a “higher level” or “drilled-down” view of the process.actually occurs. Can be a “higher level” or “drilled-down” view of the process.• In the health care industry useful forIn the health care industry useful for

– Planning a projectPlanning a project– Describing a processDescribing a process– Documenting a standard way for doing a jobDocumenting a standard way for doing a job– Building consensus about the process & correct misunderstandings Building consensus about the process & correct misunderstandings

• In resident & student teaching useful forIn resident & student teaching useful for– Teaching about PBLI– holding the “mirror ” to your practiceTeaching about PBLI– holding the “mirror ” to your practice– Teaching about SBP-understanding the “village” that delivers careTeaching about SBP-understanding the “village” that delivers care

”The first step is to draw a flow diagram then everyone understands what his job is. If people do not see the process, they cannot improve it.” W.E. Deming, 1993

CT Abd. needed

EMR order Stat? Patient transported

Exam Completed

Call Radiology Tech.

NO

YES

Process map of a clinical care issue—”higher level” process view

Teaching Case Audit

Case Audit: What is it?Case Audit: What is it?

A structured review of clinical A structured review of clinical care across a single patient’s care across a single patient’s hospital stayhospital stay

▪ ▪ Addresses a Addresses a relevant clinical relevant clinical issue issue ▪ ▪ Accepted quality measures Accepted quality measures existexist ▪ ▪ Performed by the teamPerformed by the team ▪ ▪ Fits PBLI constructFits PBLI construct

Inouye S, et al. Ann Intern Med 1992; 119:474.Inouye S., et al. Ann Intern Med 1990; 113:941.Inouye S, et al. JAMA 1996; 275:852.

From Whelan, Podrazik, Johnson. Semin Med Pract 2005; 8:70. Developed by Dr. Podrazik @ University of Chicago.

Teaching Census Audit

Census Audit: What is it?Census Audit: What is it?

A review of clinical care across A review of clinical care across patientspatients

▪ ▪ Addresses a focused clinical Addresses a focused clinical issueissue▪ ▪ Simple quality measures existSimple quality measures exist▪ ▪ Performed by the team Performed by the team ▪ ▪ Fits PBLI constructFits PBLI construct

From Whelan, Podrazik, Johnson. Semin Med Pract 2005; 8:71. Developed by Dr. Whelan @ University of Chicago.

MUSCAging Q3

http://mcintranet.musc.edu/agingq3

Knowledge to Performance

Academic Detailing Resident Cue

Participation

Activity

Falls

9/8/09 – 12/14/09

n (%)

Faculty attending in-service 17/27 (77.8%)

Residents attending didactic37/100 (37%)

Detailing encounters Detailed86/100(86%)

Skill - TUG64/100(64%)

Teaching Attendings detailing Based on all Teaching Attendings:18/21 (85.7%)

Teaching Attendings observing skill - TUG 13/15 (87%)

EMR Template