2007; 29: 660–665

Medical students learn to assess care using thehealthcare matrix

DORIS C. QUINN1,2, JOHN W. BINGHAM2, NADER A. SHOURBAJI3 & ADRIAN A. JARQUIN-VALDIVIA4

1Division of Medical Education and Administration, 2Center for Clinical Improvement, 3Vanderbilt University Medical School,MD/MBA Candidate, 4Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA

Abstract

Background: The Institute of Medicine identified six Aims for Improvement to drive the transformation of healthcare.

Simultaneously, the Accreditation Council for Graduate Medical Education issued six competencies as part of the training of

residents. American Board of Medical Specialties has also endorsed these competencies for maintenance of certification. Many

training programs have struggled with the implementation of these competencies.

Aim: This article describes two applications of The Healthcare Matrix which teaches the Core Competencies while leveraging the

IOM? Aims for Improvement? as a means of anchoring the competencies in care of patients.

Method: Third year medical students used the Matrix to identify the facilitators and barriers to quality of care. Second year internal

medicine residents also use the Matrix during their ambulatory rotation.

Results: Learners gained new insights into patient issues by using the Matrix and analysis of multiple matrices identified ?themes?

of what needed to be improved. When taught the tools and methods of quality improvement, medical students and residents learn

to lead the improvement of care.

Conclusion: The Matrix has changed the way conferences are held because they bring all the competencies to bear on the

discussion. There is less of a focus on the ?individual? and more on the systems in need improvement.

Introduction

Medical educators are being challenged now more than ever to

modify both the structure and content of medical education.

What is needed are clinicians who will be: reflective about how

they practice medicine; passionate about keeping patients safe;

collaborative in using every member of the healthcare team

effectively and efficiently; and a willingness to make changes

when presented with evidence that contradicts what they may

have learned or done for many years. Clinical leaders need to

use the tools andmethods of quality improvement to reform the

current systems that do not reliably deliver optimal care. If this is

what we need of our clinicians, the sad truth is that tomorrow’s

physicians often train in inefficient, ineffective and, too often, in

unsafe systems. Unfortunately, we have also created a culture

where complaining is perceived as ‘‘whining,’’ and those who

are adept at ‘‘work-arounds’’ (working outside the system) are

perceived as competent and effective. This circumvention of

the system ensures that the current processes, with all their

flaws, remain unchanged. As new members of the healthcare

environment, medical students and residents often see the

healthcare processes differently from veteran clinicians, but

they do not feel they have a ‘‘voice’’ to report on what they

observe. These learners need a multifaceted interpretation of

patient care that includes more than medical knowledge. They

must learn to continually ask if the care they are providing is

safe, timely, effective, efficient, equitable and patient-centered

as put forth by the Institute of Medicine (IOM 2001).

We as educators must ask ourselves how well we are

preparing future clinicians for the challenge of reforming the

current culture of healthcare. We are already seeing how

groups such as the Center for Medicare/Medicaid in the US, the

Joint Commission for Accrediting of Hospital Organizations

(JCAHO) and other public advocacy organizations are requir-

ing that performance data be submitted for accreditation and

even payment. This accountability for care will also reach the

clinician level very soon (Association of Healthcare Research

and Quality, release 2007). In medical education more

generally there has been a move to an outcome-based

model with decisions about teaching and learning related to

the specified learning outcomes (Harden 2002).

To meet the need of preparing residents for the challenge

of improving the care of patients, two quality improvement

specialists at Vanderbilt University developed an educational

tool called the Patient Healthcare Matrix (Bingham et al. 2005).

The matrix juxtaposes the six IOM aims for improvement and

Practice points

. The IOM aims and ACGME Competencies provide a

comprehensive method of assessing patient care.

. Medical Students and Residents can provide valuable

information related to patient care with this tool.

. The Matrix helps learners of all disciplines examine care

issues in a systematic way.

Correspondence: Doris C. Quinn, PhD, Vanderbilt University Medical Center, B131 VUH, 1211 22nd Ave South. Nashville, TN. 37232-7220, USA.

Tel: 615-343-6393; fax: 615-343-5967; email: doris.quinn@vanderbilt.edu

660 ISSN 0142–159X print/ISSN 1466–187X online/07/070660–6 � 2007 Informa UK Ltd.

DOI: 10.1080/01421590701593971

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the six ACGME core competencies and guides the evaluation

of patient care as seen by the medical students, residents, and

practicing physicians.

The aim of the Matrix is to teach the competencies; link the

competencies to the care of patients (in real time); assess the

medical students and residents understanding of the compe-

tencies as they relate to patient care; collect data on care of

patients; identify opportunities for improvement; and engage

medical students and residents in projects to improve care in

order to learn the science of improvement.

Using the matrix

The top row of the Matrix prompts the user to question

whether patient care has met each of the six IOM Aims (was

care safe, timely, etc.). For this row, a ‘‘Yes/No’’ answer is

sufficient. If the answer to any of these aims is ‘‘no’’, the user

moves down the Matrix row by row to assess the role of the

next four competencies in establishing why the answer was

‘‘no.’’ Was it lack of medical knowledge, inadequate commu-

nication, problems with professionalism, and/or deficiencies in

the systems supporting patient care? Once these five compe-

tencies have been addressed, the final competency, practice-

based learning and improvement, completes the care analysis

loop by asking ‘‘what was learned and what needs to be

improved’’? If this row is not completed, it serves as a reminder

that this loop has not been closed, and therefore critical

elements of quality and safety may have been overlooked.

Without changes to the current system, no improvements in

care will occur. The matrix provides a systematic approach to

identifying issues/problems of patient care in a non-punitive

manner and with a clear focus on process/systems and not

individuals. This tool allows all disciplines (nurses, social

workers, medical students, residents, etc.) to be heard because

the matrix is equally applicable to all health professions.

Aggregation of data from many matrices assists in the

identification of improvement opportunities within a specialty,

a department, or for the entire organization.

Medical students

The Matrix was introduced to the Department of Neurology by

the clerkship director. He thought that having the medical

students work with the matrix early in their careers might allow

them to complete the matrix with more ease and efficiency

than doing so later in their training, when they have a higher

workload and more responsibilities. Medical students were

asked to submit a history and physical write-up on a patient,

including an associated matrix. Data from each cell were

entered into an Excel spreadsheet (Figure 1). We then looked

for patterns and themes that could inform us about the care of

patients in this specialty. The data could be sorted by column,

Figure 1. Analysis of aggregated Matrix data using Excel Spreadsheet.

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row, diagnosis, cell content, or code (was it positive, negative

or an improvement idea) depending on the question.

For example, we looked at all the safety issues and stratified

these concerns by the competencies. It was no surprise that

communication surfaced as one of the leading negative issues

in care of patients. Of the 28 matrices completed, six were for

the care of a patient with a stroke. These matrices seemed to

generate very few negative comments overall and seemed

to reflect better team interactions and communication.

To analyze further, we sorted by competencies, specifically

system-based practice. We discovered that the medical

students observed well-defined roles and minimal

communication problems for care of patients with a stroke.

We compared these findings with those of patients with

other neurological problems. Results were not always positive,

especially if multiple specialties were involved

(e.g., a pregnant woman who develops seizures). We found

that there was no real ‘‘ownership’’ of the patient, which often

resulted in delays in referral and care. One medical student

captured this ‘‘system’’ in a diagram (Figure 2). Why was the

care different within the same department? The reason was

the creation of a stroke team with clearly defined roles and

guidelines for care. There was no such team for other services,

making the case for defining evidence-based guidelines.

Internal medicine residents

The Department of Medicine has incorporated the Healthcare

Matrix into an eight-week ambulatory medicine rotation that all

medicine residents complete during their second year of

training. During this class, the publicly reported measures for

acute myocardial infarction, congestive heart failure and

pneumonia are introduced. Each resident selects one of

his/her own patients and completes a Matrix (Figure 3).

This allows them to learn the competencies, and reflect on the

care of the patient, while providing valuable information about

the care of patients in general. The residents are then asked to

review their panel of continuity clinic patients and to identify

those with coronary artery disease. They had never before

been asked to review their patients as a ‘‘panel’’. To learn

system-based practice, the residents’ flowchart the care of

patients in the clinic and do a brainstorming exercise

documenting all the obstacles that prevent them from

providing optimal patient care. They will then review their

flowchart and brainstorming issues and decide on one or two

improvements that need to be made (practice-based learning

and improvement). If time permits, they will actually make

improvements. If insufficient time, the next class may well pick

up where the previous group left off.

Discussion

These applications of the Matrix have taught us that: medical

students and residents were able to identify both outcomes of

care and competency development issues that were previously

unrecognized and that it is possible to not only learn the

competencies but more importantly, identify where systems do

not support optimum patient care and make recommendations

to improve care. One medical student (Shourbaji) was also

completing a dual degree of MD/MBA. His reflections were

particularly poignant for so young a physician-in-training.

‘‘My journey over the past years started with medical

school, and led me to business school via the Matrix.

After seeing the inherent value in this project and deciding it

is something I would like to work with further, I pursued my

MBA so that I could learn more tools that would allow me to

contribute more effectively. The predominant problem-solving

approach in the MBA world is very team-based and organiza-

tion-focused. MBA candidates are taught to analyze situations

in the context of the overall systems in which they exist.

This way of thinking stands in stark contrast to the focused

methodology of medical training, in which students have a

Figure 2. Diagram of the ‘‘system’’ for care of patient with seizures.

D. C. Quinn et al.

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Figure

3.

Matrixofpatientwithch

est

pain.

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narrow perspective related to the diagnosis at hand. This way

of thinking persists and manifests itself in poor systems

awareness all the way up the medical hierarchy to the

attending physician level.

MBA candidates are taught to lead organizations.

Accordingly, they must analyze their course of action with

an eye on the big picture; their decisions have major impacts

on all of those around them. Particularly important to the

organizational perspective is the idea of efficiency. From an

operations standpoint, MBA students learn to pay particular

attention to stocks and flows to ensure that facilities are being

used at optimal capacity – that means avoiding both overuse

and underuse. Communication is emphasized as the ultimate

lubricant to keep organizational machines running smoothly.

As medical students, we get a brief introduction to some of

these ideas early in the pre-clinical years. Unfortunately, the

lessons come too early; in the first year, when we are

inundated with a completely new learning style and unprece-

dented volumes of information, there is little time to assimilate

the things we learn about operations. More importantly, we do

not have the clinical experience to make any of it relevant or

meaningful, so what we learn is often expunged before we can

actually apply it on our clinical rotations.

There are no equivalent lessons in clinical medical

education, where the only thing usually kept in mind is

disease and its cure. While the diagnosis and treatment of

disease should obviously be the main focus for the clinician,

the impact of his or her decisions and actions on other

providers must also be taken into account to optimize patient

care. In addition to doctors, nurses, therapists, social workers,

and many others must also work with the patient. While all

of these different stakeholders share the same ultimate goal,

healing the patient, they all may have different intermediate

goals along the way. They are all interdependent, relying upon

each other for both information and services, but,

unfortunately, they often make decisions independent of one

another. There is little coordination or collaboration between

the groups besides the daily notes and rounds. Poor practices

are often perpetuated through future generations of physicians

as they become unmoored from their pre-clinical lessons.

Students see the way their superiors get things done, and they

begin to adopt their behaviors. Residents and attendings may

sometimes forget what it is like to be a 3rd year medical

student, but superiors are the single greatest influence on

students’ behavior. Thrown into a very unfamiliar environment

with little preparation, students cope with the challenges they

face on the wards by mimicking residents, and residents in

turn behave much like their attendings. While the vast majority

of medical professionals provide a compassionate and

thoughtful mentor to emulate, the unfortunate reality is this

may often include maladaptive behaviors such as

confrontation with peers, adversarial relationships with

nurses, and condescension towards other staff.

Providers’ maladaptive behaviors result primarily from an

inability to consider the system in which they operate;

this applies to all groups of providers. The system in which

many parties depend on each other breaks down when those

parties fail to adequately consider others in their decisions.

Medicine is based on multidisciplinary teams, and there is no

way these teams can function optimally when they are not

working in unison. This is a sort of reductionism, in which

each part operates independently of the whole.

The best way to remedy the problems created by a lack of

systems understanding is to get teams in name to actually

function as teams. Providers must be trained to change the way

they view things. The healthcare matrix provides a bridge,

allowing medical practitioners without previous exposure to

systems thinking, to adapt their mental models to not only

incorporate this thinking into their practice, but to make it

second nature. By providing a clear framework, thematrix takes

a very complex and layered problem and reduces it to its

essence, one which providers can grasp and digest. One of the

prime benefits of working with the matrix is that it gives busy

practitioners a chance to reflect on patient encounters. It gives

them a framework in which to evaluate care situations. Most

importantly, through the action plan, it provides an opportunity

for learning, so that future encounters may be improved. This

knowledge can then be internalized and shared with others.’

Conclusion

Our experience, as well as that of other ‘‘early adopter’’

academic medical centers, can best be summarized by what a

fellow told us: ‘‘We are slowly transforming the educational

environment to one where learning occurs with other team

members; where facts about patient care are structured and

displayed systematically; and where decisions are made in a

collaborative manner, rather than in an environment char-

acterized by ‘‘name, blame and shame’’. This new learning

environment represents a shift in culture that acknowledges

the resident as part of a system in which he or she learns while

learning about the system of care’’ (Dr. Seth Cohen, Dept of

Otolaryngology). The healthcare matrix helps learners of all

disciplines examine care issues in a systematic way while

giving them a voice to discuss sensitive issues that may have

compromised patient care and safety.

To date, the matrix has been used in a variety of other

settings including (1) individually focused learning, where the

resident selects one patient and completes the (2) matrix;

morbidity and mortality (M&M) conference and case confer-

ences where the Matrix channels the discussion to examine the

full spectrum of competencies and not just individuals; and

(3) for the development of a curriculum for a geriatrics grant

using the analysis of all matrices that dealt with care of the

elderly. The Matrix was used as the framework for the

curriculum to assure that all IOM aims were addressed.

Vanderbilt was successful at obtaining the grant from the

Reynolds Foundation. The matrix will be used as one method

of evaluating medical students and residents’ understanding

of special issues in caring for this population.

A web-based application of the matrix has been developed

with an Oracle database, allowing all matrices to be

aggregated for learning purposes. Though not yet fully

functional, we expect a web portal to make it possible for us

to study care through the use of matrices from individual

learners, by specialty, diagnosis, institutions and even matrices

submitted from partner institutions.

D. C. Quinn et al.

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Determining improvements needed (practice-based

learning and improvement) may represent the greatest

contribution of the Matrix as it moves the discussion from

what is ‘‘wrong’’ with the system to what should be done to

improve future outcomes. Ultimately, we would like to see if

those sites using the Matrix achieve the desired behavior and

system changes that will translate into better outcomes of care

for patients. All this is intended to – and indeed, will – improve

patient care by teaching learners clinical and human interac-

tion skills and quality improvement.

Notes on contributors

DORIS QUINN is Asst. Professor in the Division of Medical Education and

Administration, Vanderbilt University Medical Center.

JOHN BINGHAM is Director of the Center for Clinical Improvement and

Vanderbilt University Medical Center.

NADER SHOURBAJI is MD/MBA Candidate at Vanderbilt University

Medical School.

ADRIAN JARQUIN-VALDIVIA is Asst. Professor in the Dept of Neurology,

Vanderbilt University Medical Center.

References

Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. 2005.

Using a healthcare matrix to assess patient care in terms of aims for

improvement and core competencies. Joint Commission Journal on

Quality and Pt Safety 32:98–105.

IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st

Century. Institute of Medicine, Washington, DC.

Harden RM. 2002. Developments in outcome-based education. Med Teach

24:117–120.

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