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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: [email protected]
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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