THE HEATLHCARE MATRIXErin Hurley, PGY 4June 16, 2020

“Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘If not—why not?’ with a view to preventing similar failures in the future.”

Ernest Codman M.D. , 1914

PATIENT SAFETY Anesthesia coined the term “patient safety” Institute of Medicine (IOM) of the US

Academy of Sciences 1999: “To Err is Human” 2001: “Crossing the Quality Chasm”

QUALITY CHASM “Health care we have and the care we could

have– represents more than a gap, but rather a chasm”

Medical education chasm

IOM Care of every patient has the potential to

improve the care of all patients yet to come Competencies are integrated into the routine

practices of daily care Decision making regarding care of the

patient is guided by the best evidence available

The quality of health care is positively related to the quality of medical education

IOM– AIMS FOR IMPROVEMENT Safe Timely Effective Efficient Equitable Patient Centered

ACGME The content of graduate education is aligned

with the changing needs of health systems Residency programs use sound outcome

assessment methods for both residents’ and programs’ achievement of educational outcomes.

ACGME COMPETENCIES“Quality of health care is positively related to

quality education”

CORE COMPETENCIES Patient Care Medical Knowledge Interpersonal and communication skills Professionalism Systems-based practice Practiced-based learning and improvement

CORE COMPETENCIES Teaching

No prescribed formulas Assessment

Interpersonal and communication skills System-based practice Practice based learning and improvement

HEALTHCARE MATRIX A formative approach to the presentation of core competencies to residents, which in turn

is having an effect on the faculty and their patient care

A response to the challenge of linking all six competencies with the realities of the current medical education system– which is focused on acquisition of medical knowledge

Healthcare Matrix: Care of Patient (s) with… AIMS

Competencies

Safe Timely Effective Efficient Equitable Patient-Centered

Patient Care

Medical Knowledge

Interpersonal/Comm. Skills

Professionalism

Systems Based Practice

Practice-Based Learning /Improvement

IMPROVEMENT

The Healthcare Matrix, 2004, John Bingham & Doris Quinn, Vanderbilt University

PATIENT CARE SHOULD BE: Safe: Avoiding injuries to patients from care intended

to help them Timely: Reducing waits and sometimes harmful delays

for those who receive and give care Effective: Providing services based on scientific

knowledge to all who could benefit; refraining from providing services to those likely not to benefit

Efficient: Avoiding waste of equipment, supplies, ideas, energy

Equitable: Providing care that does not vary in quality because of personal characteristics

Patient-Centered: Providing care that is respectful of and responsive to individual patient preferences, needs, values; ensuring that patient values guide all clinical decisions

MEDICAL KNOWLEDGE: WHAT MUST WE KNOW?

Patient care Safe Timely Effective Efficient Equitable Patient Centered

Medical Knowledge

“…about established and evolving biomedical, clinical, and cognate sciences, and application of this knowledge to patient care.”

INTERPERSONAL/COMMUNICATION SKILLS: WHAT MUST WE SAY?

Patient care Safe Timely Effective Efficient Equitable Patient Centered

MK

Interpersonal & Communication Skills

“…that will result in effective information exchange and teaming with patients, their families, & other health professionals.”

PROFESSIONALISM: HOW MUST WE BEHAVE?

Patient care Safe Timely Effective Efficient Equitable Patient Centered

MK

ICS

Professional-ism

“…as manifested through commitment to carrying out professional responsibilities, adherence to ethical principles, & sensitivity to diverse patient population.”

SYSTEMS-BASED PRACTICE: WHAT IS THE PROCESS? ON WHOM DO WE DEPEND? WHO DEPENDS ON US?

Patient care Safe Timely Effective Efficient Equitable Patient Centered

MK

ICS

Prof

Systems-Based Practice

“…as manifested by actions that demonstrate an awareness of, and responsiveness to, a larger context & system of healthcare and ability to effectively call on system resources to provide care of optimal value.”

PRACTICE-BASED LEARNING & IMPROVEMENT: WHAT HAVE WE LEARNED? WHAT WILL WE IMPROVE?

Patient care Safe Timely Effective Efficient Equitable Patient Centered

MK

ICS

Prof

SBP

Practice-Based Learning & Improvement

“…involves investigation & evaluation of residents’ (program’s, or institution’s) own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.”

VALUE OF THE MATRIX Healthcare Matrix: Improving Care by Linking

Outcomes to Competencies Over 100 matrix presentations at Vanderbilt Guide learners in analyzing the care of their own

patients by using Core competencies to identify opportunities for improvement

Change the environment of case presentations and MM conferences from one of blame to one of

system analysis and quality improvement

EFFECTIVENESS Provides a learning format that is part of

daily education and delivery of care by residents

Addresses the multidisciplinary culture in which residents practice

Being used by many health professions besides residents

Provides a solution that is standardized so that multiple programs and institutions can have a common framework to teach the competencies and learn from each other

EDUCATIONAL ENVIRONMENT The matrix allows transformation of the

educational environment Team learning Patient care– structures and systems Collaborative decision-making Collective analysis and improvement Connections/trends between cases

MATRIX AT VANDERBILT 100 matrices were analyzed to look at safety

concerns across institutions Four major themes identified

Communication Teamwork “workarounds” (circumventions of a system) Inadequate or poor documentation

CEDARS-SINAI MEDICAL CENTER Using the healthcare matrix to teach and

improve patient safety culture in an OB/GYN residency training program Utility of healthcare matrix in teaching about

safety and improvement of care

METHODS HCMC is held at least once monthly in our

residency education program The selected resident chooses the case &

develops a draft matrix under faculty supervision

A multidisciplinary team is invited based on the case

The matrix is presented at conference and a consensus action plan for implementation is generated after discussion

METHODSTwo years after the initiation of the

program, the residents completed an anonymous 15-item survey about their perception of the program using a 5 point Likert scale

RESULTS 26 HCMC were held from 2007 to 2009 PGY-4 residents prepared & conducted 77%

sessions

Case Distribution (n=26)Management concerns 42.3%Medication errors/concerns 23.1%Bleeding complications 34.6%

Clinical distributionGynecology cases 46.2%Obstetrical cases 53.8%

SUB-OPTIMAL CARE BY IOM AIMS

96%

65%

50% 46%

19% 23%

0%

20%

40%

60%

80%

100%

Safe Timely Effective Efficient Equitable PatientCentered

SUB-OPTIMAL CARE BY ACGME COMPETENCIES

65%

69%

96%

100%

46%

77%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Interpersonal & Communication Skills

Medical Knowledge & Skills

Patient Care

PBL & Improvement

Professionalism

System-based Practice

Figure 1: *Residents perception of the utility of the Healthcare Matrix (n=21)

90.50%

95.20%

71.40%

28.60%

85.70%

100%

95.20%

38.10%

90.50%

0%

95.20%

47.60%

57.10%

81.00%

100%

0.00% 10.00%20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%100.00%

Fosters learning

Helped assess errors

Review errors in blame free environment

Felt awkward presenting errors of my superiors

Changed my practice

Helped analyze a complex situation

Useful for quality improvement

Improved my communication skills

Improved ability debrief

Should be canceled

Great, continue to use

Preparation is time consuming

Would use in my clinical practice in future

Effective for teaching ACGME competencies & IOM Aims

Should be interdisciplinary

Residents perception of the utility of the Healthcare Matrix

RESULTS- RESIDENTS’ SURVEY Effective, fosters learning, and should be

continued Improved their ability to debrief, was useful

for quality improvement, helped analyze a complex situation, changed their practice, and helped assess errors

Some felt awkward presenting medical errors made by their superiors, but the majority felt that the HCMC provided them with a blame free environment to discuss errors

CONCLUSIONResidents can use the healthcare

matrix in a multidisciplinary setting to evaluate and improve patient care.

HCMC allows the IOM Aims to become a framework for reviewing patient safety culture.

Allows residents to integrate the ACGME Competencies as part of their routine clinical practice.

CONCLUSION Timeliness, medical knowledge, &

communication issues were major contributors to patient safety concerns.

Residents’ survey highlights areas that need more attention.

Healthcare matrix provides a foundation for systematic transformation in patient care, medical education, and team dynamics that could be useful for residency training programs.

MATRIX 2007Healthcare Matrix: Care of Patient with uterine atony after D+E with DIC

AIMS Competencies

SAFE(Avoiding injury from care intended

to help)

TIMELY(Reducing delays for pts and

providers)

EFFECTIVE(Evidence-based medicine, avoiding

underuse and overuse)

EFFICIENT(Avoiding waste of equipment, supplies, ideas, and energy)

EQUITABLE(Care does not vary based on race,

ethnicity, gender, SES)

PATIENT-CENTERED(Care with respect for

preference, needs, values)

Assessment of Care

PATIENT CARE(Overall Assessment)

Yes/No

No - patient nearly died from hemorrhagic shock

No - Life saving treatment was delayed at several levels

No – intrauterine ballon, uterotonics and fluid resuscitation ineffective.

No – resources such a blood products, mobilization of staff not utilized in efficient manner.

Yes Yes – Patient and family informed at all times. Patient desired to avoid hysterectomy at all costs.

MEDICAL KNOWLEDGE and

SKILLS(What must we know?)

 Ensure oxygen delivery, support BP, aggressive IV rescuscitation, treat cause

 Prompt diagnosis, recognize urgency, initiate therapy, timely transport to OR.Urgency to treat delayed.

 Treatment of uterine atony – uterotonics, intrauterine ballon used. Delayed decision to hysterectomy.

 Aggressive IV resuscitation, repletion of blood products, correction of DIC

 N/A  N/A

INTERPERSONAL AND

COMMUNICATION SKILLS

(What must we say?)

 Debriefing of all teams involved even if ICU is closed

Blood results – stat should be available sooner than 3 hrs. Crossmatched blood should be available sooner.

 More effective communication between team members. Better communication better ICU and gyn residents.

 Private MD patient involve faculty MD

 N/A  Good communication with patient and family for intended intervention.

PROFESSIONALISM(How must we

behave?)

 Do no harm    Professional duty to accompany critically ill patient to the OR, to ensure safety and to expedite therapy.

 Mobilize team members to collect blood products.

 N/A  Preserve patient autonomy

SYSTEM-BASED PRACTICE

(What is the process?On whom do we

depend? Who depends on us?)

 System should ensure that appropriate consultants notified such as anaethestiologist for intubation,

 D+E should be done in a tertiary facility so that blood can be mobilized as soon as possible.

 Crossmatch in life-threatening situations should be a priority.

   Availability of lab medicine, physician, timely transport of blood, expertise of gyn, anesthesiology should not vary from time of day/night

 

SUMMARY--CREATING AND REINFORCING A CULTURE OF LEARNING The matrix is intended to help consider patient

care in terms of the IOM Aims and the ACGME Core Competencies

Enhance learning for every resident Team learning/ team dynamics Collaborative decision Resident– part of a system of care Common framework for evaluating and

improving patient care across disciplines Integrate the ACGME Competencies as part of

their routine clinical practice Improve quality of care

THANK YOUThe End

Erin Hurley, PGY 4June 16, 2020

REFERENCES Institute of Medicine: Crossing the Quality Chasm.

Washington D.C.: National Academy Press, 2001 Using a Healthcare Matrix to Assess Patient Care in Terms of

Aims of Improvement and Core Competencies. Journal on Quality and Patient Safety, February 2005

Quinn D , The Healthcare Matrix: Improving Care by Linking Outcomes to Competencies. MedEdPORTAL; 2007.

Using the Healthcare Matrix to teach and improve patient safety culture in an OB/GYN residency training program Steven Rad, Connie Chung, Jessica Y. Hsu, Carolyn Alexander, and Dotun Ogunyemi. APGO 2010

Shine, K.: Crossing the quality chasm: The role of postgraduate training Am J Med113: 265–267, Aug. 15, 2002