The Ambulatory Long Block

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  • 1. The Ambulatory Long Block: A University of Cincinnati Educational Innovations Project
    Eric J. Warm M.D., Brian Revis M.D.,Sara McCune M.D., Jennifer Ernst, M.D., Yvette Neirouz, M.D., Tiffiny Diers M.D., Bradley Mathis M.D., Gregory Rouan M.D.
    BACKGROUND: Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting

    OBJECTIVE: Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients

    METHODS: We created the ambulatory long-block as part of the ACGMEs Educational Innovation Project. The long-block occurs from the 17th to the 29thmonth of residency, and isayear-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. Long-block residents follow approximately 120-150 patients, have office hours 3 half-days per week, and are responsive to patient needs (by answering messages, refilling medications, etc.) daily. Otherwise, long-block residents rotate on electives and research experiences with minimal overnight call. Residents receive extensive instruction in chronic illness care, quality improvement, and inter-professional teams

    RESULTS: The long-block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. There has also been a trend towards decreased emergency department visit rates and no show rates. Additionally, the long-block resulted in a robust multi-source evaluation that identified high, intermediate, and low performing residents, and suggested specific formative feedback for each

    CONCLUSIONS:An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation

    NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement
    • Patient Satisfaction is at an all time high (at left)
  • 2.Resident scores have improved the most

3.Satisfaction dips immediately after a long-block ends but then rebounds (above) 4.This may represent breakingand reforming of therapeutic relationships 5.The large team is broken up into mini-teams 6.Each mini-team consists of a nurse leader, and a group of residents, supported by many ancillary staffEDUCATIONAL RESULTS

  • The entire team, including residents, nurses, and support staff learn improvement skills, motivational interviewing and shared decision making at a yearly retreat

7.In 2007, the nursing staff transitioned from a mostly medical assistants to all RN and LPN level staff to provide case management 8.A nurse practitioner was also addedBACKGROUND

  • Most internal medicine graduate medical education is inpatient-based

9.This historical bias towards the inpatient setting has led to dysfunctional ambulatory training settings 10.Many residents receive little support for ambulatory chronic illness management, improvement science, or interdisciplinary teamwork 11.The end result of these combined deficiencies has been characterized as the training/practice gap few internal medicine graduates leave residency with the skills needed to function effectively in the ambulatory setting 12.The practice uses an electronic medical record(Centricity) and a disease registry (MQIC) 13.Residents receive extensive EMR training 14.Residents and nurses then have a pre-clinic huddle to review the patients that will be seen , and decide on an efficient plan for the day 15.Prior to each clinic session, residents review the EMR, prepare a progress note, and make a list of things that must be done during the session 16. The Learners Perception Survey demonstrated significant improvement after the long-block interventionCONTEXT

  • Residents participate in long-block board review course

17.Each long- block class has shown significant increases in in-training exam scores from PGY-2 to PGY-3 18.Our residency is in the upper quartile for passing the ABIM certification examination 19.The University of Cincinnati internal medicine residency program consists of 108 residents (69 categorical) based in a large academic health center 20.The categorical resident ambulatory practice is an urban safety-net practice located next to the main teaching hospital 21.Residents are responsible for approximately 19,000 ambulatory visits per year 22.58% of the patients have hypertension and 32% have diabetes; only 1% have private insurance 23.Residents rated their ambulatory clinic experience low during exits interviews, reported little time for learning in the ambulatory setting due to difficulty balancing ward and ambulatory duties, and reported a lack of personal reward the ambulatory setting 24.The practice also had poor patient-doctor continuity, poor clinical qualitymarkers, poor patient satisfaction, and poor staff satisfaction 25.The initial data from the first long-block showed significant improvement for many process measures and intermediate outcome measures of care 26.The initial improvements have held, and the resident practice now has many measures of care that are better than the larger health systemEVALUATION

  • Data includes quality data (above), financial performance data, patient satisfaction data, visit volume data, and the results of ongoing Plan-Do-Study-Act cycles

27.The entire team meets weekly to review data and solve problems; an open agenda is set by all team members 28.Every meeting starts with a patient story 29.Residents receive individual reports monthly 30.Each report includes a ranking on each measure compared with peers 31.Data is used as part of competency evaluation HYPOTHESIS

  • Improving resident physician continuity within a highly functional clinical micro-system would improve care and education

32.The resident ambulatory practice now meets many of the criteria for the National Committee for Quality AssurancesPatient-Centered Medical HomeINTERVENTION

  • Creation of an Ambulatory Long Block(now into the fourth year)

33.Part of the RRC-IM/ACGME Educational Innovations Project (EIP)NEW RESIDENCY STRUCTURE

  • PGY-1-2: Months 1-16

traditional residency, mainly inpatient based, with fixed half-day in the ambulatory practice
small patient panels (15-30)
each PGY-1 is paired with a long-block resident who serves as cross cover and mentor
when the PGY-1 rises to the long-block, he/she inherits long-block partners patients

  • PGY 2-3: Months 17-28 The Long Block

1 year of electives, paired with ambulatory care; minimal inpatient call service time
patient panels expand (120-150)
residents have ambulatory office hours three half-days per week on average
residents are responsive to patient needs (by answering messages, refilling medications, EMR) daily
a portion of one morning is reserved for an ambulatory education curriculum (AME, figure below))
balance of time is spent on electives (ambulatory, inpatient, research)

  • PGY 3: Months 29-36

residents return to primarily inpatient care
no ambulatory continuity practice
selected residents may elect to continue a portion of their practice one half-day per week

  • Long Block residents receive comprehensive multisource feedback (MSF) that includes self, peer, staff, attending and patient evaluations, as well as concomitant clinical quality data and knowledge-based testing scores

34.Residents are given a rank for each data point compared to peers in the class, and this data is reviewed with the chief resident and program director over the course of the long-block 35.The table above shows that in a long-block class the MSF demonstrates residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%) 36.Each high, intermediate and low performing resident had a least one aspect of the MSF significantly lower than the other, and this serves as the basis of formative feedback during long-block 37.Residents receive radar graphs (figures A-C, below) as part of their evaluation 38.Focus is given to lower scored measures (furthest from the center of the radar graph) 39.Figure A represents the top three residents, Figure B represents 3 residents in the middle of the class, Figure C represents the bottom three residentsA
CONCLUSIONS:An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation

NEXT STEPS:Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement

  • No show rates during the first long-block improved, and have maintained this level over 4 years

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