Unformatted text preview: Systems-Based Care and
Systems-Based
Practice Based Learning
Practice
and Improvement
and The Problem
The The American healthcare delivery
The system is in need of fundamental
change
change The current systems cannot do the job Trying harder will not work Changing systems is necessary We’re Driving a Powerful Vehicle,
but it has no:
but
Map Compass Speedometer Odometer, or
Odometer, Clock
Yet the pedal’s to the
Yet
floor
floor Aims for Improving Healthcare
Aims Safe Effective Patient-centered Timely Efficient Equitable To Err is Human: Building a
To
Building
Safer Health System
Why start with errors?
Why Burden of injury Understandable to providers and
Understandable
consumers
consumers Avoidable Experience in other industries Many People are Harmed Adverse event – an injury caused by
dverse medical management
medical Adverse events occur among 3-4% of
Adverse
hospitalized patients
hospitalized About 1 in 10 results in death Over half are preventable Key Findings Errors occur
Errors because of system
system failures
failures Preventing errors means designing a
Preventing safer system of care
system “Few newly qualified physicians have the
Few
necessary skills to improve health care and
safety. These include the ability to perceive
and work effectively in interdependencies, the
ability to understand work as a process, skill in
collecting, aggregating, analyzing, and
displaying data on the processes and
outcomes of care, skills in designing health
care processes, an ability to work in teams and
collaboration with managers and patients, and
the willingness to examine honesty and learn
from mistakes”
from Professional Competence: a
definition
definition
The habitual and judicious use of
The habitual
communication, knowledge,
technical skills, evidence-based
decision-making, emotions, values
and reflection to improve the
health of the individual patient and
the community
the Systems-Based Practice
Systems-Based
“Residents must demonstrate an
Residents
awareness of and responsiveness to
the larger context and system of health
care and the ability to effectively call on
system resources to provide care that
is of optimal value.”
is Why Systems-Based Practice?
Why Prepare physicians to work in the
Prepare current system
current Optimize cost and outcomes Improve the system Transform the health care system “Very few doctors understand
Very
what is happening to the health
care system in which they
practice, why the system is
changing so rapidly, and what
they can do about it”
they
-- Relman, Acad Med, 73, 1998 Why Systems-Based Care?
Why
“A systems view is critical to
systems understanding patient outcomes,
safety, values and quality”
safety, What are the components of
Systems-Based Care?
Systems-Based For your Residency Program? For your institution/hospital? Some components of SystemsSome
Based Practice System resources
Patient advocacy
Health care economics
Teamwork
Cost-benefit
Cost-benefit
considerations
considerations
Healthcare economics
Healthcare Financing Practice management
Insurance Types
Medical-Legal Issues
Coordination of health
Coordination
care
care
Documentation Issues
Social and political
Social
history of US health
care system
care Elements of Systems: The
Resident-System Interface
Resident-System
Within the hospital/clinic Admitting/scheduling Documentation Other clinical services Ancillary services Nursing Pharmacy Outside the
Outside
hospital/clinic
hospital/clinic Referring physicians Insurers, HMO’s Community services External laboratory
External
and radiological
services
services Legal system Systems Thinking Principles and
Concepts
Concepts Interdependence Structure drives behavior Cause and effect are separated by time
Cause and place
and Any change in a system has
Any
unintended consequences
unintended “The prominence of physicians
The
in highly interdependent medical
systems confers tremendous
power on them, individually and
as a profession. With this power
comes an ethical responsibility
to be deeply concerned about
medical systems.”
medical
--Nolan, Annals Intern Med, 1998 Practice-Based Learning and
Improvement
Improvement
“Residents must be able to
Residents
investigate and evaluate their
patient care practices, appraise
and assimilate scientific evidence,
and improve their patient care
practices.”
practices.” Practice-Based Learning and
Improvement
Improvement Analyze practice and improve using
Analyze systematic methodology
systematic Locate, appraise and apply scientific
Locate,
evidence
evidence Apply knowledge of study designs and
Apply
statistics
statistics Obtain and use patient population data Use information technology Facilitate the learning of others Practice-Based Learning and
Improvement
Improvement
Residents must internalize the value of
Residents
on-going, self-directed learning and
improvement of practice
improvement Reflect on and analyze practice
Reflect
experience
experience Locate and apply scientific evidence Take steps to improve practice Demonstrate improvement “Whatever we measure we tend
Whatever
to improve.”
to “We measure what we value.” Practice-Based Learning and
Improvement Where should we start?
Where Begin with what
Begin you have in place
– your resident
interactions with
their patients
their What data can be gathered about a
resident’s knowledge of Systems-Based
Practice and Practice Based Learning
through a patient encounter?
through Questions from the attending? Was the care based on a healing
Was
relationship?
relationship?
Was the care customized based on patient’s
Was
needs?
needs?
Was evidence-based decision making used?
Was safety a system property of the care?
How did you anticipate the needs of the
How
patient?
patient? Other venues for SBP and PBL
Teaching and Evaluation
Teaching Case analysis – focus on processes of
Case care
care Construction of a flow chart of a
Construction
hospitalized patient to analyze systems
of care
of Root cause analysis of an adverse
Root
event
event Activity based cost analysis of a
Activity
hospital bill
hospital Reasons this is hard
Reasons Competence is a habit
Medicine is a cooperative not a productive
Medicine
art
art
The important things are hard to measure
Residents seek practical wisdom
To become competent you have to “feel bad”
Learning occurs in microsystems
Becoming competent is a complex process Helpful Hints for Program
Directors
Directors Use current activities already in place
Use
(rounds, conferences, grand rounds,
discharge planning rounds) to teach and
evaluate SBP and PBL
evaluate
Issues related to SBP and PBL abound in
Issues
resident experiences
resident
Involve the residents in the process of
Involve
deciding how to incorporate these
competencies into your curriculum
competencies
Faculty development is a key to success ...
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Full Document
- Fall '08
- Woods,A
- Practice Based Learning
-
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