Performance Improvement

1. A willingness to work on teams tasked with improvement initiatives
2. An awareness and positive attitude toward improving health care delivery
3. A belief that PI tools and methods can improve the care delivered

1. An ongoing effort to identify the best evidence available for each clinical issue faced

1. Understand where Process Improvement theory originated
2. Be able to define a process and the outcomes produced by processes
   1. Type of outcomes
      1. Physical- the measurable physical outcomes of the patient as a result of health care provided
      2. Service- access to care and patient satisfaction with care provided
      3. Cost- appropriate use of resources and subsequent affect on costs in the care provided
3. Definition of a customer- this can be a patient, office staff, physicians or anyone who plays a role in the delivery of health care
4. How practice variation affects the cost and quality of health care
   1. Random variation
   2. Assignable variation
   3. Significance of clinical variation in the United States (e.g. Dartmouth Atlas of Health Care, 1999)
5. Teamwork Concepts and Effects of Teamwork as a Skill
   1. How to form a team
   2. Effective meeting management
   3. Tools for generating ideas- brainstorming, multivoting, nominal group technique
   4. Role of team leader and facilitator
6. Use of Performance Improvement Methodology and Rapid Cycle Improvement including Plan-Do-Study-Act (PDSA)
   1. Find, Organize, Clarify, Understand, Select (FOCUS)
      1. Find- Identify a process in need of improvement by talking to customers and owners of clinical and administrative processes
      2. Organize- Select and organize a team and draft a mission statement
      3. Clarify- General goals for the team; what are the key parameters which define the quality of the process
      4. Understand- Understand what the team is trying to improve; how will you know if a change occurs? PI tools (cause and effect diagrams, Pareto charts, tally sheets) can be used to identify the characteristics which define the quality of the process
      5. Select- The items or processes that need to be changed. Select the key improvement outcomes expected and cause and effect relationships that will change
   2. Plan, Do, Study, Act
      1. Plan- Identify a process in need of improvement and formulate a plan as to how the process might be improved. Establish a baseline so that any improvements can be measured
      2. Do- Implement the changes
      3. Act- If successful, implements the change on a broader scale. If not, reevaluate the process and changes made and determine whether to try a different approach and start over or move on to a different process
   3. Three Questions to ask in any PDSA cycle
      1. What are we trying to accomplish?
      2. What change can we make that will result in improvement?
      3. How will we know that a change is an improvement?
7. Performance Improvement Tools- flow charting a process
   1. Pareto diagrams, run charts, statistical process control (SPC) charts, scatter diagrams, flow charts, cause and effect diagrams, control charts, bar charts
      1. Graphical data presentations and their advantages over tables of data
8. Medical errors and patient safety issues
   1. Medication errors and subsequent adverse drug events (ADE)
   2. Resources- Joint Commission on Accreditation of Health Care Organizations (JCAHO), Institute for Clinical Systems Improvement (ICSI), Institute for Health Care Delivery Research (IHC), Institute for Health Care Improvement (IHI), American Academy of Family Physicians (AAFP), Institute of Medicine (IOM), Occupational Safety and Healthcare Administration (OSHA)
9. Role of information systems and informatics in process improvement
   1. Sources of data/information
      1. External organizations- NCQA, Dartmouth Atlas, JCAHO
      2. Patent accounting systems
      3. Health plan reports
      4. Hospital data systems
      5. External sources (e.g., County Health Departments, Peer Review Organizations)
10. Outcomes management
    1. Outcomes management and the various terms used to describe the process
       1. Clinical guidelines/Practice protocols/
       2. Care Process Models
       3. Disease Management
11. Critical appraisal of the clinical literature
    1. External Peer Review Organizations
       1. NCQA Health Plan Employee Data and Information Set (HEDIS) Criteria
       2. JCAHO
       3. Center for Medicare and Medicaid Services (CMS, formerly HCFA) Peer Review Organizations (PRO)

Evidenced Based Medicine:

1. Pose a relevant question
2. Search the literature using both print and internet-based resources
3. Apply the literature to the pertinent clinical issue
4. Be familiar with and able to access information from EBM data sources
   1. Cochrane Data Base
   2. Agency for Healthcare Research and Quality (AGRQ)
5. Be able to determine the outcome of a given intervention when using as well as not using relevant information
6. Be familiar with study design and statistical methods in evaluating relevant clinical information

1. Learn how to identify clinical processes which might be improved using PI methodology
2. Be able to analyze past and current clinical practice and improve future care based on previous experience
3. Participation on at least one team to improve one process or one aspect of health care delivery within the residency
4. Learn how to identify the individual/group that owns the process and ensure they participate
5. Learn how to collect and analyze data from a variety of sources
6. Demonstrate understanding by effective team participation (e.g., communication, conflict resolution, team member and team leader)

1. "Letting Good Care Drive Out The Bad" Medical Economics Sep. 95
2. "Quality of Health Care"(6 part series) New England Journal of Medicine Sep.-Oct. 96
3. "Users' Guides to the Medical Literature" (Multipart Series) Journal of American Medical Association 1993-2000 (Available online at: http://www.cche.net/principles/main.asp)
4. Berwick, Donald M. On Quality. Jossey-Bass, Oct 1995
5. Berwick, Donald M., Roessner, Jane A., Godfrey, Blanton. Curing Health Care: New Strategies for Quality Improvement. Jossey-Bass, Jan 1991
6. Family Practice Management- numerous PI articles in 1999-2000
7. Eddy, David M. Clinical Decision Making: From Theory to Practice: A Collection of Essays from JAMA. Sudbury: Jones & Bartlett, Jan 1996
8. IOM Committee on Quality of Health Care in America, “Crossing the Quality Chasm: A New Health System for the 21^st Century”, Institute of Medicine 2000
9. Kohn, Linda. “To Err Is Human: Building a Safer Health System” Institute of Medicine 1999
10. Medical Informatics and Computer Applications, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 288 (Available online at: http://www.aafp.org/eduguide.xml)
11. Research and Scholarly Activity, Recommended Core Educational Guidelines for Family Practice Residents, AAFP Reprint No. 280 (Available online at: http://www.aafp.org/eduguide.xml)
12. Sackett, David Evidence-Based Medicine: How to Practice and Teach EBM Philadelphia:Churchill Livingston, 2000
13. Silverman, William A. and Sackett, David L. Where's the Evidence?: Debates in Modern Medicine :Oxford Univ. Press, 1999

1. Best Evidence- CD-ROM based (http://www.acponline.org/catalog/electronic/best_evidence.htm)

1. AAFP Medical Quality Clearinghouse: http://www.aafp.org/quality
2. Agency for Healthcare Research and Quality: http://www.ahrq.gov
3. Clinical Practice Guidelines: http://www.guidelines.gov
4. Cochrane Library: http://www.cochranelibrary.com/enter
5. Evidence-based Medicine Resource Center (New York Academy of Medicine & Evidence-based Medicine Committee of the American College of Physicians, New York Chapter with funding from the National Institutes of Health): http://www.ebmny.org
6. Institute for Healthcare Improvement: http://www.ihi.org
7. Institute of Medicine “Crossing the Quality Chasm: A New Health System for the 21st Century”, http://www.nap.edu/catalog/10027.html
8. Joint Commission on Accreditation of Health Care Organizations
9. Medline Pubmed: http://www.ncbi.nlm.nih.gov/PubMed
10. National Association for Healthcare Quality: http://www.nahq.org
11. NHS Centre for Evidenced Based Medicine: http://cebm.jr2.ox.ac.uk/index.html
12. SCHARR Netting the Evidence: http://www.shef.ac.uk/~scharr/ir/netting
13. The Leapfrog Group: http://www.leapfroggroup.org
14. University of Alberta, Introduction to Evidence Based Medicine: http://www.med.ualberta.ca/ebm/ebmintro.htm