The heatlhcare matrix

1. The heatlhcare matrix Erin Hurley, PGY 4 June 16, 2020

2. “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

3. 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”

4. Quality Chasm • “Health care we have and the care we could have– represents more than a gap, but rather a chasm” • Medical education chasm

5. 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

6. IOM– Aims for Improvement • Safe • Timely • Effective • Efficient • Equitable • Patient Centered

7. 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.

8. ACGME Competencies “Quality of health care is positively related to quality education”

9. Core Competencies • Patient Care • Medical Knowledge • Interpersonal and communication skills • Professionalism • Systems-based practice • Practiced-based learning and improvement

10. Core Competencies • Teaching • No prescribed formulas • Assessment • Interpersonal and communication skills • System-based practice • Practice based learning and improvement

11. 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

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

13. 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

14. Medical Knowledge: What Must We Know? “…about established and evolving biomedical, clinical, and cognate sciences, and application of this knowledge to patient care.”

15. Interpersonal/Communication Skills: What Must We Say? “…that will result in effective information exchange and teaming with patients, their families, & other health professionals.”

16. Professionalism: How Must We Behave? “…as manifested through commitment to carrying out professional responsibilities, adherence to ethical principles, & sensitivity to diverse patient population.”

17. Systems-Based Practice: What is the Process? On Whom Do We Depend? Who Depends On Us? “…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.”

18. Practice-Based Learning & Improvement: What Have We Learned? What Will We Improve? “…involves investigation & evaluation of residents’ (program’s, or institution’s) own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.”

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Methods • Two 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

26. Results • 26 HCMC were held from 2007 to 2009 • PGY-4 residents prepared & conducted 77% sessions

27. Sub-optimal care by IOM Aims

28. Sub-optimal care by ACGME Competencies

29. Figure 1: *Residents perception of the utility of the Healthcare Matrix (n=21) Should be interdisciplinary 100% Effective for teaching ACGME competencies & IOM Aims 81.00% Would use in my clinical practice in future 57.10% 47.60% Preparation is time consuming Great, continue to use 95.20% Should be canceled 0% Improved ability debrief 90.50% Improved my communication skills 38.10% Useful for quality improvement 95.20% Helped analyze a complex situation 100% Changed my practice 85.70% Felt awkward presenting errors of my superiors 28.60% Review errors in blame free environment 71.40% Helped assess errors 95.20% Fosters learning 90.50% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Residents perception of the utility of the Healthcare Matrix

30. 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

31. Conclusion • Residents 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.

32. 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.

33. Matrix 2007

34. 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

35. THANK YOU The End Erin Hurley, PGY 4 June 16, 2020

36. 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