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Sara SA, Schwarz A, Knopp MI, Warm EJ. Twelve tips for creating a longitudinal quality improvement and safety education for early health professions students. MEDICAL TEACHER 2024; 46:330-336. [PMID: 37917988 DOI: 10.1080/0142159x.2023.2274137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Despite the numerous calls for integrating quality improvement and patient safety (QIPS) curricula into health professions education, there are limited examples of effective implementation for early learners. Typically, pre-clinical QIPS experiences involve lectures or lessons that are disconnected from the practice of medicine. Consequently, students often prioritize other content they consider more important. As a result, they may enter clinical settings without essential QIPS skills and struggle to incorporate these concepts into their early professional identity formation. In this paper, we present twelve tips aimed at assisting educators in developing QIPS education early in the curricula of health professions students. These tips address various key issues, including aligning incentives, providing longitudinal experiences, incorporating real-world care outcomes, optimizing learning environments, communicating successes, and continually enhancing education and care delivery processes.
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Affiliation(s)
- S Anthony Sara
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Anna Schwarz
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Michelle I Knopp
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Eric J Warm
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Khoo JEJ, Lim CW, Lai YF. Performance management of generalist care for hospitalised multimorbid patients-a scoping review for value-based care. FRONTIERS IN HEALTH SERVICES 2024; 3:1147565. [PMID: 38469170 PMCID: PMC10925702 DOI: 10.3389/frhs.2023.1147565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 12/29/2023] [Indexed: 03/13/2024]
Abstract
Objectives Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients. Design and setting A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review. Outcome measures The performance measures used across the studies were analysed and other qualitative findings were also obtained. Results We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care. Conclusion The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care.
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Affiliation(s)
- Jia En Joy Khoo
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Life Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Cher Wee Lim
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yi Feng Lai
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
- School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
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Reilly JB, Kim JG, Cooney R, DeWaters AL, Holmboe ES, Mazotti L, Gonzalo JD. Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:146-152. [PMID: 37289829 DOI: 10.1097/acm.0000000000005294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
ABSTRACT The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.
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Kinnear B, Weber DE, Schumacher DJ, Edje L, Warm EJ, Anderson HL. Reconstructing Neurath's Ship: A Case Study in Reevaluating Equity in a Program of Assessment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S50-S56. [PMID: 37071695 DOI: 10.1097/acm.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Inequity in assessment has been described as a "wicked problem"-an issue with complex roots, inherent tensions, and unclear solutions. To address inequity, health professions educators must critically examine their implicit understandings of truth and knowledge (i.e., their epistemologies) with regard to educational assessment before jumping to solutions. The authors use the analogy of a ship (program of assessment) sailing on different seas (epistemologies) to describe their journey in seeking to improve equity in assessment. Should the education community repair the ship of assessment while sailing or should the ship be scrapped and built anew? The authors share a case study of a well-developed internal medicine residency program of assessment and describe efforts to evaluate and enable equity using various epistemological lenses. They first used a postpositivist lens to evaluate if the systems and strategies aligned with best practices, but found they did not capture important nuances of what equitable assessment entails. Next, they used a constructivist approach to improve stakeholder engagement, but found they still failed to question the inequitable assumptions inherent to their systems and strategies. Finally, they describe a shift to critical epistemologies, seeking to understand who experiences inequity and harm to dismantle inequitable systems and create better ones. The authors describe how each unique sea promoted different adaptations to their ship, and challenge programs to sail through new epistemological waters as a starting point for making their own ships more equitable.
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Affiliation(s)
- Benjamin Kinnear
- B. Kinnear is associate professor of internal medicine and pediatrics, Departments of Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0003-0052-4130
| | - Danielle E Weber
- D.E. Weber is assistant professor of internal medicine and pediatrics, Departments of Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-4857-6936
| | - Daniel J Schumacher
- D.J. Schumacher is tenured professor of pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0001-5507-8452
| | - Louito Edje
- L. Edje is professor of family and community medicine, Department of Medical Education and Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric J Warm
- E.J. Warm is professor of internal medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6088-2434
| | - Hannah L Anderson
- H.L. Anderson is clinical research associate, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-9435-1535
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Burk-Rafel J, Sebok-Syer SS, Santen SA, Jiang J, Caretta-Weyer HA, Iturrate E, Kelleher M, Warm EJ, Schumacher DJ, Kinnear B. TRainee Attributable & Automatable Care Evaluations in Real-time (TRACERs): A Scalable Approach for Linking Education to Patient Care. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:149-159. [PMID: 37215538 PMCID: PMC10198229 DOI: 10.5334/pme.1013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/30/2023] [Indexed: 05/24/2023]
Abstract
Competency-based medical education (CBME) is an outcomes-based approach to education and assessment that focuses on what competencies trainees need to learn in order to provide effective patient care. Despite this goal of providing quality patient care, trainees rarely receive measures of their clinical performance. This is problematic because defining a trainee's learning progression requires measuring their clinical performance. Traditional clinical performance measures (CPMs) are often met with skepticism from trainees given their poor individual-level attribution. Resident-sensitive quality measures (RSQMs) are attributable to individuals, but lack the expeditiousness needed to deliver timely feedback and can be difficult to automate at scale across programs. In this eye opener, the authors present a conceptual framework for a new type of measure - TRainee Attributable & Automatable Care Evaluations in Real-time (TRACERs) - attuned to both automation and trainee attribution as the next evolutionary step in linking education to patient care. TRACERs have five defining characteristics: meaningful (for patient care and trainees), attributable (sufficiently to the trainee of interest), automatable (minimal human input once fully implemented), scalable (across electronic health records [EHRs] and training environments), and real-time (amenable to formative educational feedback loops). Ideally, TRACERs optimize all five characteristics to the greatest degree possible. TRACERs are uniquely focused on measures of clinical performance that are captured in the EHR, whether routinely collected or generated using sophisticated analytics, and are intended to complement (not replace) other sources of assessment data. TRACERs have the potential to contribute to a national system of high-density, trainee-attributable, patient-centered outcome measures.
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Affiliation(s)
- Jesse Burk-Rafel
- Division of Hospital Medicine, NYU Langone Health, and assistant director of Precision Medical Education, Institute for Innovations in Medical Education, NYU Grossman School of Medicine, New York, USA
| | - Stefanie S. Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sally A. Santen
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joshua Jiang
- University of California Los Angeles, Los Angeles, California. At the time of this work he was a medical student, NYU Grossman School of Medicine, New York, USA
| | - Holly A. Caretta-Weyer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Matthew Kelleher
- Internal Medicine and Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Eric J. Warm
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Daniel J. Schumacher
- Department of Pediatrics, director of Education Research Unit, Cincinnati Children’s Hospital Medical Center/ University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin Kinnear
- Internal Medicine and Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Smirnova A, Chahine S, Milani C, Schuh A, Sebok-Syer SS, Swartz JL, Wilhite JA, Kalet A, Durning SJ, Lombarts KM, van der Vleuten CP, Schumacher DJ. Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:367-375. [PMID: 36351056 PMCID: PMC9944759 DOI: 10.1097/acm.0000000000005084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). METHOD EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. RESULTS 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. CONCLUSIONS For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.
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Affiliation(s)
- Alina Smirnova
- A. Smirnova is clinical assistant professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada, and adjunct assistant professor, Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: https://orcid.org/0000-0003-4491-3007
| | - Saad Chahine
- S. Chahine is associate professor of measurement and assessment, Faculty of Education, Queen’s University, Kingston, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0488-773X
| | - Christina Milani
- C. Milani is clinical research assistant, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abigail Schuh
- A. Schuh is associate professor of pediatrics, Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0002-6422-2361
| | - Stefanie S. Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California; ORCID: http://orcid.org/0000-0002-3572-5971
| | - Jordan L. Swartz
- J.L. Swartz is clinical associate professor, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, and director of clinical informatics, Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Jeffrey A. Wilhite
- J.A. Wilhite is senior research coordinator, Department of Medicine, NYU Langone Health, New York, New York; ORCID: https://orcid.org/0000-0003-4096-8473
| | - Adina Kalet
- A. Kalet is professor and Steven and Shelagh Roell Chair, Robert D. and Patricia P. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0003-4855-0223
| | - Steven J. Durning
- S.J. Durning is professor and vice chair, Department of Medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0001-5223-1597
| | - Kiki M.J.M.H. Lombarts
- K.M.J.M.H. Lombarts is professor of professional performance, Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, and Amsterdam Public Health research institute, Amsterdam, The Netherlands; ORCID: https://orcid.org/0000-0001-6167-0620
| | - Cees P.M. van der Vleuten
- C.P.M. van der Vleuten is professor of education, Department of Educational Development and Research. Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; ORCID: http://orcid.org/0000-0001-6802-3119
| | - Daniel J. Schumacher
- D.J. Schumacher is professor of pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: http://orcid.org/0000-0001-5507-8452
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Early Outcomes from a Pediatric Education Research Unit. J Pediatr 2022; 249:3-5.e1. [PMID: 35227756 DOI: 10.1016/j.jpeds.2022.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/21/2022]
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Lam AC, Tang B, Lalwani A, Verma AA, Wong BM, Razak F, Ginsburg S. Methodology paper for the General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED): a retrospective cohort study of internal medicine resident case-mix, clinical care and patient outcomes. BMJ Open 2022; 12:e062264. [PMID: 36153026 PMCID: PMC9511606 DOI: 10.1136/bmjopen-2022-062264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Unwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards outcomes-based and competency-based medical education, current assessment strategies in residency do not routinely incorporate clinical outcomes. The widespread use of electronic health records (EHRs) may enable the implementation of in-training assessments that incorporate clinical care and patient outcomes. METHODS AND ANALYSIS The General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED) is a retrospective cohort study of senior residents (postgraduate year 2/3) enrolled in the University of Toronto Internal Medicine (IM) programme between 1 April 2010 and 31 December 2020. This study focuses on senior IM residents and patients they admit overnight to four academic hospitals. Senior IM residents are responsible for overseeing all overnight admissions; thus, care processes and outcomes for these clinical encounters can be at least partially attributed to the care they provide. Call schedules from each hospital, which list the date, location and senior resident on-call, will be used to link senior residents to EHR data of patients admitted during their on-call shifts. Patient data will be derived from the GEMINI database, which contains administrative (eg, demographic and disposition) and clinical data (eg, laboratory and radiological investigation results) for patients admitted to IM at the four academic hospitals. Overall, this study will examine three domains of resident practice: (1) case-mix variation across residents, hospitals and academic year, (2) resident-sensitive quality measures (EHR-derived metrics that are partially attributable to resident care) and (3) variations in patient outcomes across residents and factors that contribute to such variation. ETHICS AND DISSEMINATION GEMINI MedED was approved by the University of Toronto Ethics Board (RIS#39339). Results from this study will be presented in academic conferences and peer-reviewed journals.
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Affiliation(s)
- Andrew Cl Lam
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Brandon Tang
- Department of Medicine, Division of General Internal Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Anushka Lalwani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Brian M Wong
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Shiphra Ginsburg
- Department of Medicine, Division of Respirology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Division of Respirology, Sinai Health System, Toronto, Ontario, Canada
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