Factors predicting training transfer in health professionals participating in quality improvement educational interventions.

BACKGROUND: Predictors of quality improvement (QI) training transfer are needed. This study aimed to identify these predictors among health professionals who participated in a QI training program held at a large hospital in the United States between 2005 and 2014. It also aimed to determine how these predictive factors facilitated or impeded QI training transfer. METHODS: Following the Success Case Method, we used a screening survey to identify trainees with high and low levels of training transfer. We then conducted semistructured interviews with a sample of the survey respondents to document how training transfer was achieved and how lack of training transfer could be explained. The survey's response rate was 43%, with a Cronbach alpha of 0.89. We then conducted a thematic analysis of the interview transcripts of 16 physicians. RESULTS: The analysis revealed 3 categories of factors influencing the transfer of QI training: trainee characteristics, training course, and work environment. Relevant trainee characteristics included attitude toward change, motivation, mental processing skills, interpersonal skills, and the personality characteristics curiosity, humility, conscientiousness, resilience, wisdom, and positivity. The training project, team-based learning, and lectures were identified as relevant aspects of the training course. Work culture, work relationships, and resources were subthemes of the work environment category. CONCLUSIONS: We identified several QI training transfer predictors in our cohort of physicians. We hypothesize that some of these predictors may be more relevant to QI training transfer. Our results will help organizational leaders select trainees who are most likely to transfer QI training and to ensure that their work environments are conducive to QI training transfer.

Improving the Delivery of High-Quality Cancer Care in Medically Underserved Communities: A Formative Evaluation Method.

BACKGROUND AND OBJECTIVES: In 2015, the American Society of Clinical Oncology launched a new program: Improving Quality of Care in Underserved Communities with the overarching aim of serving patients with cancer who have traditionally had difficulty accessing the care they need. Cancer care requires intense coordination of complex services to provide safe, effective, timely, and equitable care. If chemotherapy and/or radiation is needed, patients must navigate a complex system of care many times, a formidable challenge for many disadvantaged patients. Many practices believe that these patients face such significant issues that it is almost impossible to provide high-quality care. A grant from the Stavros Niarchos Foundation allowed us to select 4 oncology practices serving high proportions of racial minorities and persons of low socioeconomic status to participate in the new American Society of Clinical Oncology program. The program had 2 objectives: (1) to improve the capacity and capability of the participating practices to provide evidence-based, high-quality care; and (2) to identify and disseminate lessons learned for improving quality of care among oncology practices serving underserved patients. METHODS: The program leveraged existing programs including the Quality Oncology Practice Initiative, which is a national performance measurement and improvement program that collects data about processes of care provided in the outpatient medical oncology setting, and the American Society of Clinical Oncology Quality Training Program, which provides training in how to apply the tools and methods of quality improvement in routine care settings. Training was provided in face-to-face and virtual meetings and participants were provided mentors throughout the program. At the conclusion, a formative evaluation method was used to assess whether the goals had been achieved. Objectives, activities, and desired outcomes were identified for each of the goals and thus became the framework for the evaluation. RESULTS: The program met the stated goals and objectives. The evaluation revealed many successes, some surprises, and a list of improvements that were incorporated in the next iteration of this program. Based on data from the evaluation, the Niarchos Foundation provided funds for an additional 10 practices to participate in a similar program in 2020. CONCLUSION: This article outlines the evaluation of a new program demonstrating that medical oncology practices can make improvements in the care of their underserved populations if provided with the proper tools, methods, and coaching. The use of formative evaluation methodology also identified opportunities for improvement and ultimately resulted in additional funding for more practices to participate in the program.

ASCO Quality Training Program: A Five-Year Review.

PURPOSE: ASCO introduced the Quality Training Program (QTP) in 2013 with the aim to train oncology professionals to design, implement, and lead successful quality improvement (QI) activities and assume leadership positions to champion culture change in their practices. METHODS: The QTP is a formal 6-month program taught by QI faculty and mentored by QI coaches over 5 days of in-person learning across 3 sessions and hands-on learning at the participants' practices. Sessions include seminars, case examples, and small-group exercises. Participants attend in multidisciplinary teams and focus on a problem they wish to solve in their practice. Scheduled conference calls with QI coaches are held between sessions. Participants complete pre- and post-QTP surveys (10-point Likert scale, with 1 = no knowledge/competence and 10 = complete knowledge/competence) and provide direct written feedback. RESULTS: Since its inception, QTP has had 15 courses (10 domestic and 5 international) with 120 teams and 544 total participants. QTP is led by an 8-member steering group with 16 faculty and coaches. All postsurvey items showed an increase in knowledge and competence. Each item's score was calculated as the mean difference between before and after scores. Participants stated an increase of 46%-84% (overall mean increase: knowledge, 38%; competence, 37%). The greatest increases were in methodology and practical tools to make changes in practice (writing an aim statement, implementing rapid improvement, using process analysis tools, flowcharting the process). The most common suggestion for improvement was allowing more time for the project. Participants are encouraged to write articles and present work in poster and plenary sessions. QTP courses have led to 7 manuscripts and 21 abstract presentations to national meetings. Six QTP alumni are now QI coaches and faculty. CONCLUSION: The QTP is a successful QI course for oncology professionals who need to measure performance, investigate quality and safety issues, and implement change. It is the only oncology-focused QI training, as all faculty and coaches are providers and QI specialists with oncology experience, which makes this a unique opportunity. The success will provide further momentum to offer QTP domestically and around the world.

Using the healthcare matrix with interns and medical students as a tool to effect change.

The Healthcare Matrix is a tool developed at Vanderbilt University Medical Center which assesses the care of patients using the Accreditation Council for Graduate Medical Education (ACGME) competencies and the Institute of Medicine (IOM) Aims for Improvement. House staff have been using this tool since 2004 as a means of learning the competencies in the daily care of patients. As the residents fill in the cells of the Matrix, the opportunities for improvement become evident. Anesthesia interns were introduced to the Matrix at bimonthly meetings to analyze a real case of complex and/or flawed patient management. Each resident completed his/her own Matrix and then the group selected one Matrix as their improvement project. This article will present one Matrix case, how quality improvement (QI) tools and methods were utilized and what resulting improvements were made. The analyzed case revealed numerous flaws with nonstandardized handoffs, incorrect and insufficient documentation, and unclear roles/responsibilities. An ideal process flowchart was developed highlighting improved handoffs and the need for a new admitting policy to the intensive care unit (ICU). The Healthcare Matrix is an effective tool for teaching the ACGME competencies in patient care. The resequencing of the competencies in the Matrix makes it easy to identify where improvements are needed. When taught the tools and methods of quality improvement, even interns can make a significant contribution to the improvement of patient care.

The health care matrix formulation: a tool for competency assessment in psychiatry residency training.

OBJECTIVE: To assert the importance of the use of the healthcare matrix formulation for competency assessment in psychiatry residency training. METHODS: We present a case from our inpatient psychiatric facility and format it in the form of the healthcare matrix, which was developed at Vanderbilt University incorporating the Institute of Medicine 'aims' and the Accreditation Council for Graduate Medical Education 'core competencies'. We also analyze the healthcare matrix and elucidate its use in clinical practice. RESULTS: The healthcare matrix provides us with a practical tool to analyze any complex episode of patient care, like the one in our psychiatric setting, and allows us to learn from the shortcomings in order to improve. CONCLUSION: The optimal utilization of this tool in the competency assessment of psychiatry residents has an enormous practical implication by transforming the case and morbidity and mortality conferences into a well-structured learning and improvement format.

Medical students learn to assess care using the healthcare matrix.

BACKGROUND: The Institute of Medicine identified six Aims for Improvement to drive the transformation of healthcare. Simultaneously, the Accreditation Council for Graduate Medical Education issued six competencies as part of the training of residents. American Board of Medical Specialties has also endorsed these competencies for maintenance of certification. Many training programs have struggled with the implementation of these competencies. AIM: This article describes two applications of The Healthcare Matrix which teaches the Core Competencies while leveraging the IOM? Aims for Improvement? as a means of anchoring the competencies in care of patients. METHOD: Third year medical students used the Matrix to identify the facilitators and barriers to quality of care. Second year internal medicine residents also use the Matrix during their ambulatory rotation. RESULTS: Learners gained new insights into patient issues by using the Matrix and analysis of multiple matrices identified ?themes? of what needed to be improved. When taught the tools and methods of quality improvement, medical students and residents learn to lead the improvement of care. CONCLUSION: The Matrix has changed the way conferences are held because they bring all the competencies to bear on the discussion. There is less of a focus on the ?individual? and more on the systems in need improvement.

ReCAP: Feasibility and Effectiveness of a Pilot Program to Facilitate Quality Improvement Learning in Oncology: Experience of the American Society of Clinical Oncology Quality Training Program.

PURPOSE: Studies have demonstrated that structured training programs can improve health professionals' skills in performing clinical care or research. We sought to develop and test a novel quality training program (QTP) tailored to oncology clinicians. METHODS: The American Society of Clinical Oncology QTP consisted of three in-person learning sessions and four phases: prework, planning, implementation, and sustain and spread. We measured two primary outcomes: program feasibility and effectiveness. Feasibility was evaluated by recording participation. Effectiveness was measured using the Kirkpatrick model, which evaluates four outcomes: reaction, learning, behavior, and results. We collected qualitative feedback through a focus group of participants and mixed quantitative­qualitative results from a 6-month follow-up evaluation survey. Results are presented using descriptive statistics. RESULTS: We received feedback from of 80% of participants who took part in 92% of in-person program days. QTP deliverables were completed by 100% of teams; none withdrew from the program. Regarding reaction, 100% of respondents expressed interest in actively contributing to future QTP courses. For learning, most teams continued to use the core methodology tools (eg, project charter, aims statements) after the program. Regarding behavior, when asked about intention to serve as a local quality improvement leader, a majority said they "definitely will" serve as: team leader on a specific project (75%), project champion or sponsor (75%), or teacher or trainer for others (64%). In evaluating outcomes, 50% reported applying learned methodology to new projects at their local institution. CONCLUSION: We demonstrate one of the first feasible and effective training programs to facilitate quality improvement learning for oncology clinicians.

Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies.

BACKGROUND: In 2001, the Institute of Medicine (IOM) recommended six Aims f or Improvement; the dimensions of quality describe a health care system that is safe, timely, effective, efficient, equitable, and patient centered. In 1999, the Accreditation Council of Graduate Medical Education (ACGME) adopted six core competencies that physicians in training must master if they are to provide quality care. A Healthcare Matrix was developed that links the IOM aims for improvement and the six ACGME Core Competencies. The matrix provides a blueprint to help residents to learn the core competencies in patient care, and to help faculty to link mastery of the competencies with improvement in quality of care. HEALTHCARE MATRIX: The Healthcare Matrix is a conceptual framework that projects an episode of care as an interaction between quality outcomes and the skills, knowledge, and attitudes (core competencies) necessary to affect those outcomes. For example, an anesthesiology resident used the Healthcare Matrix for a complex 18-hour episode of care with a life-threatening situation. ONGOING WORK AND RESEARCH AGENDA: Collecting and analyzing a series of matrices provides the foundation for systematic change in patient care and medical education and a rich source of data for operational and improvement research.

Assessing patient care in palliative care using the healthcare matrix.

The healthcare matrix is a novel assessment tool that facilitates systematic examination of patient cases using criteria established by the Accreditation Council for Graduate Medical Education and the Institute of Medicine. It is particularly useful for analyzing complex cases, although its use in the palliative care setting has not been documented. We describe here the use of the healthcare matrix to examine the healthcare encounters of a 63 year-old patient with advanced cancer. The healthcare matrix helped us to dissect the physical, psychosocial, logistical, professional, and ethical aspects of care, and to highlight multiple opportunities for quality improvement. In addition to the case example we will be discussing the advantages and disadvantages for using the healthcare matrix and its potential utility in palliative care.

Residents Learn to Improve Care Using the ACGME Core Competencies and Institute of Medicine Aims for Improvement: the Health Care Matrix.

OBJECTIVES: This article describes how internal medicine residents at Vanderbilt University Medical Center learn to assess and improve care using the Institute of Medicine aims for improvement and the Accreditation Council for Graduate Medical Education core competencies combined in a tool called the health care matrix. The most important and popular use of the health care matrix has been with suboptimal care, in which care is not safe, timely, effective, efficient, equitable, or patient centered. BACKGROUND: The core competencies provide a means of defining why care was not safe, timely, effective, efficient, equitable, or patient centered. The Institute of Medicine aims for improvement are also important because they are used to frame most publicly reported measures of quality. Few residents have an understanding of these public measures and how their futures will be affected by the growing trend toward quality report cards. INTERVENTION: To help the residents understand the significance of public measures of quality, they learn to assess their patients as a "panel," looking at the care they provide for patients with coronary artery disease and diabetes mellitus. Residents use the health care matrix to analyze 1 of their patients, and then as a group they select a health care matrix for their improvement project. The way the health care matrix is formatted and the sequencing of the core competencies allow for the analysis of the cells to lead to the final question "What was learned and what needs to be improved?" The residents are then taught the tools and methods of quality improvement and complete their project. Some of these projects have had a significant influence on external measures of quality for this organization. The article describes the 8-week course that residents complete, the use of the health care matrix, the analysis of the patient panel, and finally an example of a completed project in which they improve the timeliness of antibiotics administration to patients with pneumonia (a public measure of quality).

Improving glycemic control in adults with diabetes mellitus: shared responsibility in primary care practices.

BACKGROUND: Primary care physicians provide care for most patients with diabetes mellitus, but few have the resources to achieve the level of glycemic control needed to avert complications METHODS: Primary care physicians referred patients with unsatisfactory glycemic control, frequent hypoglycemia, or inadequate self-management to an endocrinologist-directed team of nurse and dietitian educators for a 3-month program of intensive diabetes care. Patients had at least weekly contact with a diabetes educator and received changes in insulin and/or other medication, coupled with extensive individualized instruction. The main outcome measurement was change in glycosylated hemoglobin (HbA1c) level at 3 months. RESULTS: The first 350 patients who completed the program had overall mean decrease in HbA1c level of 1.7% (95% CI 1.4%-1.9%). CONCLUSIONS: Barriers to improving glycemic control may be overcome by establishment of a system of collaboration between primary care providers and endocrinologist-directed diabetes educators.