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CQI Curriculum

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					        Curriculum In Continuous Quality
                 Improvement




                           Alexander M. Djuricich, MD
                             Department of Medicine
                       Indiana University School of Medicine
                               Ambulatory Rotation




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   1
                                  Table of Contents




Curriculum Document                                                3
       Introduction                                                3
       Goals                                                       3
       Objectives                                                  3
       Context                                                     4
       Timeline                                                    5
       Overview                                                    5
       Table                                                       6
       Learning Methods                                            7
       Evaluation                                                  7
Bibliography                                                       8
       QI – General                                                8
       QI – Institutional                                          8
       QI – Residents and Residency                                9
       QI – Medical Students                                       10
       QI – Faculty                                                11
       QI – Web-Based Curricula                                    11
Lecture Handout                                                    12
Template for Projects                                              16
PreTest                                                            17
PostTest                                                           19
Grading Instrument                                                 21




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   2
                       Curriculum for the
             Continuous Quality Improvement Module
                                  Ambulatory Rotation
Introduction

        Continuous quality improvement (CQI) is a set of principles, concepts and
methods adopted originally in the business world. CQI has become an ever increasingly
important part of the health care industry, both in terms of its effect on improving the
care of patients1, as well as on improving the educational environment2,3. A recent
national policy statement from the Institute of Medicine urged leaders in health care
professions as well as practicing physicians to take the lead in improving the quality of
the U.S. health care system4.
        Resident participation in CQI is a relatively new activity. The ACGME
competency of “Practice-based learning and improvement” has introduced the
requirement that residents should “perform practice-based improvement activities using a
systematic methodology5”. Many residency programs have published data emphasizing
projects designed by house staff that ultimately improved patient care3. Indeed, even
improving the residency program itself can be a CQI project6. We are currently
developing methods in which residents participate in CQI activities with “real world”
experiences. Potential benefits for residents in learning this important skill are the
opportunity to be integrally involved in improving patient care, and also to have a sense
of ownership, or “buy-in” in their own education.

Curriculum Goals

After completion, learners (residents) should be able to:
   1. Demonstrate knowledge and skills necessary to effectively participate as a
       contributing member or leader of a CQI effort.
   2. Demonstrate an appreciation for the need to improve quality in health care and the
       contribution that CQI methodology can make to the health care system and its
       “customers.”

Curriculum Objectives

By the end of the month-long Advanced Ambulatory rotation, residents should:


1
  Joshi, MS, et al. CQI: Making a difference at one academic health system. Seminar Med Pract
1999;2(1):11-15.
2
  Goldberg, E, et al. Total quality management of a medical residency. Am J Med Qual 1995
Spring;10(1):10-13.
3
  Headrick, LA, et al. Continuous improvement learning for residents. Pediatrics 1998;101(4):768-773.
4
  Kohn, LT, Editor. To Err is Human; Building a Safer Health System. Committee on Quality of Health
Care in America, Institute of Medicine. Washington DC, 1999.
5
  www.acgme.org.outcome/
6
  Ellrodt, AG. Introduction of total quality management (TQM) into an internal medicine residency. Acad
Med 1993;68:817-823.

CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04          3
    1. Define and contrast basic quality terminology, including “quality”, “CQI”, and
       “customers”.
    2. List four core concepts of CQI and be able to provide clinical examples of CQI in
       health care.
    3. List and describe the elements of the PDSA cycle.
    4. Construct and present ideas for a CQI project related to the improvement of
       patient care (preferably within the resident’s own ambulatory practice).
    5. Construct and present ideas for a CQI project related to the improvement of the
       IU medicine residency program.

Context

       The CQI curriculum is organized as two one-hour sessions consisting of a faculty
member and 2-6 residents and one one-hour “working group” session during which the
residents can work together on project writing.

   1) The first session is given at the beginning of the rotation, and consists of a brief
       lecture exposing the resident to CQI terminology, core concepts, and examples of
       CQI in practice. The PDSA cycle is described in great detail, as it is used as the
       construct for the projects. The residents are given handouts and required readings,
       and are given the task of constructing projects on their own. One project must
       relate to improving patient care, ideally care within the ambulatory setting.
       Another project will focus on how to improve the residency program itself.
   2) Over the first week, the residents are to exchange ideas and contact the faculty
       (email or pager) as a resource for questions.
   3) A “preliminary draft” of project ideas should be sent to Dr. Djuricich one week
       after the first session (via email). Written suggestions and feedback will be
       provided to the resident based on adherence to the PDSA cycle.
   4) In the middle of the rotation, residents are given a protected session to brainstorm
       as a group as to how to further revise the projects. The faculty member remains
       available for consultation.
   5) The third session occurs in the last week of the rotation, when the faculty collects
       the CQI quizzes and provides a one-hour precepted discussion of their projects.
       Quiz results and project summary will be submitted into each resident’s portfolio.
   6) Creative and/or well-designed projects will be selected for distribution to the
       appropriate faculty who might be interested in supervising the implementation.
       Residents may express interest in pursuing their projects as an advanced
       competency and personal interest.
   7) In summary, we are looking for projects that are:
       a. relevant,
       b. feasible,
       c. measurable, and
       d. affordable.
       Since implementation of most projects will not be attainable within the current
month-long rotation, residents may choose to implement these projects within an
Advanced Ambulatory Elective. Alternately, much the same as resident research may be
done independently during off hours across other scheduled rotations, residents may
choose to develop and implement their project as an independent advanced activity.

CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   4
Timeline

1st Monday                       Lecture and small group discussion on basics of CQI
2nd Monday                       Preliminary project ideas due
                                 Feedback to be provided via email within 2-3 days
“Middle” of rotation             Brainstorming session to “refine” projects
Last Monday                      Final project submission and “test” completion
One week after rotation          Grade of test and final evaluation of projects (via email)


Overview of the Curriculum



                              CQI curriculum

 Background                        PDSA Cycle                            Projects


           Definitions                      3 questions                      Patient Care

        Core concepts                             Plan                        Residency

            Examples                               Do

                                                 Study

                                                   Act




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   5
Curriculum Table

      Objectives                  Content               Instructional                Learner
                                                          Strategies               Evaluation
                                                                                     Methods
Define and contrast        Definitions              Lecture / Handouts        Who are customers
basic quality                                                                 of a residency?
terminology                Core concepts            Precepted small-
    1. Quality                                      group discussion of       What is the
    2. CQI/TQM             Examples of CQI in       CQI examples              difference between
    3. Customers           health care                 1. Salt                quality and CQI?
                                                           restriction
List four core             Examples of CQI in              education as       Give a clinical
concepts of CQI and        residency education             a prevention       example of CQI in
be able to provide                                         of hospital        health care.
clinical examples of   PDSA cycle                          re-admission
CQI in health care     What are we trying                  for CHF            List elements of
                       to accomplish?                  2. Study group         PDSA cycle.
List and describe the How will we know                     for ABIM
elements of the        that a change is an                 Certifying         Choose which item
PDSA cycle             improvement?                        Examination        is not a core concept
                       What changes can                    review             of CQI (multiple
Construct and present we make that will                                       choice question).
ideas for a CQI        result in                    Small-group
project related to the improvement?                 discussion (faculty-      Creation of new
improvement of             1. Plan                  led) of residents’        CQI project on
patient care               2. Do                    suggestions for CQI       improving patient
(preferably in the         3. Study                 projects                  care, utilizing PDSA
resident’s own             4. Act                                             cycle. OR
ambulatory practice)                                Brainstorming             Creation of new
                       Required readings            session of residents      CQI project on
Construct and present (see bibliography)            only (self-directed       improving residency
ideas for a CQI                                     learning) to discuss      program, utilizing
project related to the                              and format projects       PDSA cycle.
improvement of the
IU medicine                                         Email discussion (if      Participation in
residency program                                   needed) regarding         small-group
                                                    CQI projects              discussions.

                                                    Examples of
                                                    projects written by
                                                    previous residents

                                                    Self-directed
                                                    readings




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   6
Learning Methods

        All meetings will take place on campus, usually in offices within Medical
Education. The first session will take place on the first Monday of the month-long
rotation. The brainstorming session will be scheduled in the middle of the rotation. The
final session will take place on the last Monday of the rotation. Any questions are
welcomed by email (adjurici@iupui.edu), and Dr. Djuricich will be happy to answer
questions at any time.

Evaluation

        Evaluation will consist of several parts:
            1. participation in the small-group sessions
            2. written test completion, and
            3. a written CQI project.
        Participation in the small-group discussion on the last day will be a small portion
of the evaluation. The written test consists of short-answer questions on principles and
definitions in CQI, and is distributed on the last group meeting. The majority of the
grade will be related to the written projects on improving patient care and/or on
improving the residency. The written projects will be graded according to the
following criteria:
        1. adherence to PDSA cycle
        2. relevance (perceived neeed)
        3. feasibility (ability to “do” the project)
        4. ability to measure outcomes
        5. affordability.




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   7
                                        Bibliography
Those in bold are required readings, and will be provided to residents.

Divided into the following sections:
General
Institutional
Residents and Residency
Medical Students
Faculty
Web-based “Off the Shelf” Curricula

Quality Improvement – General
Cleghorn GD. The PDSA cycle at the core of learning in health professions education. J
Comm J Qual Improv 1996;22(3):206-212.

Headrick LA, et al. Continuous quality improvement and the education of the generalist
physician. Acad Med 1995;70(1 Suppl):S104-S109.

Kizer KW. The emerging imperative for health care quality improvement. Acad Emerg
Med 2002;9(11):1078-1084.

McGlynn EA, et al. The quality of health care delivered to adults in the United States.
NEJM 2003;348(26):2635-2645.

Plsek P. Quality improvement methods in clinical medicine. Pediatrics 1999;103(1 Suppl
E):203-214.

Steinberg EP. Improving the quality of care – can we practice what we preach? NEJM
2003;348(26):2681-2683.


Quality Improvement – Institutional
The Academic Medical Center Working Group of the Institute for Healthcare
Improvement. The imperative for quality: A call for action to medical schools and
teaching hospitals. Acad Med 2003;78(11):1085-1089.

Baker G. Collaborating for improvement in health professions education. Qual Manag
Health Care. 1998;6:1-11.

Heard JK, et al. An institutional system to monitor and improve the quality of residency
education. Acad Med 2004;79:858-864.

Joshi MS, et al. CQI: Making a difference at one academic health system. Semin
Med Pract 1999;2(1):11-15.

CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   8
Quality Improvement – Residents and Residency
Ashton CM. “Invisible” doctors: making a case for involving medical residents in
hospital quality improvement programs. Acad Med 1993;6:823-824.

Coleman, MT, et al. Introducing practice-based learning and improvement ACGME core
competencies into a family medicine residency curriculum. Jt Comm J Qual Saf
2003;29(5):238-247.

Croskerry P et al. Quality and education. Acad Emerg Med 2002;9:(11):1108-1115.

Djuricich, AM et al. A continuous quality improvement curriculum for residents:
addressing core competency, improving systems. Acad Med 2004;79(10):S65-S67.

Eliastam M, et al. Quality improvement, housestaff, and the role of chief residents. Acad
Med 1996;71(6):670-674.

Elliott RL, et al. Quality in residency training: toward a broader, multidimensional
definition. Acad Med 1996;71(3):243-247.

Ellrodt AG. Introduction of total quality management (TQM) into an internal medicine
residency. Acad Med 1993;68:817-823.

Farquhar D, et al. Education in quality of care in an internal medicine residency program.
Acad Med 2001;76(5):562.

Fox C, et al. Improving diabetes care in a family practice residency program: a case study
in continuous quality improvement. Fam Med 1998;30:441-445.

Goldberg E. et al. Total quality management of a medical residency. Am J Med Qual
1995;10(1):10-13.

Griffith, CH, et al. Internal medicine residency training and outcomes. J Gen Intern Med
1997;12:390-396.

Headrick, LA, et al. Continuous improvement learning for residents. Pediatrics
1998;101(4):768-773.

Jay SJ. Residents and quality care. Hosp Physician 1988;15-19.

Leshan LA, et al. Increasing clinical prevention efforts in family practice residency
programs through CQI methods. Jt Comm J Qual Improv. 1997;23:391-400.

Mohr JJ. Integrating improvement competencies into residency education: a pilot project
from a pediatric continuity clinic. Amb Pediatrics 2003;3(3):131-136.




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   9
Ogrinc G, et al. A framework for teaching medical students and residents about practice-
based learning and improvement, synthesized from the literature. Acad Med.
2003;78:748-756.

Ogrinc G, et al. Teaching and assessing resident competence in practice-based learning
and improvement. J Gen Intern Med 2004;19:496-500.

Opila DA. The impact of feedback to medical housestaff on chart documentation and
quality of care in the outpatient setting. J Gen Intern Med 1997;12:352-356.

Schillinger, D, et al. The populations and quality improvement seminar for medical
residents. Acad Med 2000;75(5):562-563.

Volpp KGM, Grande D. Residents suggestions for reducing errors in teaching
hospitals. NEJM 2003;348(9):851-855.

Weingart SN. A house officer-sponsored quality improvement initiative: leadership
lessons and liabilities. Jt. Comm J Qual Improv 1998;24(7):371-378.

Weingart SN. House officer education organizational obstacles to quality improvement.
Jt. Comm J Qual Improv 1996;22(9):640-646.

Weingart SN. Creating a quality improvement elective for medical house officers. J Gen
Intern Med 2004;19:861-867.



Quality Improvement – Medical Students
Gould B. Improving patient care outcomes by teaching quality improvement to medical
students in community-based practices. Acad Med. 2002;77:1011-18.

Headrick LA et al. Teaching medical students about quality and cost of care at Case
Western Reserve University. Acad Med 1992;67:157-159.

Henley E. A quality improvement curriculum for medical students. Jt. Comm J Qual
Improv 2002;28(1):42-47.

Wilcock P. Putting improvement at the heart of health care; medical students need to
learn continuous quality improvement skills as core skills. BMJ 2002;325:670-671.




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   10
Quality Improvement – Faculty
Cleghorn, GD. What faculty need to learn about improvement and how to teach it to
others. J Interprof Care. 2000:14:147-159.

Coleman, MT, et al. Teaching medical faculty how to apply continuous quality
improvement to medical education. Jt. Comm J Qual Improv 1998;24(11):640-652.




Quality Improvement – Web-based curricula “off the shelf”
Multiple curricula are available on the web. The following are notable:

Best practices for busy clinicians: applying continuous quality improvement in practice.
Available at: http://www.futurehealth.ucsf.edu/cnetwork/events/ruddworkshop.html

Curriculum Category: quality assessment and improvement. Available at:
http://www.thci.org/other_resources/HCQualityImprove.htm

Diamond HS. Continuous Quality Improvement (CQI) Curriculum for Primary Care
Residents. Available at:
http://www.mceconnection.org/mce/catalog/rscInfo.asp?docId=164

Getting started in continuous quality improvement. Available at:
www.sgim.org/Handouts/am04/Precourses/PW08.pdf

Partnerships for Quality Education. ACT (Achieving Competence Today) Online.
Available at: http://www.actcurriculum.org




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   11
                        Continuous Quality Improvement
                               Lecture Handout
                                    Alex Djuricich, MD
                                  Department of Medicine
                               Advanced Ambulatory Rotation

Goals:
After completion, learners (residents) should be able to:
          1. Demonstrate knowledge and skills necessary to effectively participate as
              a contributing member or leader of a CQI effort.
          2. Demonstrate an appreciation for the need to improve quality in health
              care and the contribution that CQI methodology can make to the health
              care system and its “customers.”

Objectives:
By the end of the month-long Ambulatory rotation, residents should:
   1. Define and contrast basic quality terminology
           a. Quality
           b. CQI/TQM
           c. Customers
   2. List four main concepts of CQI and be able to provide clinical examples of CQI in
       health care
   3. List and describe the elements of the PDSA cycle
   4. Construct and present an idea for a CQI project designed to improve patient care OR
   5. Construct and present an idea for a CQI project designed to improve an element
       of the medicine residency program.

Area 1. Basic Quality Terminology
Objectives: Define, provide examples of, compare and contrast and correctly use basic
quality terminology
   1. Quality
   2. Continuous Quality Improvement/Total Quality Management
   3. Customers

Area 2. Core Concepts
Objectives: List four core concepts of Continuous Quality Improvement and be able to
provide clinical examples of CQI in health care
   1. Quality can be defined by how well we meet the needs of those we serve
   2. Most problems are in processes, not people
   3. Unintended variation in processes can lead to unwanted variation in outcomes
   4. Continual improvement can be achieved through serial experimentation (PDSA
       cycle)




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   12
Area 3. The PDSA cycle
Objective: List and describe the elements of the cycle


(taken from www.ihi.org)




Area 4. Patient Care Project
Objective: Construct and present ideas for a CQI project related to the improvement of
patient care (preferably in the resident’s own ambulatory practice).
Area 5. Residency Program Project
Objective: Construct and present ideas for a CQI project related to the improvement of an
element of the medicine residency program at Indiana University.
Example projects:
A. Salt restriction and CHF readmission
B. Study groups to improve “Board” pass rate




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   13
Project A: Improve patient compliance with salt restriction for the treatment of
patients with CHF and prevention of hospital readmission rates.

Background. CHF is the #1 reason for admission to a hospital, and costs for these
hospitalizations are easily higher than any other admission diagnosis. Salt restriction is a
crucial element to keeping patients with a history of CHF out of the hospital. The
explanation of salt restriction to patients seems simple, and yet many patients with a
history of CHF continue to use too much salt with meals and thus have a higher rate of
hospital readmission. Design an outpatient form for intervention when salt intake is
excessive.

What are we trying to accomplish? Decrease the readmission rate for patients with CHF
by increasing compliance with salt restriction.
How will we know that a change is an improvement? If the readmission rate to the
hospital is lowered over a specific time period.
What changes can we make that will result in improvement? Design a brief intervention
handout explaining to patients salt intake’s role in exacerbation of CHF. Present the form
to patients on their first outpatient visit after a CHF exacerbation.

Plan: Design the project. Patients will be identified to be a part of the project when they
have a primary discharge diagnosis of CHF. Their primary care outpatient physician will
be informed of their admission, and will facilitate presentation of an intervention at the
next outpatient visit. They will counsel the patient on salt restriction, and present to them
a handout which provides the patient with simple ways of adjusting their diet, so as to
lower the salt intake, thus (hopefully) preventing future hospital readmission for CHF.
Do: The project will start when the forms are ready. The residents will look at the
readmission rate over the next six months from the time of the intervention to the patient.
Study: Study the results. How many patients were readmitted? Was the readmission due
(in part) to lack of salt restriction? If so, why? If not, was it due to medication non-
compliance?
Act: Adjust the form based on the results, or realize that readmission is indeed not due to
non-compliance with salt restriction, but rather other process problems (ability to get
medications).




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   14
Project B: Improve the pass rate for Indiana University Medicine residents on the
ABIM Certifying Examination by utilizing study groups to review material.

Background. Upper level residents realize the ABIM (American Board of Internal
Medicine) certifying examination (“The Boards”) is looming less than two months from
graduation from the residency program. Many residents have good intentions of forming
small study groups to review material deemed likely to be tested on “The Boards.”
However, many residents start out with a study group, but the group quickly dissipates,
and the studying is done (if at all) on one’s own, instead of with the study group.

What are we trying to accomplish? Increase the passage rate on “The Boards” and
develop a system where residents have a regular peer study group to review material for
“The Boards.”
How will we know that a change is an improvement? If the passage rate on “The Boards”
is higher this next year than in years past, and if the study groups meet a certain minimum
number of times. This will include determining if/whether study groups are currently in
existence. If so, are they actually meeting and reviewing material? If not, they will need
to be created.
What changes can we make that will result in improvement? Design a questionnaire and
send it to the residents to determine what the current status of study groups is. Inquire
whether they are interested in forming these groups. Form the groups, and “take
attendance” at each group meeting. Is the attendance satisfactory (this must be defined
prior to the groups’ meeting) in the last two months of the year? What is the passage rate
on the boards for our residency class?

Plan: Survey the current 3rd year residents on their interest in study groups to review
material for “The Boards” and see if/whether current study groups exist. Determine if
they want to use these study groups for reviewing material. Determine the passage rate
on the ABIM certifying examination for the last year.
Do: form the study groups, and take attendance at each group meeting. Is the attendance
adequate at each of the meetings. Compare the passage rate of “The Boards” this year to
that of last year’s class.
Study: Review the results. Did the study group continue to meet up to the last two
months of the residency?
Act: Adjust accordingly. Tell next year’s class about the success of the study groups.
Determine if the study groups are accomplishing the goal of improved pass rates on “The
Boards.”




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   15
                                  Template for CQI projects
Background




What are we trying to accomplish?




How will we know that a change is an improvement?




What changes can we make that will result in improvement?




Plan




Do




Study




Act




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   16
                             CQI PreTest Questions
Name: ___________________________                          PGY year: ________________
Please fill out the answers to the questions below. You should select ONLY one answer
for each question.

Knowledge
1. How much do you know about continuous quality improvement (CQI)?
 Absolutely nothing.
 I have heard of it, but nothing more.
 I have heard of it and discussed it before.
 I have heard of it and understand the basic terminology and concepts, although I
   could not teach it to others.
 I have heard of it, understand the terminology and concepts, could give a lecture to
   residents/other health care personnel about CQI.

Experiences
2. What kinds of experiences have you had with CQI?
 Absolutely none.
 I have attended a meeting (not a lecture) discussing quality improvement.
 I have been a passive part of a quality improvement team (i.e., not actively involved
   in the planning or decision making).
 I have been an active part of a quality improvement team (i.e., been involved in the
   planning and decision making).

Self-efficacy
3. I believe I am able to develop and implement a CQI project.
 Strongly Agree
 Agree
 Don’t Know
 Disagree
 Strongly Disagree

Interest
4. I would like to participate in a project if it helped improve patient care or improve the
residency program.
 Strongly Agree
 Agree
 Don’t Know
 Disagree
 Strongly Disagree


TURN THE PAGE OVER; THERE ARE MORE QUESTIONS!




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   17
General Knowledge
   5. Who are the customers of a residency?




    6. What is the difference between quality and CQI (Continuous Quality
       Improvement)?




    7. Give a clinical example of CQI in health care.




    8. List elements of PDSA cycle.




    9. Which is NOT a core concept of CQI?
         a. Continual improvement can be achieved through serial experimentation
         b. Process variation (unintended) can lead to unwanted variation in outcomes
         c. Most problems are in people not working hard enough
         d. We define quality by how well we meet the needs of those we serve




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   18
                            CQI PostTest Questions
Name: ___________________________                          PGY year: ________________
Please fill out the answers to the questions below. You should select ONLY one answer
for each question.

Knowledge
1. How much do you know about continuous quality improvement (CQI)?
 Absolutely nothing.
 I have heard of it, but nothing more.
 I have heard of it and discussed it before.
 I have heard of it and understand the basic terminology and concepts, although I
   could not teach it to others.
 I have heard of it, understand the terminology and concepts, could give a lecture to
   residents/other health care personnel about CQI.

Experiences
2. What kinds of experiences have you had with CQI?
 Absolutely none.
 I have attended a meeting (not a lecture) discussing quality improvement.
 I have been a passive part of a quality improvement team (i.e., not actively involved
   in the planning or decision making).
 I have been an active part of a quality improvement team (i.e., been involved in the
   planning and decision making).

Self-efficacy
3. I believe I am able to develop and implement a CQI project.
 Strongly Agree
 Agree
 Don’t Know
 Disagree
 Strongly Disagree

Interest
4. I would like to participate in a project if it helped improve patient care or improve the
residency program.
 Strongly Agree
 Agree
 Don’t Know
 Disagree
 Strongly Disagree


TURN THE PAGE OVER; THERE ARE MORE QUESTIONS!




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   19
General Knowledge

    5. Who are the customers of a residency?




    6. What is the difference between quality and CQI (Continuous Quality
       Improvement)?




    7. Give a clinical example of CQI in health care.




    8. List elements of PDSA cycle.




    9. Which is NOT a core concept of CQI?
         a. Continual improvement can be achieved through serial experimentation
         b. Process variation (unintended) can lead to unwanted variation in outcomes
         c. Most problems are in people not working hard enough
         d. We define quality by how well we meet the needs of those we serve



Reflection

    10. Regarding CQI, what did you learn that surprised you the most?




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   20
                Grading Instrument for CQI Projects
Resident’s name:                          Grader’s name:


Project is graded on five main questions (bold and shaded).

Adherence to PDSA cycle                                                             Score:

Contains the following sections: background, answers to three questions, and four
“PDSA” components

        Background.                                                           Score:
        Poor             Minimal        Fair            Excellent     Outstanding
        0                1              2               3             4
                This contains necessary information regarding situation for the system in
        which the project is to be implemented. Usually describes the hospital situation
        (type, size, patient population), or the residency program information (size, # of
        residents, # and type of sites at which residents provide patient care).

        Comments:



        What are we trying to accomplish?                                  Score:
        Poor          Minimal         Fair          Excellent      Outstanding
        0             1               2             3              4
              This is the goal to the project. Needs to be very specific. Improve
        WHAT?

        Comments:



        How will we know that a change is an improvement?                  Score:
        Poor            Minimal     Fair            Excellent        Outstanding
        0               1           2               3                4
                This is how we measure achieving the goal. How to measure the project.
        Examples include surveys, decrease in waiting times, things able to be
        documented. The key here is to create appropriate data, based on what the
        project is. Measurement needs to be as specific as possible.

        Comments:



        What changes can we make that will result in improvement?      Score:
        Poor         Minimal       Fair             Excellent    Outstanding
        0            1             2                3            4

CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   21
               These are the ideas for creating improvement. These are the solutions
        behind the problems.

        Comments:



        Plan                                                                   Score:
        Poor            Minimal         Fair            Excellent       Outstanding
        0               1               2               3               4
                This contains the initial stages for setting up the project. Other ways to
        assess include explaining the following:
                Possible problems preventing you from achieving your goals.
                Identify potential solutions to the problems.
                How is it measurable?
                Collect baseline data.

        Comments:



        Do                                                                 Score:
        Poor            Minimal          Fair          Excellent     Outstanding
        0               1                2             3             4
                This is the project itself. Measuring ____ by doing ____.
                Need to see explanations of implementing process improvement (potential
        solutions) identified above.

        Comments:



        Study                                                                Score:
        Poor            Minimal         Fair           Excellent      Outstanding
        0               1               2              3              4
                This is the evaluation of the project data. The times went from ___ to ___.
                Look for discussion of collecting of follow up data.
                See if target goals are met.
                Make necessary changes to interventions.

        Comments:



        Act                                                                  Score:
        Poor            Minimal        Fair           Excellent      Outstanding
        0               1              2              3              4
                Based on results of the project, we will either abandon the project (too
        broad), or hone in on one more specific piece of the project, and restart the cycle
        all over again.


CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   22
               Implement a modified or refined intervention and/or implement additional
        interventions to achieve goals.



        Comments:




Relevance (perceived need)                                                        Score:
      Poor          Minimal               Fair             Excellent        Outstanding
      0             1                     2                3                4

               Is there a need for this project? (Only someone from the institution would
        know this)
               Is it already being done or already has been done? (want “no” to this
        question)
               Will the institution/patients benefit from this project?

        Comments:



Feasibility (ability to “do” the project)                                         Score:
       Poor             Minimal      Fair                  Excellent        Outstanding
       0                1            2                     3                4

                Is the project something that actually can be implemented?
                Are those involved in the project capable of achieving the goal?
                Are those affected by the project able to be involved in the project?
                Example: if the project involves communication with nurses, how would
                nurses be involved?

        Comments:



Ability to measure outcomes                                                       Score:
       Poor          Minimal              Fair             Excellent        Outstanding
       0             1                    2                3                4


              Can a physician/health care worker see that the project led to
        improvement?
              Is there something “measurable” by the project?
              Does the project show us that something changed from ___ to ___?

        Comments:


CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   23
Affordability                                                                     Score:
      Poor               Minimal          Fair             Excellent        Outstanding
      0                  1                2                3                4


        Is the project so expensive as to not be realistic (e.g., change the entire computer
        system)? (want “no” to this question)
        Could the project be paid for (in reasonable amounts of $$$) within a smaller
        grant (such as under $1,000) dedicated to that project?

        Comments:



Total Score (for project):
        Comments:

Score on PostTest:
        Comments:

Score on Participation:
        Comments:

Final comments:




CQI curriculum/Indiana University School of Medicine/Dept. of Medicine/Djuricich/Ambulatory/9-04   24

				
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