Anne Tomolo, MD, MPH
MEDICINE/EMERGENCY MEDICINE, VAMC
email Dr. Tomolo
phone: 791-3800-3297

THE OUTCOMES CARD: A TEACHING TOOL FOR PRACTICE-BASED LEARNING AND IMPROVEMENT AND SYSTEMS-BASED PRACTICE

Background: Medical students work and learn in complex healthcare delivery systems but frequently lack the knowledge and skills necessary to continuously evaluate and improve patient care. Recent medical school graduates frequently are well prepared to discuss the scientific aspect of medicine on individual patients but are not comfortable with other dimensions of medicine. The Accreditation Council for Graduate Medical Education (ACGME) core competencies for postgraduate trainees also apply to undergraduates. Practical methods to teach practice-based learning and improvement and systems-based practice need to be developed, and it is not clear how to achieve trainee competency in these areas.

Purpose: Design, implement, and evaluate a tool called an outcomes card that facilitates follow-up of patient outcomes in the clinical setting and self-evaluation and encourages an awareness of systems issues.

Methods: Subjects: Third and fourth year medical students on clinical rotation. Intervention: Each subject participates in a didactic session prior to the clinical rotation that reviews the theories and methods of Quality Improvement. During this session the subjects will receive an outcomes card and instruction on its use during the rotation. This card is used for multiple patients. It compares the preliminary and final assessments of a patient and identifies medical error and system improvement opportunities for each case. Measures: Each subject will complete a case-based pre- and post- test questionnaire that includes questions related to the identification of healthcare systems and gaps in a process, along with development of a flowchart of the process described in the scenario. The responses to the test will be scored and compared with the test key. Subjects also participate in a focus group to address the use of the tool in the clinical environment. Analysis: The pre- and post- test results compared using a paired t-test. Qualitative data reviewed from the focus group.

Project Description

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of post-MD medical training programs within the United States. In September of 1999, it endorsed six core competencies and requirements for residency evaluation, which included the following areas: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. These core competencies also apply to undergraduates. Most recent graduates of medical school are comfortable with the scientific aspects of medicine and the clinical skills required for a medical evaluation and exam. However, trainees are operating in complex healthcare delivery systems and are not equipped with the knowledge or skills to analyze and continually improve patient care.1

The project that I am proposing focuses upon the use of an outcomes card as a teaching tool for two of the ACGME competencies, practice-based learning and improvement and systems-based practice. The idea of systematically tracking medical outcomes originated with Ernest A Codman. In the early part of the 20th century Codman set a standard for open, honest, and public evaluation of the end results of medical and hospital care.2 As a medical student Codman kept records of the patient’s condition during anesthesia and as an assistant surgeon at Massachusetts General Hospital he tracked the end results of care provided on one of the surgical services. Tracking outcomes is a professional responsibility of all physicians but it is not integrated or emphasized in medical training throughout the United States. The outcomes card assists medical students in tracking the preliminary and final assessment of multiple patients on a clinical rotation. The final assessment includes an evaluation of the final diagnosis, a description of medical error associated with the case, and an identification of opportunities for system-based improvement. Through this process the cards facilitate the follow-up of patient outcomes in the clinical setting, as well as trainee self-evaluation. Additionally, they encourage an awareness of system issues, including medical error.

The card’s ability to effectively assist in the development of new knowledge would be assessed through quantitative and qualitative measures. Quantitative data would be obtained by case-based pre- and post- test questionnaires that focus upon system failures. The testing would include questions related to the identification of healthcare systems and gaps in a process, along with the development of a flowchart of the process described in the scenario. Further evaluation of the use of the tool in the clinical environment could be obtained through focus groups.

The ACGME has acknowledged gaps in physician training and the development of the new competencies provides an opportunity to establish teaching tools that help trainees to achieve competency in these areas. The two competencies of practice-based learning and improvement and systems-based practice tap new ground for medical education, as they focus upon other dimensions of medicine. The outcomes cards are tools that can be used by all students throughout their clinical rotations, which makes it distinctly different from most changes in curriculum that focus upon the development of new knowledge by adding a new rotation or elective. Instead this tool is integrated into the current clinical practice of students and acts to integrate improvement knowledge into the process of care as opposed to distinct from it.

A project that assists in the development of knowledge and skill in the competencies of practice-based learning and improvement and systems-based practice would be invaluable to the medical school curriculum, which strives to provide innovative and effective education to future physicians.

References:
1. Aron DC and Headrick LA. Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Qual Saf Health Care 2002; 11:168-173.
2. Codman EA. A Study in Hospital Efficiency [reprinted]. Chicago: Joint Commission on Accreditation of Healthcare Organizations, 1996. Introduction: Ernest Amory Codman and the End Results of Medical Care, by Duncan Neuhauser, pp. 7-47.