From July 2006 to June 2007, 34 PGY2 residents participated in the first and second QAIC blocks. During the first block, the residents each performed a prospective sequential sample of 5 patient chart reviews, asked 5 patients to complete the ABIM CPS PIM Patient Survey, and met with clinic leadership to complete the ABIM Systems Survey. A total of 170 of 170 (100%) chart reviews were performed, and 130 of 170 (76%) patient surveys were collected. During a formal feedback session, the residents received group-level data regarding the quality of care they provided and their patient’s opinions of the quality of care the clinic provided. Group level data included 18 patient demographic data points, 9 outcome measures (e.g., body mass index [BMI]
25, low-density lipoprotein cholesterol at goal), 49 processes of care measures (e.g., height recorded, breast cancer screening performed), and 107 systems enhancements (e.g., record contains an up-to-date medication list, practice provided smoking cessation counseling).
Residents noted suboptimal performance on 2 outcome measures: (1) BMI at goal of less than 25 in only 7 of 170 (4%) charts and (2) tobacco cessation counseling documented in 46 of 154 (30%) of relevant charts. The residents realized that while documentation of weight was exceptional (163 of 170 [96%] charts), height was recorded only 25% of the time (42 of 170), which was a major barrier to calculating the BMI for their patients. Results from the patient survey highlighted that 20% (38 of 117) of patients reported difficulty obtaining medication refills. Using this data, residents were able to brainstorm QI goals including: (1) increasing percentage of charts that had height recorded as a step to increase BMI screening, (2) increasing percentage of patients receiving smoking cessation counseling, and (3) improving the refill process. The CPS PIM then asked residents to develop a plan for improvement and to report results of this improvement.
During the second QAIC block, the residents developed a group project that was implemented in their continuity clinics addressing 1 of the 3 areas of improvement highlighted by the CPS PIM. The 3 projects included: (1) BMI collaborative (January block), (2) tobacco cessation collaborative (March block), and (3) the medication refill collaborative (May block; see Table ).
Title: Summary of Quality Improvement Projects Resulting from Quality Assessment and Improvement Curriculum
To address the poor rate of height documentation and, by default, BMI documentation, the BMI collaborative worked with the nursing staff to integrate height into the triage process, posted BMI charts throughout the clinic, and educated residents on the importance of calculating and documenting BMI. Residents developed an educational module to be used by the clinic preceptors during the first 30 minutes of the continuity clinic, which was set aside for standardized clinic education. The BMI collaborative was able to increase documentation of height from 22 of 206 (11%) of all charts in the week before intervention to 143 of 163(88%) of all charts in the week after intervention (P
.001). Although not identified as a problem, it is noteworthy that dictation of weight also improved from 185 of 206 (90%) to 158 of 163 (97%; P
.008). Ultimately, rates of dictation of BMI improved from 9 of 206 (4%) to 129 of 163 (79%; P
The tobacco cessation collaborative worked with clinic nursing staff to document smoking status and to give patients a “readiness to quit” handout if the patient was currently smoking. The collaborative also educated residents on tobacco cessation counseling and documentation. The tobacco cessation collaborative improved documentation of smoking status from 31 of 75 (41%) charts before intervention to 56 of 84 (67%) charts after intervention (P
The refill collaborative worked with the continuity clinic medication refill center staff and the local pharmacies to streamline the refill process for both patients and residents. The key part of their intervention was to educate residents on the proper use of the clinic medication refill center and the importance of having an accurate and up-to-date medication list. The residents found in their preintervention data that many residents changed a medication dose/stopped a medication/started a new medication in the dictated plan but did not make the corresponding change in the dictated medication list that was used by the medication refill center. These outdated medication lists were deemed “inaccurate” as they had the potential to lead to improper refills for patients and increased paperwork for the residents. By educating their peers, the residents were able to decrease the number of “inaccurate medication lists” from 54 of 216 (25%) preintervention charts to 27 of 296 (9%) postintervention charts (P
Themes that were common to all 3 projects included: (1) interdisciplinary effort between residents and clinic staff, (2) resident education that focused on correct documentation, (3) a publicity campaign, and (4) a patient education component. The group QI projects also resulted in a spillover into the attending clinics and into future QI projects. For instance, the attending clinic’s patients also had height and smoking status documented on clinic vitals sheets. The resident groups tended to build on previously implemented initiatives to improve awareness of their project. For instance, the tobacco cessation and refill QI projects added stickers/reminders to the laminated BMI charts that were posted in cubicles around the clinic.
To evaluate the effect of this curriculum, we administered a previously described [2
] self-assessment tool of QI skills to the residents before and after the first 2 blocks of the curriculum. The percent of residents reporting that they were comfortable writing a clear aim statement improved from 71% (24 of 34 residents) to 96% (27 of 28 residents; P
.01, chi-square test). The percent of residents reporting that they were comfortable using a PDSA cycle improved significantly from 9% (3 of 34 residents) to 89% (25 of 28 residents; P
.001, chi-squared test). Preliminary evaluation of resident’s qualitative responses has shown a positive reaction to the QAIC curriculum. The following comments were excerpted from the free-text commentary on the post-assessment:
“It helped me realize that I can change things when they don’t work well, instead of just criticizing the current system.”
“I learned how to break QI projects into small manageable steps.”
“I gained experience using the PDSA cycle which is essential to my research interests.”