Innovating in Education and Patient Care to Reshape the Future: - PowerPoint PPT Presentation

Innovating in Education and Patient Care to Reshape the Future: Medical Education 2030 and Beyond Vineet Arora MD MAPP AIAMC 2019 ANNUAL MEETING

Objectives  Learn a conceptual framework for how bridging leadership can promote alignment between education and exceptional clinical care  Learn to create educational initiatives to promote alignment;  Learn how to create health systems innovation that aligns with needs of trainees 2

It is 2030

iGen

8

Picture of alexa in our  Alexa/ai house (AI)

11

 Coding toy of the year

Homo sapiens digitalis

“The arrival of Gutenberg’s printing press, in the 15th century, set off another round of teeth gnashing. The Italian humanist Hieronimo Squarciafico worried that the easy availability of books would lead to intellectual laziness, making men “less studious” and weakening their minds.”

Innovations in Medical Care Today

“Genomic Prescribing System” (GPS) from Ratain CPT 2007

Slide courtesy Peter Odonnell MD

Slide courtesy Peter Odonnell MD

AI to Warn Clinical Team about a Patient Risk 21 Slide courtesy Dana Edelson MD

Post-Discharge Physical Therapy Let’s start arm Mobile App curls. Find some Caregiver hand weights, water bottles, or soup cans… Photo by rawpixel on Unsplash Smart Speaker You have a new Older Adult message from Ellen: ‘Keep up the great work, mom!’ Website Photo by rawpixel on Unsplash Authors: Huisingh-Scheetz M & Hawkley L; Programmers: Orbita, Inc.

Healthcare Teams Today

Medical Training Now

Current State of Medical Training  Apprenticeship model  Uniform timeline  Standardized testing  Service vs. learning  Duty hours debates 25

Are we stuck with a QWERTY keyboard?

How Do We Innovate?

What kills innovation?  Innovation is hampered by: Expertthink Grouptthink  Surrounding yourself with like-minded individuals 28

Key to Innovation: Zero Gravity Thinkers  Psychological distance: maintain an open mind.  Diverse interests: a wide range of interests, experiences, and influences  Expertise in intersectoral areas: strength in a relevant area may lead to "intersection points" at which solutions are often found 29

Role of Brokers in Innovation  Brokers Member in multiple groups—powerful transmitter of information People connected to groups beyond their own can expect to find themselves delivering valuable ideas, seeming to be gifted with creativity. This is not creativity born of genius, but as an import-export business. An idea mundane in one group can be valuable insight in another. Ron Burt, PhD

Diverse Types of Innovation Primary Care Delivery Scribes Innovations Personalized Minute Medicine Clinic Initiatives 31

Marketing Innovation is Necessary Figure adapted from Satpathy R 32

Overcome the Status Quo  Status quo bias an emotional preference for the current state of affairs Any change from baseline is perceived as A LOSS  “nudges” needed to promote better decisions about personal health  Adapt nudges to clinician behavior

Aligning Innovation in Training & Care

Bridging Leaders as “Brokers”

Bridging Leader to Broker Innovations Between Education & Clinical Enterprise Education Clinical Operations Foster development & testing curricula Implement & scale evidence-based Implementation Science aligned with clinical operations interventions to improve care Disseminate innovations to frontline Develop & implement delivery Dissemination Expertise clinicians to improve their learning innovations to improve operations Adapted from Moriates & Arora. Healthcare

Engaging Zero Gravity Thinkers Supervision Healthcare Quality Patient Safety Professionalism Duty Hours Transitions of Care

Provide Framework for Sustaining Practice Innovations in Value Interventions Description Skip the Drips Subspecialty faculty Valuing cost-consciousness and resource Culture C champions recruited to stewardship at the individual and team level email peers Pharmacy receives a monthly Requiring accountability for cost-conscious Oversight O decision-making at a peer and audit of PPI drips ordered organizational level and why Creating systems to make cost-conscious Systems Epic now requires indications S decisions using institutional policy, decision- for PPI drips when ordering Change support tools, and clinical guidelines “Brochures” on Skip the Providing knowledge & skills clinicians need Training T Drips shared in workrooms & to make cost-conscious decisions at morning report Adapted from Understanding Value-Based Healthcare

Market with Right Message & Messenger Choosing Wisely Challenge SKIP THE DRIPS Improve meaningful use of continuous infusions to improve value of care PPI FOR UPPER GI BLEED •Goals  Improve survival from life threatening GI bleed  Avoid complications such as C diff  Improve likelihood of successful endoscopy •Recommend  Pre-endoscopy: reserve PPI drip for suspected Dr. Gautham Reddy, high risk upper GI bleeds.  Post-endoscopy: GI Fellowship • All PPIs should be discontinued unless endoscopy identifies Program Director ulcers or erosions • Continuous IV PPI can be used for ulcers with high-risk lesions Special thanks to UCM Office of Clinical Effectiveness, led by Michael Howell, MD. 40

Skip the Drips: Inappropriate PPI Orders Nikhil Bassi 100% 90% 80% + 3 SD 70% 60% 50% Mean 40% 30% - 3 SD 20% 10% 0% Jul-14 Aug-14Sep-14 Oct-14Nov-14Dec-14 Jan-15 Feb-15 Mar- Apr-15 May- Jun-15 Jul-15 Aug-15Sep-15 Oct-15Nov-15Dec-15 Jan-16 Feb-16 Mar- Apr-16 15 15 16 Statistical process control chart using standard UCL (LCL/UCL is defined by +/- 3 standard deviation)

Patient List Indicators for Tele /Foley Charlie Wray 42

Usage of Telemetry & Foley with FLIP Wray, Farhenbach, Howell, Arora.

Studying PCP Handoffs in Resident Clinic Amber Pincavage Transitioning to 3 rd PCP in 5 yrs 97% scheduled By 3 months, 26% of ALL patients had ED visit or 29% “No 44% saw hospital stay Show” or correct cancelled first PCP By 6 months, new PCP visit 19% lost to follow-up Resident ownership a problem: 48% PGY2s reported patients not ‘theirs’ until seen in clinic Pincavage et al.: JGIM 2012

Innovations Emerged from Patients  Notify and prepare patients for the handoff  Telephone visits with the new physician  Give guidance to residents how to assume care  Recognize patients for their role as valued educators of trainees  Importance of personal sharing  Empower patients during the handoff

Recognize patients for role in training mission

Improve Recall of Packet

Rates Acute Care & Loss to Follow Up Pincavage, et al AJM 2014

Leaders at Resident Forum, Resident Advisory Committee, GMEC Inter- departmental QI/Safety Curriculum

IGNITE I mproving G ME- N ursing I nterprofessional T eam E xperiences Program Aim: to engage residents, nurses, & other staff in institutional performance improvement through approaches at two levels: Unit-level: unit-based teams, Institution-level: institutional performance composed of Resident-Nurse improvement “mini Kaizen” events to champions, who work to identify & engage residents & staff on improving implement practice changes that issues for which they are stakeholders & improve both care & learning process owners.

Why ? Patients not always localized Absence of a nursing school

What does this look like? IGNITE Internal Medicine IGNITE Pediatrics IGNITE Surgery Cohort 1 Project aim: I mprove the % of patients who Project aim: Improve MD/RN communication Project aim: Improve efficiency of understand their discharge teaching early in the multidisciplinary rounds via structured reporting via including RN on morning bedside rounding morning of day of discharge Metric: teach- Metric: % nurses attend rounds tool Metric: resident report time backs failed IGNITE Kaizen - Peripheral IV Placement IGNITE Kaizen - Transportation Delays Kaizen Project aim: improve processes to reduce Project aim: Improve policy/procedures for patient transportation delays inpatient peripheral IV placement Metric: reduce in-hospital transport delays for Metric: fewer patients with more than 3 sticks testing and procedures IGNITE Neurology IGNITE Ob\gyne IGNITE Orthopaedics Cohort 2 Project aim: Improve shared mental model of Project aim: Improve % low-risk patients Project aim: Improving discharge MD/RN on-call issues overnight via afternoon B- discharged before noon via enhanced MD/RN communication to patients via standard EHR- BRAINS huddle communication after attending rounds based discharge template Metric: on-call pages at night Metric: Discharge before noon 52 Metric: Pages regarding discharge instructions