QI proposal for Team B

Ok, I haven't talked with team B yet but this is what I have so far....plenty of room for improvement but I think could be nicely done....

Mirko.

QI research project proposal x Team B

Clinical question:
Does early recognition and patient awareness improves the outcome in newly diagnosed metabolic syndrome patients?


Hypothesis:
Early diagnosis and patient awareness of metabolic syndrome and it's long term implications could potentially lead to a significant decrease in cardiovascular risk factors (Primary endpoint) and improvement of quality measurement values i.e HbA1c, LDL, BP, etc. (Secondary endpoint)


Methods:
Not clear yet but this is what I was thinking.

1. Population determination: First we would have to decide if we want to work with newly diagnosed MS (metabolic syndrome) patients or instead make a chart review from year X to year Z and after that contact the patients. Also consider variables such as sex, age, etc.

2. After we have the population defined, we could create 2 big groups of patients, one of those groups(if ethical, yet to be determined)will attend to a single "professional scary session" where we show them slide of cases of end stage renal disease, advanced DM etc. and the other group of patients we just do what we regularly do on a health maintenance visit; we mention to them that they meet criteria for MS and that they should make lifestyle changes( i.e. exercise and diet). Other option could consist of putting together a Power Point Slide set for patient education, showing the natural progress and terrible outcomes of MS if not addressed on time. This PP would have to be peer–reviewed and considered a standarized tool that later on we could all use and show to the patients, so at the same time with this study we could potentially validate such tool.?

3. We follow all those patients on 15 minute appointments at 3, 6 and 9 months (those could essentially be nurse only visits?) where we check specifically BP, waist circumference, weight & height (we could include other variables here too, but the idea is too keep it simple so is easy and affordable). Another approach to these follow up visits could be introducing a short questionnaire asking about physical activity changes, dietary changes, etc.

4. After 6-12 months (we would have to define time frame) we check all the data gathered and hopefully we will see some improvement on our study variables, or not, as well as on quality improvement variables and overall patient condition.

I feel like prison tonight

I thought it would be a nice idea to write down the experiences of a night moonlighting in the prison.

7:50 pm I just left Journal Club at Liz Westby's house and am making my way down the east side of town to the FMC

8:00 pm A little worried I'm late, I walk into the 'Sallyport'-the gate at the prison. The PA is waiting for me for handoff, but she says I'm not late, just on-time. Nothing to pass on. They had sent a guy to St. Mary's an hour earlier for a GI bleed.

8:10 pm I've gone through all the security stuff and I'm at the nurses station. Nothing to pass on.

8:15 pm On the second floor of building 9 at the nurses station there is a place to sign in and check for physical exams to do. There can be up to 3, but luckily tonight there's only 1.

8:30 pm There's a computer on the first floor of building 9 with Mayo access. I'm working on my notes and billing from today while I wait to do the physical.

9:15 pm The inmate has been brought up to the exam room for the exam. Pretty straightforward and takes about 20 minutes. Usually done on the computer, but my access to the prison system wasn't set up yet.

9:45 pm I'm back on the Mayo computer finishing up my stuff.

10:45 pm I figured I might as well go up to the sleep room to get some rest.

5:30 am No calls or issues overnight. I get my stuff together to go.

6:00 am I signed out at the 2 logs on the second and first floors of building 9.

6:15 am Driving home... I just made $500 for a 20-minute physical!

OB skills workshop 10/22/09

Some rough ideas for an agenda from Dr. Brost:

ultrasound skills

using fetal pigs:
1) identifying stomach, kidneys, diaphragm, spine, extremities, ?bladder on fetal pigs
2) measuring crown-rump length
3) identifying the yolk sac
4) measuring cervical length (in development)
5) using M-mode
6) AFI
7) BPD
8) turning dials and knobs and looking smart

patient encounter
approach to the OB patient when there is uncertainty or bad news
[can't find the fetus, or can but there's no heartbeat, etc)

OB emergencies
dystocia
post-partum hemorrhage

Research opportunity - ultrasound workshop

Here's some information on the OB ultrasound workshop and a possible research opportunity for a resident:

As you all probably know, Dr. Brost is one of the higher ups at the simulation center.

He has a big interest in research on medical education. He's been thinking about teaching residents ultrasound. He has some pretty interesting ideas and has a goal of developing a reproducible curriculum for family medicine residents (specifically family med, but also OB residents, ultrasound techs, etc...). The current training format for everyone who's learning ultrasound is to be thrown into it and see how far you can get in 5 minutes or so.

In the process, you fumble around and look like you don't know what you're doing, at least at the start.

Ultimately, it would be nice if the biggest part of the learning curve happened in the simulated environment.

The simulation center has 3 machines set up for OB ultrasound.

Dr. Brost has already designed learning materials or lesson plans for (no particular order):
1) identifying stomach, kidneys, diaphragm, spine, extremities, ?bladder on fetal pigs
2) measuring crown-rump length
3) identifying the yolk sac
4) measuring cervical length (in development)
5) using M-mode
6) AFI
7) BPD
8) turning dials and knobs and looking smart

He would like to study how we learn to become proficient in using the ultrasound for specific tasks like these.

From our training standpoint, it looks like we've got a session at the simulation center on 10/22 in the afternoon.

Dr. Brost was thinking that this could be a good "kick-off" for a more frequent learning program on ultrasound use. At this point it would tentatively be lunchtimes at the simulation center with no more than 3 residents at a time (one learner per ultrasound machine).

The simulation center has the capability of getting statistics on times at task and other metrics while the residents are learning, so that kind of data would be used in the research.

Specific research questions wouldn't just be how long it took to get proficient in x, y, or z, but also what the definition of proficiency would be for each task. So this would involve coming up with what are the goals fore each station and what are the goals for testing. For instance, measure the femur length in 2 minutes.

He's offering himself as a resource. He's also going to try to get the MFM fellows to assist in the sessions.

An aside: he showed me a demo on a fetal pig which was a little weird, but surprisingly similar to a human fetus (except for the snout and the hind legs). Anyways, he wants people to leave this with a systematic approach to the ultrasound. Find your landmarks and then proceed. It's really neat.

The bottom line:
1) this would be good for us individually, our program, Mayo, and potentially all Family Medicine Programs as an ultrasound training curriculum. Ask Dr. Matthews or Bonacci if education research is important. It is, and Mayo loves it. Brost was talking a lot about that.
2) I'd like to be a part of this, but I'm not interested in OB that much and I'm a third year. This is more geared for someone who has a few years to really see this through. I need volunteers to work on this and it will be a little bit of work, but not too bad. If you're actually interested in OB, I think it would be great.
3) Two early on goals are getting things ready for the 10/22 workshop and preparing a poster presentation for the FM forum. This isn't that big a deal, and I would help with it.

Clinical reviews

This is unofficial and Dr. Garrison it the consultant working on this for us:

He thinks theres a really good chance this will be covered by all who can attend (at least of the 3rd years). They're looking into having a poster presentation at the FM Forum in October counting as a presentation day. He was saying that might be able to be used as a day for Clinical Reviews.

FPIN update

I think this is likely to be continued. I heard an unofficial 'yes' from Dr. Bernard.

We should try to get people together to discuss their experiences with FPIN and ideas to get better participation.

QI update

Looking ahead to next meeting (Thursday August 13)

#1 We need to figure out teams and team leaders. Here's where it stands:

Group (Care team) A.
Leader: Sawyer
Members: Morgan, Garcia, McManus, Lynch, Robertson
Group (Care team) B
Leader: ?
Members: Truitt, Schoofs, McClone, Meier, Lovold, Rybar, Oberhelman, Ludwig
Inpatient team
Leader: ?
Members: Michaud, Mansukhani, Caro, Couch, anyone else interested?

#2 We need to get topics squared away
Group A and Inpatient topics seem pretty settled.
What about something with smoking for Group B? I was thinking about taking all those who are quitting smoking and see about doing care team phone calls every so often to see if it impacts cessation rates...

#3 Poster presentations
FM forum is in October.
Each group is going to have a poster presentation about the project.
That's really not too far off.

Workshops and Conferences

OB ultrasound workshop
Meghna and Casey got the ball rolling on this and we hopefully are going to have a few days of simulation center time to hone your ultrasound skills.

We'd like to have your specific goals/interests for the workshop, so please take a look at what others have said and add your 2 cents at:
http://spreadsheets.google.com/ccc?key=tk9zNc28dao3raRQjNT71Yw (you need to sign in if you're going to add/change your info)

Other ideas
It's early in the year and I've got time (obviously) so please give us your ideas for other workshops and conferences (same survey as the link above) so I can get to work on it. Any ideas you'd like to spearhead would be fine with me, too. I'd be happy to help or get out of your way.

FPIN

Family Practice Inquiries Network http://www.fpin.org/

Our residency is probably not going to be renewing its membership with FPIN.

It's the group that runs the Help Desk Answers and Clinical Inquiries publications. And, this is a program that encourages research and publication that got some use in the previous academic year. It is pretty costly to the program (I think about $4000/year) and it was only a small percentage of residents who were utilizing the program. Since it was possible to get published (kind of) quickly, it has that benefit for residents who are trying to get a publication done in order to fix up their CV for fellowship or whatever.

From my standpoint, I'm a little weak on this issue since I've never used FPIN, I haven't had anything published during residency, and I'm not up for a fellowship.

So, if you have personal experience with FPIN, have an opinion about the program, would like to share thoughts on other potential replacement programs, or were counting on FPIN to get a publication together for a fellowship application please add your thoughts here.

Journal Club

7/27 at 6 PM at Dr. Westby's house.

Watch this beforehand if you can:

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Less formal this time.

Journal Club is the last Monday of every month. Next month's Journal Club will be on Monday, August 31. If you have an idea for a venue or (better yet) a topic which you'd like to lead the discussion on, let us know.

Some questions to think about while viewing the film:

1) What is the key difference in health care in the 5 developed countries in the video when compared to the U.S?

2) What are the four basic health care models around the world?

3) Which model (country) is Medicare similar to? What about the VA?

4) What does the Republican Party advocate for? What about the Democratic Party?

5) What is the AMA's position on reform? How does this compare to the AAFP position? How do these compare to Mayo's stated position?

6) Going beyond question #5.. Where are all the other 'stakeholders' in health care coming from? What do they stand to lose or gain?

a) Doctors, b) Other providers, c) Hospitals, d) Insurance companies, e) Drug companies, f) Employers, g) Oh yeah, Patients.

Ongoing Research

There's been some response from the consultants and from you guys to my survey about ongoing research.
You can take a look at who's doing what at:

spreadsheets.google.com (you need to sign in if you're going to add/change your info)

You might (or probably) know more about this than I do, but there are about 4 different places on Mayo's intranet where you can find information about what our consultants are doing. Dr. Thacher is now our head of research and he's going to be working on improving this, as well as the research connections between residents and consultants. If you haven't already given us your interests/information, please do so.

Quality Improvement Meeting 7/9/2009 Recap

What is this all about?

1. We've got to figure out better ways to collaborate in our residency because we really can't all meet up at the same time and place with any regularity
2. Here we can exchange information and we won't gum up our Mayo email boxes.

What is Quality Improvement?

1. Looking at how we do things. Objectively analyzing it. Making changes for the better.
2. Examples abound at Mayo: Sentinel events, root cause analyses, human factors, simulation
3. One approach: PDSA
   1. Plan
   2. Do
   3. Study Results
   4. Act
   5. {repeat just like shampoo}
4. Quality Improvement will be a fact of life once we're out of residency

The short history of Quality Improvement

1. Process improvement fairly successful during World War II (we won).
2. Pioneered by W. Edwards Deming
3. After WWII, Gen. McArthur (in charge of post-war Japan) brings W. Edwards Deming to Japan to help rebuild
4. The Japanese idea of Kaizen: improvement for good
5. Fast-forward and now they’re building the Prius and we’ve got … General Motors.

In medicine currently we are increasingly being held responsible for results

1. Reexamining the way we address medical processes because cost controls are coming
2. Some core measures [for Minnesota Community Measures Project]
   1. Diabetes Care
      HgA1c <>
   2. Vascular Disease (CAD)
      LDL <>
   3. Depression
      PHQ-9 <>
   4. Preventive Services
      mammo, PAP, lipids, immunizations, etc.

Quality Improvement

For second and third years… The nature of our program is that we rarely can be at the same location at once.

I tried to figure out the probability of it but basically I think it boils down to every senior is probably going to miss one meeting and every second year is going to end up missing 3 meetings this year.

spreadsheets.google.com

So for those 2nd and 3rd years who couldn't attend the Quality Improvement Seminar on 7/9/2009 the point of this is to get you all up to speed about the plan for QI this year.

Please take a look at the posting and add your own comments.

I'm not running this thing, but I would like to help it succeed. To that end, I think setting up reachable goals and making communication as easy as possible will be the keys to success.

Because we're not all going to be making each meeting...

And remember...

... the first rule of Journal Club is you DO NOT talk about Journal Club.

...what happens in Journal Club stays in Journal Club.

...the fourth step to overcoming Journal Club is to make a searching and fearless moral inventory of ourselves

...as Gregor Samsa awoke one morning from uneasy dreams he found himself transformed in his bed into a gigantic Journal Club.

...this may be the only way for you to meet each other and discover whether you're more than an athlete, a basket case, a princess, or a criminal and thereby challenge mean Mr. Vernon's simplistic assumptions about us all.

...Journal Club can be spread by direct contact with nasal or throat secretions of infected people, or, less frequently, by airborne transmission. It is very important that you wash your hands after each Journal Club.

I'm going to keep these coming until someone logs on to this frickin' blog...