Please find the full details of our QI project here.
Full details of our teaching programme can be found here.
These projects are part of our larger parent project - UDHC CBBLE (User drive health care & case based blended learning ecosystem)
Quality Improvement Cycle 1
Case 1 - "A 35-year-old female complaining of cough for 1 month under treatment of Lupus" (June 2017)
Scores
Domain 1 - History Taking - Poor (Score - 1/4)
An insight into the patient's life events is conspicuously missing; Although her past history of systemic lupus erythematosus and uterine fibroids get a passing mention, there is an incomplete inquest into her current problems, which are chronic cough and low grade fevers. This inhibited us from broadening our differential diagnoses list and may have impeded delivery of higher quality of care.
Domain 2 - Physical Exam - Average (Score - 2/4)
Images of her skin lesions are well demonstrated. However, there is incomplete data on targeted respiratory system exam. Although, they will have been checked, there is no documentation of data on vitals and a longitudinal approach to her clinical problems is lacking. Deidentification of patient data was well maintained
Domain 3 - Interpretation of Lab/Imaging Data - Good (Score - 3/4)
Images of chest x-rays and HRCT chest are clearly demonstrated with adequate interpretation of her lung lesions, a functional problem, with an anatomical and pathophysiological diagnosis was well demonstrated.
Domain 4 - Case Analysis - Good (Score 3/4)
The author has managed to adequately analyze her problem, supported with imaging data. He has also managed to generate a meaningful conversation (on our case based blended learning ecosystem - CBBLE network on blogger and also on Facebook) on this patient's problems and attempted to deliver improved quality of care.
Total Score - 9/16
Case 2 - "A woman with SLE, and Cutaneous Lesions (applying ayurvedic medicines)" (March 2018)
Scores
Domain 1 - History Taking - Good (Score - 3/4)
The patient's medical history is well detailed. There is good demonstration of longitudinal data logging. Although not in full detail, an insight into how the patient suffered from photosensitive rashes is evident. There is also fairly good detail into her past medical events and her resort to alternative medicine too.
Domain 2 - Physical Exam - Good (Score - 3/4)
A key pivot in this case was the nonerosive synovitis and symmetrical small joint pains, which enabled a diagnosis of Systemic Lupus Erythematosus (SLE). Demonstration of joint examination or at least antero-posterior and lateral views of her joints with in text description of joint examination would have made it thorough and targeted. Demonstration of her skin lesions in a longitudinal fashion is par excellence and also provides an in-depth understanding into how the patient is dealing with them.
Domain 3 - Interpretation of Lab/Imaging Data - Average (Score - 2/4)
Some important labs such as the anemia and hypoalbuminemia, with the mild hypercalcemia have been recorded but not analyzed. There is excellent demonstration of cotton wool spots in the retina and a brief analysis of why the patient developed cotton wool spots in her retina is merited.
Domain 4 - Case Analysis - Average (Score 2/4)
Although, excellent data collection and good data logging was demonstrated, a thorough case analysis was missing and framing a problem statement and analyzing all her problems should have been prioritized. Yes, her skin lesions have been demonstrated excellently with a report of her skin biopsy and good cross-consultations, a differential list was not generated and thus, the score for this domain drops from good to average.
Total Score - 10/16
Case 3 - "Medicine case cervical spondyloarthropathy" (July 2020)
Scores
Domain 1 - History Taking - Average (Score - 2/4)
Some insight into the patient's life and medical events is demonstrated. The author was able to glean a longitudinal sequence of events well but data points allied to the patient's current medical problems were poorly approached. However, the author was able to cover most domains of history taking well.
Domain 2 - Physical Exam - Poor (Score - 1/4)
The author attempted to stick to a standardized template for clinical examination, which was applied poorly to this patient. No hypothesis was generated from the history and the clinical exam was not in sync with the patient's history and medical problems. No video demonstration of clinical exam scores poorly in this domain.
Domain 3 - Interpretation of Lab/Imaging Data - Poor (Score - 1/4)
Lab data was well taken and there is some evidence of logging radiological images of the patient. There, however, is no evidence of analysis of either the labs or the images. The radiologist's report is shown and pointers in the image of the findings should have been done.
Domain 4 - Case Analysis - Poor (Score 1/4)
A diagnosis was not made or shown in the log. No analysis of any data is demonstrated. The case strays far from the history and clinical exam.
Scores
Domain 1 - History Taking - Average (Score - 2/4)
The author has done fairly well in highlighting the sequence of medical events in this patient. However, he has fallen short in getting more detail on how the symptoms affected the patient and some other history required to generate a hypothesis and a differential list.
Domain 2 - Physical Exam - Average (Score - 2/4)
A standardized physical exam was conducted well but this doesn't appear to be driven by the history. The clinical images have been taken well but there is little elucidation on her joint examination which would have enabled in ruling in and ruling out problems in the differential list.
Domain 3 - Interpretation of Lab/Imaging Data - Excellent (Score - 4/4)
Although not fully detailed, the author has done well in showing an understanding of the patient's problems and requesting for the right tests. There is no textual description for some of these images but data of proteinuria and her renal function is well demonstrated. Interpretation of the x-rays of hands and wrists would have enabled in narrowing the differential list. The biopsy images are impeccable and are excellently marked showing the findings diagnostic of the suspected disease. Kudos to the author to get the images from pathology, inspite of getting the renal biopsy elsewhere.
Domain 4 - Case Analysis - Good (Score 3/4)
A diagnosis often requires pathological confirmation. The renal biopsy conclusively diagnosed lupus nephritis. Other autoimmune markers like ANA and RF are also shown, although their utility and sensitivity & specificity analysis was not done. The author has generated a short differential diagnosis list, although, in some parts he has shown no evidence of arguments in favor or against a diagnosis in the list.
Total Score - 11/16
Case 5 - "A 55 yr old with chronic inflammatory symmetrical polyarthritis" (September 2020)
Scores
Domain 1 - History Taking - Good (Score - 3/4)
The author has gleaned out a good longitudinal history. She has also highlighted the patient's travails with the medical system and the problems faced by the patient in keeping his paper based medical records. A good history of his joint pains and how they were poorly treated prior to this presentation were brought out well.
Domain 2 - Physical Exam - Excellent (Score - 4/4)
A thorough and targeted physical exam was conducted and data on musculoskeletal system exam was laid out excellently. The author has also taken some good clinical images of the patient. The author has done well by integrating the clinical exam with the differential diagnosis list and has demonstrated analysis of her clinical findings very well.
Domain 3 - Interpretation of Lab/Imaging Data - Average (Score - 2/4)
The x-rays of the hands were taken well and shown but the analysis of these images is missing. This analysis would have been pivotal in tallying with her clinical exam findings. Thus, she falls short in widening and narrowing her differential list at the same time.
Domain 4 - Case Analysis - Good (Score 3/4)
The author has done well in ruling in her first differential diagnosis and demonstrates features in favor of this diagnosis. Elucidation of the EULAR classification criteria for RA was done well. However, no other causes of symmetric polyarthritis were considered and this is where she falls short in providing a better analysis.
Total Score - 12/16
Case 6 - "A 60 yr old female with polyarthritis and bilateral pedal edema" (September 2020)
Scores
Domain 1 - History Taking - Good (Score - 3/4)
The author has done well in gleaning the sequence of medical events. She has also shown the patient's travails with our healthcare system and how she was shuttled around from one hospital to another. Polyconsultations and polypharmacy with irrelevantly ordered tests have been laid bare. There is also some insight into her medical problems but some more detail should have been presented,
Domain 2 - Physical Exam - Excellent (Score - 4/4)
A superbly done clinical exam is well documented and the clinical images also show the degree of damage the patient suffered. The author has also made sure to address her non rheumatological problems with a thorough examination of her heart and lungs. Although these findings were not well analysed, the detail and depth of clinical exam is impeccable.
Domain 3 - Interpretation of Lab/Imaging Data - Good (Score - 3/4)
The author has done well in collecting all labs and imaging data. The analysis of most images is presented, although pointers in the images would have been better. Lab data is adequately supporting her first differential diagnosis and the author has also laid out the clinical classification criteria to support her primary diagnosis. However, key findings in her HRCT, Knee x-ray and x-rays of hands were missed, which could have broadened her differential list.
Domain 4 - Case Analysis - Average (Score 2/4)
The single most important aspect in this domain is analysis of data generated in the above 3 domains and generation of a differential list. Although data presentation was good, analysis was incomplete and integration of lab and imaging data with the history and physical would have generated a few obvious differentials that could altered the clinical course of this patient. This could have probably impacted the treatment course in the hospital.
Total Score - 12/16
Case 7 - "65 yr old with pedal edema ,knee pain and low back ache" (September 2020)
Scores
Domain 1 - History Taking - Good (Score - 3/4)
The history is well taken and we get some insight into the patient's life and medical problems and how she ended up consulting our department.
Domain 2 - Physical Exam - Excellent (Score - 4/4)
The detail and depth of the physical exam is immaculate. Thorough and focused, a differential list was generated with good data collection in these domains.
Domain 3 - Interpretation of Lab/Imaging Data - Good (Score - 3/4)
The author has considered the possibility of degenerative vs inflammatory arthritides and ordered for appropriate tests and imaging. The data are presented well and pointers in the images would have scored better in this domain.
Domain 4 - Case Analysis - Good (Score 3/4)
Data from the 3 domains above was generated and presented well and some case analysis making a diagnosis was also performed. All problems have been explained, functionally, anatomically and pathophysioloically (degenerative) but an etiological diagnosis was missed and this could have made it complete and thorough.
Total Score - 13/16
Data Analysis of QI Cycle 1
*Areas shaded in blue indicate data gathered after implementation of our online teaching programme
 | ||
| The total number of blogs included in QI Cycle 1 were 7. With the introduction of our online teaching programme, the number of blogs included from 2020 were significantly more than from 2017 or 2018. |
The average scores of blogs sorted by year. The scores have improved significantly from 2017 & 2018 to 2020. Blogs from 2020 performed above the average score of 10.3 for all 3 years.
This chart shows scores in the domain of history taking. Although the sample size is small, this chart shows a steady increase in scores in 2020 (since the implementation of our online teaching programme). The average score for history taking was 2.4.
This chart shows scores in the domain of conducting a physical/clinical exam. 3 out of 5 blogs from 2020 scored a perfect 4, well above the average of 2.9.
This chart shows scores in the domain of demonstrating competency in interpretation of laboratory or imaging data gathered in the blog. Only one blog scored a perfect score and 3 out of 5 blogs from 2020 were above the average score of 2.6
This chart shows scores in the domain of demonstrating competency in performing a thorough analysis of the history, clinical exam and laboratory and imaging data and the ability to generate a differential diagnosis list. No blog was able to get a perfect score but 3 out of 5 blogs from 2020 were able to score above the average score of 2.4.Summary
- The implementation of our online teaching programme, enabled logging of online health data for a significantly higher number of patients. Currently all patients admitted to the Department of General Medicine will have a similar online health record (with due consent and de-identification). Please find our full case bank here, You will find a bank of links sorted by designations (such as interns, PGs, online global students etc.)
- This has enabled us to run a QI on our records, with the ultimate aim of improving patient care.
- This QI cycle was specific to rheumatology and thus only a limited set of cases were available. 5 blogs from 2020 (from July to September 2020) were included in the first cycle.
- A demonstrable improvement in physical/clinical examination is noted with a perfect score of 4 for 2 blogs and with a high average of 2.9.
- History is the single most important domain in any patient's care and although blogs from 2020 showed good scores of 3, we aim to improve the average to 3 or above and hope to achieve perfect scores of 4 soon.
- Collection of lab and imaging data has been impeccable. However, interpretation of these data has remained woeful and we will strive to improve in this domain.
- Case analysis was performed fairly well but most blogs could not generate a differential list and with it, we may run the risk of missing crucial diagnoses and thus may fall short of providing the best possible care to our patients.
- This cycle will now form the basis for our cycle 2, which we will run in due course of time. A list of blogs have already been shortlisted and we certainly anticipate higher average scores across all domains.
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