Quality Improvement Project – Improving Inpatient Medical Care

We, from the Department of General Medicine, at Kamineni Institute of Medical Sciences have made it our top priority to improve patient care across several domains by embracing and enhancing the ‘collective’ goals of various stakeholders in providing health care at our hospital.

We understand that we are a low-resource setting and have made it our mission to embrace and utilize tools which can greatly augment delivery of optimized health care within our accepted constraints. The delivery of this purported optimized health care involves the use of some third-party applications like – WhatsApp and Blogger blogs to log patient data (such as history and clinical examination) in a deidentified manner and provide evidence-based care using a CBBLE (case based blended learning ecosystem). This system has formed the basis of our online teaching programme. 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).

Thus, in order to further consolidate online learning (especially since the advent of the COVID-19 pandemic), we have designed a QI (quality improvement) programme on our teaching programme. Full details of this QIP are listed below –

Our QIP (quality improvement project) is based on PDSA (Plan-Do-Study-Act) methodology.

What conditions indicated the need for the project?

What conditions precipitated the project?

·       Poor data documentation (of history and physical exam) coupled with inadequate oversight and lack of transparency in data capture.

·       Inadequate generation of a differential diagnoses list.

·       Inability to add data gleaned from review of literature, on which patient-centered decisions were made.

Who or what areas are affected?

·       Difficulty in establishing continuity of medical care, particularly with paper-based records.

·       Patients may suffer from decisions made based on heuristics and a system 1 approach due to lack of uptake of evidence-based care (system 2 approach).

·       Medical students retorting to textbook-based learning and seeing diseases as isolated entities by dehumanizing them.

Who decides to do something about it?

The key stakeholders involved in this project – consultants supervising patient care, postgraduate students who deliver the care, interns and undergraduate students who are a vital cog in gleaning patient data and documenting them.

The programme will be chaired by me and my professor. All key stakeholders, such as our PGs, Interns and UGs will have key roles in this project.

What is our ‘Aim’?

As stated in our teaching programme link above, the stated objectives of our QIP are furnished below –

1.    To improve history taking with a focus on patient-centered problems.

2.    To perform a targeted clinical exam with video demonstration of relevant clinical signs.

3.    To perform a critical and clinically sound analysis of the history and physical exam and generate a list of differential diagnoses.

4.    To perform interpretation of laboratory data and demonstrate an understanding of test characteristics by performing a review of literature.

5.    To demonstrate procedural competencies on video.

With these objectives, we aim to increase –

·       Quality of patient care

·       Data transparency

·       Provide objective evidence for core clinical competencies of all our students in the network

·       Use of paperless, electronic health records

·       Provide evidence-based care to all our patients

We also aim to decrease –

·       Reliance on authoritative style of learning

·       Reliance on textbooks for providing patient care

Is it SMART: Single-focused, measurable, action-oriented, realistic, and timely?

Yes, our goals are single-focused (improving patient care), measurable (number of blogs showing improved history taking and physical exam against a set standard), action-oriented (history taking and physical exam purported to improve over time with regular QI cycles), realistic (deals with our everyday workflow) and timely (analysis of blogs will be provided as soon as they are made available).

What is the Problem?

1.    Characterize the problem

Oslerian medicine is one of the key bedrocks driving our practice. We believe that diseases and human lives are deeply intertwined, and thus medical histories should not be dehumanized. One key problem we identified was how patient histories here are often taken with a view to an end goal of ‘making a diagnosis’. We believe, medical histories should go to the depths of the patient’s life before the disease process may have started and after it, and how they have dealt with it. Thus patient-centered outcomes are prioritized, and the focus is now on improving the patient’s quality of life, rather than simply making a diagnosis.

2.    What causes are explored?

This is a decades long problem and dehumanizing medicine has always plagued us. The current medical education system prioritizes rote learning of disease entities and recognizing patterns of diseases. Our approach would be to make a functional assessment of the patient, understand the anatomical problem, link the anatomy with pathophysiology and then generate a list of possible etiological diagnoses.

This approach may take a lot of time and burden some of our key stakeholders, but they prioritize patient centered learning, integrating their lives with their disease processes. This makes both entities as one whole rather than two isolated entities. This seeds the uptake of evidence-based care because patients may not always display the signs and symptoms mentioned in textbooks and thus there is an understanding that although the disease process remains the same, its manifestations vary from one life to another. Hence providing generic, textbook based care may not be efficient.

How do you know it is a problem?

The baseline will be measured against a set standard. One example of a blog which exceeded these standards is shared here.

• Take a history which gives insight into a patient’s life and how they dealt with their disease.
• Perform a targeted clinical examination.
• Perform a critical and clinically sound analysis of the data generated from history and physical exam.
• Interpret lab data appropriately

An analysis of our cases from Rheumatology clinics shows none or very few blogs have reached these set standards. Some problems which were apparent were –

• No insight into the patients’ lives.
• Imprecise and poorly targeted clinical exam.
• A differential list was not generated.
• No/minimal appraisal of all available lab data

What is the solution?

As detailed before, the solution is to improve the standards of history taking and performing a thorough, targeted, and adequate physical exam, ordering labs appropriately and performing a sound critical analysis of all the available data.

·       Does it cover short and long term?

Yes, because this QI project is integrated into our daily practice, the project aims to improve short term patient care and eventually maintain the same standard of care in the long term too.

·       Does it consider up and downstream?

Yes, the project is run by consultants and involves teamwork from all key stakeholders including interns and undergraduate students. The project is aimed at improving medical education (for students) and also improving patient care (for patients).

 

What is the plan for successful implementation?

Online and offline faculty coordinators will facilitate postgraduate students, interns, and undergraduate students in taking better histories and performing targeted physical exams on patients (against a rigorously reviewed and established standard), to improve medical education and quality of care, beginning simultaneously with the inception of our online teaching programme.

·       How will I set a target?

Our bimonthly exams are where our targets will be measured. Our online bimonthly exams, which are integrated into our teaching programme will make the process swift. Each and every student’s individual blogs will be thoroughly reviewed and matched against the set standards. Thus, with simple descriptive statistics, the number of students who have reached the set standards can be measured.

 ·       How often will progress be measured?

Progress will be measured on a monthly basis (frequency of QI cycle may increase or decrease based on the availability of rheumatology specific cases)

Predictions : What do we expect to see and why?

Although not subjected to a well-designed QI project, the institution of our teaching programme brought out a subjective but demonstrable improvement in quality of data logging and maintenance of data continuity. Some principles of Oslerian medicine were evident in most blogs. Thus, with the implementation of this formal QI project, we expect to see a demonstrable and measurable increase in quality of history taking, physical exams and interpretation of lab data.

What consequences may there be?

We are confident that we will largely notice positive consequences as stated above, although, we may run the risk of plagiarism, improper patient deidentification and extra cognitive burden. We are also aware that not all students will be enthusiastic towards online learning and blogging.

Could the change make something worse?

We have found a few instances where the required commitment and dedication to the programme precipitated a complete abandonment of the project. Over the past 2 years, the incidence has certainly decreased, and we certainly hope to keep it that way.

 

*Scoring System for Blogs

 

Domain	Poor (1)	Average (2)	Good (3)	Excellent (4)
History taking
Physical exam
Interpretation of lab data
Case analysis
Procedural competencies (optional)

 

*A maximum of 16 marks can be attained in the 4 mandatory domains and extra marks can be scored for video demonstration of procedural competencies. The score for procedural competencies will not be included in this QIP.

Results

QI Cycle 1

QI Cycle 2