Rethinking Performance Audit: Chronic Illness Panel Management
Setting and Problem
The Accreditation Council for Graduate Medical Education Internal Medicine Milestones anticipate that residents should “monitor [their] practice with a goal for improvement” and “learn and improve via performance audit.” Performance audits can take the form of metric reports (for example, completion rates for cancer screening tests), but the relatability of metric audits is problematic for residents due to transitory stewardship of empaneled patients (the metric may not reflect resident performance) and potential overemphasis on numeric outcomes. A focus on quality metrics can lead residents to feel that they are treating a number, not treating a patient.
Intervention
Performance audit can alternatively be achieved through self-assessment of competency in comprehensive chronic illness management. At Oregon Health & Science University (OHSU), we facilitate a practice-based learning and improvement (PBLI) curriculum for residents in this model.
Prior to each session, a faculty champion prepares an illness registry report that displays an array of relevant data for resident-empaneled patients. The curriculum is provided in a conference room with computers for each resident.
We start each 90-minute session with a brief tutorial designed to expand resident awareness about primary care management for a common chronic disease. A typical tutorial might cover guideline recommendations, screening and immunization needs, awareness and prevention of complications, relevant clinic-based resources, and applicable electronic health record (EHR) tools. Residents are then guided to their subgroup listing of empaneled patients with that chronic illness diagnosis. If available, relevant lab, treatments, risk scores, and care gaps are highlighted in an accessible display. Time is provided for targeted chart review, patient-specific improvement planning (frequently, a deeper charting activity for 1 to 3 patients), and reflection. The faculty champion is available for mentorship and troubleshooting. Time spent in panel management engages learners in proactive planning, setting of chart reminders, and outreach to patients, with a goal to close gaps in care. The table describes examples of activities undertaken as part of this curriculum. We leverage the use of our EHR for this curriculum. The faculty champion, having developed familiarity with EHR registry tools, prepares panel-specific dashboard reports and shares them with each resident to be “run by user.” The relevant subset of patients is identified through use of diagnosis grouper search tools. Our medical center utilizes EpicCare and other useful tools including Reporting Workbench, SlicerDicer, and Sticky Notes.
Outcomes to Date
Chronic illness panel management provides a versatile framework for teaching core ambulatory medicine topics and is an active method of performance audit and improvement. This curriculum promotes a culture of resident engagement and stewardship in ambulatory care.
Relative to metric-based panel management, outcomes are less easily measured and are more often anecdotal. Residents commented, “This changed my framework of approaching cancer care. I realized that there is a great deal of responsibility…in long term care”; “I really appreciate PBL for the interaction with other residents—to learn from their troubles and victories!”; and “I am still [6 months later] using notes from this ASCVD review as I see patients.”
Since the development of this PBLI curriculum at OHSU's university-based clinic, it has been successfully spread to practice sites (with and without EpicCare), including the OHSU resident clinic at Central City Concern and the internal medicine clinic at the University of California, San Francisco.
PBLI sessions have felt meaningful to both faculty champions and residents. This program has encouraged the use of charting tools and reminders to enhance effective patient care. It has fostered peer teaching and camaraderie, facilitated outreach to patients with gaps in care, and enhanced team-based care. We have seen an increasing number of residents attracted to practice in primary care in our program, and the structure of this PBLI curriculum may be a factor.
Author Notes
