Author Archives: akost

Quality Improvement Project Charter

Watch the module from the IHI Online Open School “ QI Project Charter”

  1. Review the purpose of the QI project charter and the steps involved in completing the document.
  2. This module will guide you through the completion of the IHI project charter.

Watch the Ted Talk “Got a Wicked Problem? First tell me how you make toast.

  1. Discover how making steps in a process visible and tangible can lead to improvement by clarifying problems.
  2. This short Ted Talk describes the process map, a critical thinking tool used in quality improvement work to identify steps in a process for possible improvement changes.

IHI Online Open School courses in Quality Improvement and Patient Safety and Certificate program are available for additional support and review.

  1. Utilize the resources from the IHI online open school to provide additional support for project creation.  Interested students may wish to complete any final modules to obtain the IHI Certificate in Quality Improvement and Patient Safety.
  2. The IHI modules will provide a review or additional context regarding the model for improvement and the steps in the quality improvement process.      

 

Trauma Informed Care

Reading Assignment

Matchinger, E, et al. From Treatment to Healing: Inquiry and Response to Recent and Past Trauma in Adult Health Care.  Women’s Health Issues, 29 (2)  2019

Context: This brief article by Matchinger et al describes a trauma-informed approach to inquiring about and responding to patients’ recent and past trauma.  It also provides an overview of the other principles of trauma-informed care.

GoalIdentify components of trauma-informed care and how they apply to inquiring and responding to patients’ previous traumatic experiences within the clinical encounter.  Compare and contrast universal screening, targeted screening, universal education, and universal trauma precautions.

Reflect: How have you seen inquiries about and responses to patients’ experiences of trauma approached in your clinical settings?  What has worked well?  What pitfalls have you seen?  Have you ever been screened for current or past trauma within a clinical encounter?  How have your personal experiences affected the way you approach these encounters with your own patients?

Online Module

Complete Aquifer Trauma-Informed Care: Module 06: Trauma-Informed Care: Practice Patient-Centered Communication and Care

https://owhtic-re.meduapp.com/document_sets/7778

Instructions: Access or set up an Aquifer account using your uw.edu email address.  Complete the 4 cases of Module 06 of Trauma-Informed Care Course.  At the completion of each case, download the case summary PDF, which will summarize the key points of the case and provide you a document to upload as completion of the assignment in Canvas.  Credit for completion will be given when all 4 documents have been uploaded.

Context: Experiences of trauma can affect how patients engage with healthcare providers and how patients are affected by the healthcare encounter. These cases explore concepts of traumatic stress, universal trauma precautions, and other trauma-informed care principles.

Goal: Apply principles of trauma-informed care to the clinical encounter through exploring these four online cases.

Further learning: The entire Aquifer Trauma-Informed Care course is free to students, and contains excellent, clinically relevant information and skills.

Pre-class Required Reflection (bring written answers and a description of case to the small group discussionno submission is required) :

90% of adults have been exposed to trauma in their lives.  A history of trauma can affect how a patient engages with and/or experiences health and healthcare.

Please consider a case you have been involved in where you know or suspect that the patient may have been affected by past trauma, and consider:

  1. How did/may have trauma affect this patient’s health and wellbeing? Consider physical and emotional health, socioeconomic status including employment, relationships, outlook, health “behaviors”, etc.
  2. How did trauma affect this patient’s engagement in the healthcare system?  Consider access to care, followup, participation in care, communication style, behavior in the clinic, etc.
  3. How did trauma affect this patient’s experience of the healthcare encounter? Consider signs or symptoms of trauma that were apparent.
  4. What components of traumainformed care were implemented in the care of this patient? What worked well?  What didn’t work well?
  5. What components of trauma-informed care would have helped this patient or encounter?  What would have been different?
  6. What barriers did you or the team experience that interfered with implementing those aspects of trauma-informed care?  What additional skills or support do you feel you need in order to provide excellent traumainformed care?
  7. If relevant, how has your own personal experience of trauma, or personal experiences of team members, affected the way you engage with patients experiencing the effects of trauma? (Personal experiences will not be shared in class.)  
  8. How can implementation of trauma-informed care provide a safer, more responsive environment for providers as well as patients?

Optional reading:

  • Book: The Body Keeps The Score, Bessel Van Der Kolk MD.  The Body Keeps the Score” is a seminal work by one of the preeminent pioneers in trauma research and treatment. This essential book unites the evolving neuroscience of trauma research with an emergent wave of body-oriented therapies and traditional mind/body practices.”  
  •  Website and TED talk: The Trauma Stewardship Institute, Laara van Dernoot Lipsky. Offers “practical tools for cultivating the deep self-knowledge and systemic insights that are at the core of trauma stewardship.” Addresses self-care for those who care for others experiencing trauma.   Her 20 min TED talk “Beyond The Cliff” is a good introduction.
  • Article: “Violence Is a Public Health Problem”, American Public Health Association Policy Statement Nov 2018 . This 2018 policy statement looks at the rationale for viewing violence as a public health problem. Risk factors for and differential impacts of violence are reviewed. Successful public-health based intervention programs are discussed, and recommendations for physician practice, collaboration and advocacy are made. 
  • Book Chapter: Medical Management of Vulnerable and Underserved Patients: Principles, Practice and Populations, 2e.  Talmage and Wheeler.  “Chap 36: Trauma and Trauma-Informed Care”, Kimberg.
  • Database of Articles: Reducing Firearm Related Injuries and Deaths In the US: Annals of Internal Medicine database:
  • Website: King County Violence Prevention Resources:  Hosted by King County Public Health, this website has excellent general information on prevention of and resources for domestic violence, gun violence, trafficking and suicide.  Most resources are general or national, although some are King County specific. 

Resources:

  1. PEARR tool”

Dignity Health tool outlining trauma-informed approach to identifying and responding to survivors of interpersonal trauma.   https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool

  1. Excellent Safety Planning worksheets in multiple languages.

Some of the worksheets include California specific resources, but all include general resources as well.    https://www.leapsf.org/html/safety_plan.shtml

  1. Futures without Violence training videos on implementing universal education using wallet cards  https://www.futureswithoutviolence.org/health-training-vignettes/  and downloads (free) for wallet cards for many different populations https://secure3.convio.net/fvpf/site/Ecommerce/15587835?FOLDER=0&store_id=1241 (Note, in order to download, “add to cart” the pdfs you want, then “checkout” and you will be able to download for free)
  2. MyPlanApp: web or phone based app for patients to assess the safety of their relationship make plans to become safer, and to access resources:  https://www.myplanapp.org/home 
  3. State-by-State reporting requirements for violence towards adults  https://drive.google.com/open?id=1GGGhtc93exi1KuBS42A0acMef5PlUVAN
  4. Gun safe storage “Lock It Up” resources for physicians

https://www.kingcounty.gov/depts/health/violence-injury-prevention/violence-prevention/gun-violence/LOCK-IT-UP/providers.aspx 

7. National hotlines

  • National Domestic Violence Hotline
  • https://www.thehotline.org/ 1800-799-(SAFE) 7233 has online chat
  • National Human Trafficking Hotline
  • 1 (888) 373-7888 SMS: 233733 (Text “HELP” or “INFO”)
  • 200 languages available
  • Website: org
  • National Sexual Assault Hotlineof the Rape Abuse and Incest National Network
  • Call 1-800-656-4673
  • rainn.orgonline chat

SOAP Q Faculty Resources

SOAP-Q: An innovative curricular intervention to promote quality improvement behaviors within the clinical learning environment

Physician competency in quality analysis is necessary to optimize the quality and safety of patient care, yet current undergraduate medical education in these areas remains highly variable. The University of Washington School of Medicine (UWSOM) introduced a novel, pre-clinical phase curriculum (the Ecology of Health and Medicine- EHM- course) encompassing health systems, advocacy, equity, quality, and patient safety beginning in the academic year 2017-2018.  To facilitate experiential learning opportunities within the clinical environment, we created an innovative curricular intervention: the SOAP-Q framework. Medical communication and documentation conventionally rely upon the SOAP format (Subjective, Objective, Assessment, Plan). We add a fifth element to this format, “Q,” triggering students to assess and advocate for quality patient care. We now disseminate this framework to all medical students as they enter the clinical phase and now pilot clinical integration within the Family Medicine clerkship. We hypothesize that students and faculty will respond positively to the framework and student confidence in advocating for quality patient care and in addressing quality gaps will increase.  Subsequent assessment phases will examine impact on student behavioral metrics including documentation of quality assessment, participation in error identification and reporting, and performance on quality measures.   The multiphase project will utilize the framework as scaffolding for student quality improvement project charter design, implementation of projects for fourth year students participating in a quality improvement pathway, and creation of a project catalogue with tiered implementation and mentoring throughout the medical education and faculty continuum.  In utilizing SOAP-Q, the University of Washington offers opportunities for students to build competency in the newest of the AAMC’s Entrustable Professional Activities for Entering Residency, EPA-13.  This EPA calls for the student to identify system failures and contribute to a culture of safety and improvement.

A similar tool, SOAP-V, has demonstrated utility in assessment of high-value, cost-conscious care within the clinical encounter (3).   Initial studies indicated that SOAP-V increased comfort with discussing value and considering cost when providing care.  SOAP-Q utilizes a quality-driven focus rather than cost focus, but is similarly intended to help the learner communicate effectively. The clinician considers the following in every patient encounter:

  • Safety- Conditions contributing to unsafe practice and systems solutions
  • Timeliness– Issues contributing to delay or process lead time
  • Efficiency- Value conscious utilization of resources with minimal waste
  • Efficacy- Evidence-based approaches to improve health outcomes
  • Equity – An approach to care that recognizes sociodemographic drivers of health inequities and actively advocates for equitable outcomes
  • Patient-Centeredness- Patient engagement and patient experience.

An oral case presentation using the SOAP-Q framework integrates an assessment of one of the six STEEEP aims within the body of the presentation.  It calls attention to the aim in a single line callout at the conclusion of the presentation beginning with identification of the aim.  A progress note written in the SOAP-Q framework similarly embeds discussion within the text and delineates the issue in a single line at the conclusion of the note beginning with aim identification.  As faculty, please encourage student use of SOAP-Q format and where appropriate utilize the quality call out as a prompt for discussion and teaching (see the one minute preceptor models for examples).

Faculty resources are below.  Thank you for your support of student programs.   Please help us evaluate SOAPQ by completing a baseline faculty survey at the following link:

LINK TO FACULTY SURVEY

Faculty resources:

References:

  1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st  Washington, DC: National Academies Press, 2001.
  2. The Core Entrustable Professional Activities for Entering Residency Drafting Panel. Core Entrustable Professional Activities for Entering Residency.  Association of American Medical Colleges 2014.
  3. Moser, EM, Huang, GC, Packer, CD et al. SOAP-V: Introducing a method to empower medical students to be change agents in bed in the cost curve.  J of Hosp Med 2016; 11: 217-220.

 

 

Practical Topics in Professionalism for Clerkships

READ: Physician impairment: When should you report?  Current Psychiatry. 2011 September;10(9):67-71  

Read this article which describes examples of physician impairment and colleagues’ responsibilities around reporting.

READ: AMA Opinion on Romantic or Sexual Relationships 

Read this opinion piece that reviews the AMA’s position on romantic and sexual relationships with patients.

READ: Responding to Requests about Prayer 

Read this article which talks about situations when patients ask clinicians to pray with them.

READ: Gifts from Patients. AMA Ethics Opinion 

Read this opinion piece about accepting gifts from patients.  AMA Ethics opinions are good resources for discussions on professionalism and ethics issues.

Evidence Pyramid and PICO for Clerkships

You now have experience developing PICO questions and have learned about different study designs including their strengths and weaknesses.  During your clerkship experiences you and your team will have many questions about how to best care for your patients. Throughout your career you will need to seek evidence on best practices to make clinical decisions and will have to sort through journal articles, practice guidelines and evidence summaries to determine how to proceed with diagnostics and therapies.  Understanding different ways to appraise literature will help you answer your questions and make decisions based on evidence.

There are many resources available to you through the University of Washington Health Sciences Library to assist in this process.

For a list of sites to search for evidence see http://guides.lib.uw.edu/hsl/ebp

Here is a refresher on PICO questions.

For this session, please reflect on your case study.  Consider possible interventions or therapies that may be beneficial to the patient. Develop a PICO question before the session as you will be reviewing and appraising literature in order to answer this in class.

Additional Resources:

Patient Oriented Evidence that Matters (POEM) https://www-essentialevidenceplus-com.offcampus.lib.washington.edu/content/poems

Violence

1) Pre-class reading

  • Raja, S.  Trauma Informed Care In Medicine: Current Knowledge and Future Research Directions.  Family and Community Health 38(3):216-26. July 2015
    • Context: Exposure to trauma is nearly universal, and yet differential incidence and impact of trauma are a large source of health disparities.  Trauma informed care uses an understanding of the prevalence and impact of trauma to provide care that is responsive, safe and empowering for providers and survivors.  Through universal and trauma specific practices, this approach serves to reduce health disparities.
    • Goal: Describe the components of a trauma informed clinical practice.
    • Reflect: Which of these practices have you seen implemented in your primary care practicum?  Have you participated in patient encounters that, in retrospect, may have benefitted from this approach?  How do you think implementation of trauma informed practices benefits providers?

2) Pre-class Module

  • Aquifer Trauma-Informed Care Course, Module 1: Understand the Nature and Prevalence of Trauma: Understand how simple and complex trauma may present in a diverse patient population, Cases 1-4  https://owhtic-re.meduapp.com
    • Instructions: Students will create an account using their UW email address.  After completing each case, click on “case summary download.”  This will provide you with a pdf of the instructional content.  Keep these completed pdfs for your own use and reference.
    • Context: These four clinical cases demonstrate a range of ways in which trauma may affect health and the clinical encounter.  Through the cases the concepts of trauma, the epidemiology of IPV and child abuse, and screening are reviewed.  Trauma informed care is introduced including universal trauma precautions and trauma specific interventions.  
    • Goal: Appreciate the prevalence and impact of trauma on patients’ health and interaction with the healthcare system.  Acquire skills for applying trauma informed care principles to the clinical encounter.
    • Reflect: Which patients from PCP do these cases remind you of?  What is one patient you might approach differently after working through these cases?
    • Further reading: interested students may complete other modules from this Aquifer course.

Optional Reading

  • Amnesty International Maze of Injustice: Sexual Violence Against Indigenous Women in the USA.(chapters 1,2,4)
    • 4 in 5 American Indian and Alaska Native women have experienced violence.  1 in 2 have experienced sexual violence.  Alaska Native women have 10 x risk of IPV compared to the general US population.  On some reservations indigenous women are murdered at more than 10x national average, many by non-indigenous men.  This report explores the complex etiologies and impact of this violence.
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively?
  • Violence Is a Public Health Problem, American Public Health Association Policy Statement Nov 2018
    • This 2018 policy statement looks at the rationale for viewing violence as a public health problem.  Risk factors for and differential impacts of violence are reviewed.  Successful public-health based intervention programs are discussed, and recommendations for physician practice, collaboration and advocacy are made.
    • This statement by the American Public Health Association reviews the epidemiology of violence, the differential impact on traditionally marginalized communities, the similarities to other types of epidemics and chronic health problems, the evidence available for physicians’ role in primary and secondary prevention and a call for further action in approaching violence through a public health lens.
    • Goal: Describe the scope of interpersonal violence and its impact on health.     Recognize structural factors that contribute to disparities in frequency and impact of violence in different populations.  Describe the potential role of physicians in responding to and preventing violence.  Understand the role of interprofessional and community partnerships in preventing and responding to violence.
    • Reflect:  What factors contribute to the resistance of the political and medical community to viewing violence through a public health lens?  What is one idea from this reading that you hope to take with you into your clinical work as a medical student?
  • Seattle: King County Violence Prevention Resources
    • Hosted by King County Public Health, this website has excellent general information on prevention of and resources for domestic violence, gun violence, trafficking and suicide.  Most resources are general or national, although some are King County specific.

Optional Videos

  • Futures without Violence video resource library: universal screening, education and referral
    • https://www.futureswithoutviolence.org/health-training-vignettes/
  • Violence Against American Indian and Alaska Native Women and Men, National Indigenous Women’s Resource Center.
    • http://www.niwrc.org/resource-topic/videos
    • This video describes the findings of a National Institute of Justice (NIJ) supported study on the prevalence of violence against American Indian and Alaska Native women and men, and briefly examines the impact of violence int that community.
    • Interested students can read about the some of the complex factors involved in the optional reading below, “Maze of Injustice, an Amnesty International report.”
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively

Additional Resources

  1. PEARR tool: Dignity Health Tool universal education and screening approach https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool
  2. Excellent Education and Safety Planning worksheets in multiple languages. (some of the worksheets include California specific resources, but all include general resources as well.   https://www.leapsf.org/html/safety_plan.shtml
  3. Futures without Violence training videos on implementing universal education using wallet cards –  https://www.futureswithoutviolence.org/health-training-vignettes/
  4. Futures without violence wallet card pdfs (link to wordpress IPV site resource)“Is Your Relationship Affecting Your Health” safety card
  5. Link to MyPlanApp website https://www.myplanapp.org/home
  6. State-by-State reporting requirements for violence towards adults Information on rules/requirements for mandatory reporting by state
  7. Hotlines: If it is safe for you to do so, consider programming these hotlines into your own phone.

Structural Competency Cases

These three readings explore the complexities of identity and power in the clinical setting from the patient and physician perspectives.

  1. Manning, Kimberly D. “The nod.” JAMA 312.2 (2014): 133-134.
  2. Gridley, Samantha. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Third Place Gauze and Guns.” Academic Medicine 90.10 (2015): 1356-1357.
  3. Lynch, Katrina. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Second Place The Doctor Will See You Now.” Academic Medicine 90.11 (2015): 1530-1531.

Optional readings for students who want to explore more:

Power and Hierarchy

READ: A young doctor’s fear of raising questions causes a mistake

This article was written by a medical student (who is now faculty in the Department of Medicine at UW) who describes feeling uncomfortable with a patient care task he was asked to perform. He felt silenced by the medical hierarchy and didn’t speak up at the time due to fear. He emphasizes the importance of changing the culture of medicine to one that respects open communication and respectful advocacy to promote safety in the learning environment and patient care.

National and Global Health Systems

In an article published in the American Journal of Public Health in 2003, Kindig and Stoddard defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”[1] Population health aims to improve the health status of entire human populations, and includes efforts by organizations and institutions at the local, state, federal, national, and global levels to measure the distribution of outcomes and link them to health policies and interventions. More information can be found in that article [READ this linked article by Kindig and Stoddard].

Many organizations involved in public health in the US support the overall goals of population health and fill important roles such as surveillance, national registries, health surveys, and collection of administrative data that can help decision-makers form effective policy. For an overview of how organizations in the US Public Health system provide core functions and essential services, please see the powerpoint at [READ this linked presentation – US Public Health 101]. For a description of the different US government agencies involved in supporting public and population, please see the brief descriptions posted by the US Public Health Service, describing agencies within the Department of Health and Human Services (https://www.usphs.gov/aboutus/agencies/hhs.aspx) and those in other departments of the federal government (https://www.usphs.gov/aboutus/agencies/non-hhs.aspx).

Internationally, the United States has an important impact on global health. For descriptions of the main institutions and agencies that have responsibilities and roles in international efforts to promote global health, see https://globalhealtheducation.org/56_nutrition_in_global_health/.

Value Based Healthcare Policy

  1. READ AND REVIEW: “Medicare Delivery System Reform” https://www.kff.org/medicare-delivery-system-reform-the-evidence-link/

GOAL: Familiarize yourself with the most common Medicare value-based payment models: bundled payments, accountable care organization, and patient-centered homes.

The Centers for Medicare and Medicaid are major drives of innovative health care delivery models in the US.  There have been significant changes to payment and structure of care over the past 10 years.

Other Reference Materials:

The following papers report the impact of care models on outcomes of interest such as cost and quality. These do NOT need to read before class:

There are potential harms related to performance-based programs such as the creation of inappropriate incentives and inappropriate penalties. The following papers discuss these in more depth. These do NOT need to be read before class: