Yale Psychiatry Grand Rounds: March 12, 2021

March 12, 2021

"Crossing the Quality Chasm in Psychiatry: Quality Improvement Projects Across Multiple Health Systems."

Michael Sernyak, Jr., MD, Professor of Psychiatry, Deputy Chair for Clinical Affairs and Program Development, Yale Department of Psychiatry, Yale School of Medicine; CEO, Connecticut Mental Health Center

Luming Li, MD, Assistant Professor of Psychiatry, Yale School of Medicine; Associate Medical Director of Quality Improvement, Yale Psychiatric Hospital; Medical Director of Clinical Operations, Yale New Haven Health

Eric D. A. Hermes, MD, Associate Professor of Psychiatry, Yale School of Medicine and VA Connecticut Healthcare System

John Cahill, MD, PhD, Assistant Professor of Psychiatry, Yale School of Medicine; Medical Director, STEP Clinic and Acute Services Division, CMHC Chief of Behavioral Health, Continuum of Car, Inc.

Tobias Wasser, MD, Assistant Professor of Psychiatry, Yale School of Medicine; Associate Program Director, Yale Psychiatry Residency Program, Adult Psychiatry

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00:00Today's grand rounds is also
00:02really important, I mean.
00:06Uh. It's a reminder that at
00:09our heart it as a Department.
00:11We're committed to excellence
00:13in in the way in which we,
00:16we deliver care for people.
00:20Very good to excellent is not good enough
00:25that we can find in the work that we do.
00:30Opportunities to better serve the
00:33patients that we treat and their families.
00:36Anne Anne at the same time as we're
00:41learning about how to do better. We're also.
00:46Learning generalizable lessons about
00:47how, as a
00:49field we can do better
00:50to take care of patients,
00:52and so the commitment to quality is not
00:55just a commitment to local excellence,
00:58but a commitment to seeing that all
01:00psychiatric patients thrive to the extent
01:03possible when they come to us for help.
01:06So I'm really excited about this lecture.
01:08I'm really pleased to see
01:10the diversity of people who,
01:12insights and projects that that
01:14we'll talk about in terms of our
01:17commitment to excellence and.
01:18And thank the speakers for what
01:21I know will be a great session.
01:24So Michael Doctor Sarniak,
01:25I'll turn it over
01:27to you. Thank you
01:29very much. Doctor crystal.
01:31First, I want to thank everyone for
01:34attending today and I would thank them
01:36for giving me a reason to wear a coat
01:39and tie for the first time in a year.
01:42And so I got that going and appreciate
01:44it I'm the deputy chair for clinical
01:47Affairs and program development
01:49and the CEO at CMH. See today.
01:51I just have a distinct pleasure.
01:53I presenting the work of
01:55a four very thoughtful.
01:57I won't say junior junior to mid level
01:59faculty who are working throughout the
02:01Department on on quality issues and I
02:04think to echo what Doctor Crystal said.
02:06I think to put a four in in the grand
02:09rounds format of our tripartite mission.
02:13Of research,
02:13education and clinical care,
02:15and I think that those of us who are
02:17old enough to know that there have been
02:20times where there were case conferences
02:22and other things occurred in grand rounds.
02:25And so I would ask also as people
02:27listen to these wonderful presentations
02:29that they get to us also with ideas
02:32about how we can have that sense of
02:35community coming together to talk
02:37about the clinical care as we strive
02:40for excellence in that as we already have.
02:42I excellence education and research
02:44and many aspects of clinical care.
02:46But I think one of the enduring things you'll
02:48see today is that you can always improve,
02:51and that's a really important message and
02:53hopefully one of the ones that comes through.
02:56So I will give you a little bio about each of
03:00the presenters in the order that you'll hear.
03:03They'll go through their
03:05presentations or get to the end.
03:07I'll make a few comments and
03:09then really hope to open it up
03:12to a robust period of questions,
03:14answers, comments,
03:15and have that kind of discussion at the end.
03:19So I'd start with looming looming Lee,
03:21MD, who is an assistant professor,
03:24an IT department and also the medical
03:26Director of clinical operations.
03:28Yona Haven Health she serves as
03:30the Associate medical director
03:32for Quality Improvement at Yale,
03:34New Haven Psychiatric Hospital and
03:36her research interests are focused
03:38on quality improvement,
03:39psychiatric services, delivery,
03:41health systems,
03:41science and leadership education.
03:43Then that will be filed
03:45by Eric Ermes Erickson,
03:47associate professor in the Department of
03:50Psychiatry and outpatient psychiatrist,
03:51Health Services Research and chair
03:53of the mental Health Process
03:55Improvement Committee at the VA,
03:57Connecticut Health Care Center.
04:00And then John Cahill,
04:01Johns deputy medical director
04:03at CMH C and Chief of Behavioral
04:06Health at the Continuum of care.
04:08And then he wrote this.
04:10He identifies himself as a
04:12recovering e.g biomarker researcher.
04:14As well as a clinical administrator
04:16and educator,
04:17his primary interest is in developing
04:19models for embedding knowledge
04:21generation and translation into
04:22real world systems of clinical care.
04:24Forging links with basic and
04:26clinical research as well service
04:28users and other stakeholder groups,
04:30and then the last presentation
04:32will be Tobias,
04:33Wasser and Tobias is the Chief
04:35Medical Officer of Whiting
04:36Forensic Hospital and Associate
04:38Program director for the Psychiatry
04:40Residency program where he overseas
04:42the reflective practice curriculum.
04:44Focusing on the areas of systems
04:46based practice and problem
04:48based learning and improvement.
04:50I'm just a note before we started.
04:52I think you know the idea of quality
04:56definition that I would like people
04:58to think about as we go through the
05:00talks from the IOM and we can go
05:03into the details of each of these.
05:06I want to read it lengthy,
05:08but if you think in terms of safe,
05:11effective, patient, centered,
05:12timely, efficient and equitable,
05:13think those are all themes.
05:15Hopefully that will touch on and we can
05:17go into greater detail in the discussion.
05:21And then my absolute last comment
05:23before I let Doctor Lee start is to
05:26thank her for her work as being the
05:29energy behind this and bring this
05:32together in record time against other
05:35time consuming aspects of her life.
05:37And I really appreciate the energy
05:39that she's brought to this and
05:42I look forward to hearing hers
05:44and the other presentations.
05:46So Doctor Lee, if you would start.
05:50Thanks
05:50so much like I'm really delighted
05:52to be here and I'm looking forward
05:55to sharing a really exciting
05:57presentation about some of my work
05:59going on in quality and safety.
06:01And so we're going to be sharing about
06:03some of the work that's happening
06:06at the Yale New Haven Health site
06:08on around quality and safety.
06:10And you know what will really talk
06:12about today is the interplay of quality
06:15and safety within clinical care,
06:17and so I'm going to be sharing a project,
06:20but I wanted to start out with this.
06:24The scaffold,
06:25which is that quality and safety
06:27lies at the heart of clinical
06:29care and that there are a number
06:31of different components to it,
06:33including safety, event review,
06:35patient experience,
06:35quality assurance and core measures.
06:37Data informatics,
06:38clinical operations and measurement
06:40based care and clinical outcomes
06:42that all come together to really
06:44center around how we can deliver
06:45high quality care and safe care
06:47to the patients that we serve.
06:49And so Tord that, and at Yale. New Haven.
06:52We've done a number of different.
06:55Things to be able to move toward that,
06:58including having a series
06:59of educational conferences.
07:01We've also worked on a number of
07:03different committees to address
07:05quality and safety.
07:06We've developed a number of clinical
07:09dashboards and have a team here to
07:12really work on being able to showcase
07:15how data can help us track quality of care.
07:18Overtime lately,
07:19what we've been working on has been a
07:22focus on innovation and being able to.
07:25Incorporate aspects of equity
07:26in our quality and safety work,
07:29and being able to acquire data elements
07:32and really work on covid response and
07:34quality metrics over the last year or so.
07:37And so I wanted to showcase some of the
07:41broader work that we're doing at Yale,
07:43New Haven and then transition our talk.
07:46And I wanted to be brief here,
07:49but really mention that we're very
07:51focused on a number of different
07:53domains here at Yale, New Haven on.
07:56Specifically around how we
07:58do quality and safety,
08:00and so I'm going to transition now
08:02to talking about really exciting
08:04project that we're working on.
08:07So in this, you know,
08:09in this work around quality and safety
08:12we've wanted to work on reducing
08:14variations and variations can occur
08:16in a number of different ways,
08:19and clinical care delivery.
08:21And there's that aspect of care delivery
08:24that is really great and focus on.
08:27Patient center care that my
08:29talked about earlier,
08:30but there's also an aspect of being
08:32able to ensure consistent care
08:34and being able to provide evidence
08:37based care to patients and so with
08:39a care signature project that
08:41we've taken on this is a larger
08:43health system project within Yale,
08:45New Haven that we've also been able to
08:48work on in the psychiatry service line.
08:51We wanted to,
08:52you know,
08:53the core tenants of this project
08:55has been to ensure best.
08:57Practice on minimize variations
08:59that can occur,
09:00and when I mentioned about variation,
09:03I wanted to highlight the idea of
09:05unnecessary care variation and this
09:07can be ordering extra tests or delaying
09:10treatment on different processes.
09:12Aspects to care that we can try to
09:15streamline to be able to allow more
09:18efficient care and also allow for
09:20high quality care and might gave
09:23a definition from the Institute
09:25of Medicine earlier on in the.
09:28Beginning of the talk,
09:29but the idea is to really allow
09:32us to move toward evidence based
09:34treatment in a meaningful way.
09:36The other aspect to care signature that
09:38I wanted to emphasize as being able to
09:41improve health care access and quality.
09:44An idea there is being able to provide
09:46us a patient centered approach to access
09:48and ensure that there is equitable
09:51care processes and outcomes to do so.
09:54And so these are the core principles
09:56that we're working on within care.
09:58Signature an.
09:59I wanted to.
10:00Provide that scaffold before we talk
10:03about the projects themselves and
10:05exactly how we're setting this up,
10:07because conceptually being able to
10:09provide a consistent care signature or
10:12something that we want to strive toward
10:14as part of broader quality improvement work,
10:17and so the way that we've set
10:20up here signature is to have
10:23an overarching clinical body.
10:24The Care Signature Council and the
10:26idea is that this care Signature
10:29Council has service line leadership,
10:31including.
10:32John, as chair of the Department and
10:34Michael Holmes as the senior vice president.
10:36Frankfurt and Audio who I saw earlier
10:39on the on the screen grounds as
10:41well as the Council chair and then
10:43I work as the quality and safety
10:45lead and the care signature leave.
10:47The idea is that we bring together a
10:50group of people that have an interest in
10:53being able to advance this work in care,
10:55signature and also across our delivery
10:57network so that we can ensure consistent
10:59care to Bridgeport and Greenwich,
11:01Ann Lawrence and Memorial.
11:02I under her bed as well as other
11:06sites that we have in the ambulatory
11:08spaces and this governing Council
11:11allow works to select ideas for us
11:14to work on around places where there
11:16are increased areas of variation.
11:19So if we think that and so the first 2
11:22projects that this group has selected
11:25include working on acute mania
11:27and the treatment of acute mania,
11:30the second project is around.
11:33Behavioral symptoms of dementia and
11:35being able to develop a consistent
11:37set of care.
11:38And So what we found is that in
11:41clinical practice the starting
11:43dose of lithium could be variable
11:45across our providers.
11:47There might be variations in terms of
11:49who gets access to ECT and so creating
11:53guidelines for how we identify on
11:55the process for the treatment of
11:57mania was one of the things that
12:00the group wanted to focus on and so.
12:04Mature of that is Doctor Hummel ARD,
12:06and for the behavioral symptoms of
12:08dementia it's doctor Arti grouped up.
12:10And So what we do,
12:12after we've decided on these topics
12:14in the Care Signature
12:16Council, is to create these clinical
12:18consensus groups to be able to
12:20really work through the nitty gritty
12:22of the clinical care pathways.
12:24And so I'll talk a little
12:26bit more about that.
12:28So within the clinical consensus groups,
12:30the idea is that we bring together a
12:33multitude of clinical experts and also.
12:35Individuals with different backgrounds,
12:37including residents,
12:38as well as fits that are working
12:40in interventional psychiatry
12:42pharmacists to come together with,
12:44you know, come away with consensus.
12:46So the idea is that there might be
12:50variations and how we choose the
12:52starting dose of lithium and group
12:55can help us potentially be able to
12:58pull that together and identify
13:00what's the best starting dose and
13:02then the pathway for treatment.
13:05And similarly with the behavioral
13:07symptoms of dementia.
13:08One of the things that we noticed
13:11was there was variation in how
13:14we treat agitation,
13:15and so the group has identified well.
13:18What's the best treatment for agitation?
13:20The starting dose for?
13:23In the treatment selection
13:25for an agitated patient,
13:26so the group is working toward being
13:29able to identify those treatments
13:30so that if you were in Bridgeport
13:33or you're in your New Haven that
13:35we're recommending the same starting
13:37medication based on evidence that we
13:39gather from the field and from prior studies,
13:42and so the way that we are able
13:44to do this is that with these
13:47clinical consensus groups,
13:49what we do is we have what's called
13:51a pathway kickoff and the idea is.
13:54To identify well what are we working on?
13:57Who are the patients that we
13:59want to work to help an address
14:02a particular treatment topic?
14:04Ensure that there is
14:05stakeholder representation.
14:06We then go through the
14:08literature an review well.
14:10What are we trying to treat?
14:12What's recommended based on
14:13literature that we review,
14:15we determine pathways and
14:17goals for the metrics.
14:18Following that,
14:19we start to drop draft different
14:21kinds of you know what the
14:24treatment algorithm can look like.
14:26I'm mapping the discrete steps
14:28and identifying areas of gas and
14:30also process gaps that can occur
14:33and then what we do afterwards is
14:35if we do identify some consensus
14:38gaps or variations in care that
14:40are common in clinical practice,
14:42we're able to build consensus
14:44statements and work through,
14:46you know,
14:46the the group to be able to drive
14:49toward agreement and the idea is to
14:52be able to provide short statements
14:54that are action oriented with.
14:57Recommendations the rationale
14:59for why we're recommending those
15:01treatments and then also provide
15:04references toward the literature
15:06that supports those recommendations?
15:08One idea is that once we have
15:10all of the consensus statements
15:12as well as the steps,
15:14what we can do is translate this
15:16into a clinical care pathway,
15:18and the idea is that this is going
15:20to be embedded in the electronic
15:22medical record so that an individual
15:24that wants to look through.
15:26How do we treat acute mania or
15:28acute agitation and behavioral
15:29symptoms of dementia?
15:30They can go look it up and be able to
15:33get those recommendations right there
15:35when they are on at the point of.
15:39Of clinical practice and what's
15:41really nice is that there is
15:43many iterative steps to this,
15:44and this really focuses on the quality
15:47improvement opportunities where we get
15:49a group of people who are experts.
15:51And then we also then have many people
15:53look at the pathway before it goes
15:56live and we have representation from
15:58different stakeholders around the utility.
16:00And then we're able to publish this
16:03and use this in clinical practice.
16:05So what I'll do is share a demo
16:08of what this might look like.
16:10An on in real life this is going
16:12to be in the test environment,
16:14so there's no patient data,
16:16but I'm going to share a video
16:18of how how this might work out.
16:20Once we launched us in in the
16:23electronic medical records.
16:28Her signature pathways are embedded directly
16:30in the epic electronic medical record.
16:33When fully built and integrated into epic
16:36of provider can directly click on the
16:39Pathways tab and access relevant pathways.
16:42Today, the inpatient psychiatry
16:44pathway for acute mania will be
16:46demonstrated in the testing environment.
16:49A similar look and feel will be
16:52used once the pathway is fully
16:55built and available in epic.
16:58Hyperlinks will take you to
17:00additional resources if needed.
17:02In addition, you're able to see important
17:06information relevant to the pathway,
17:09including consensus statements as well
17:12as patient information in the helpful
17:15resources tab on the left order.
17:18Sets order panels orders can be
17:21launched directly from the pathway.
17:25The orders can be selected individually or
17:28grouped together by clicking this icon.
17:31All orders in the pathway or pre
17:34populated with options and indications
17:37appropriate for the condition.
17:39For example,
17:40instead of having to populate distinct
17:44medication information for ordering
17:46with young medication fields will
17:48be pre populated with the correct
17:51starting dose frequency and indication
17:53for a patient with acute mania.
17:56Thus,
17:57saving the clinician time and clicks
17:59the first decision point in this
18:02pathway is assessing whether or not
18:05a patient is acutely agitated and
18:07in need for immediate treatment.
18:10The next decision point is assessing
18:12whether or not the patient is pregnant
18:16as the treatment recommendations
18:18for those who are pregnant do.
18:20The are different than those who
18:23are not due to the risk for fetal
18:26malformations with some mood stabilizers
18:29and other key decision point in
18:32this pathway include the initial
18:34starting treatment for acute mania.
18:36The consensus group determines
18:38specific criteria as well as
18:40medication recommendations.
18:42For treatment of both the acute
18:44mania as well As for insomnia.
18:48In addition,
18:49the pathway also includes information
18:52about discontinuing ineffective
18:55psychotropics as well as links that
18:57allow you to look at treatment scales
19:00such as the Young Mania Rating scale.
19:04To assess for patient clinical improvement.
19:07In addition,
19:09the pathway allows you to identify whether
19:12or not easy T and the interventional
19:15psychiatry service should be consulted,
19:19as well as criteria for discharge
19:22and considerations with regard
19:25to medication transitions.
19:30So I just wanted to do a brief demo so
19:33that you can see what we're talking about
19:36with regard to how this can all pull
19:39together with the clinical care pathways.
19:41So with that I know we're going
19:43to have some other speakers,
19:45but I look forward to being able to talk
19:48more about the pathways and if you have
19:50any questions related to this project,
19:53we have many, many projects that we've
19:55taken on and quality improvement,
19:57but it highlights one network.
19:59Really excited about implants.
20:00Dear for many other conditions as well,
20:03we just started with two and
20:04will look forward to hearing
20:06your feedback and thoughts.
20:08So what I'll do is I'll pass it
20:10off to my colleague Doctor Hermes.
20:15Great hey thanks Doctor Lee,
20:17let me share my screen here.
20:21So good morning everyone.
20:25Great, so I'm talking today to you as
20:27the chair of the V8 Connecticut mental
20:30health Process Improvement Committee.
20:32And So what I'd like to do is take a
20:35few minutes first to describe kind
20:37of the breath of quality improvement
20:39that's going on at Villa Connecticut
20:42and then dive into a specific project
20:45we have that will hopefully be able to
20:48to bring from that some generalizable
20:50principles about quality improvement.
20:52Great so it started out.
20:54Basically there is a heck of a lot
20:56of quality improvement activity
20:57going on at BA Connecticut.
21:00I sent out an email earlier in the
21:02month asking providers to to get
21:04to be kind of with their projects
21:06and what's going on and as of today
21:09we're up to 31 projects so that's
21:11a lot and it's really represents a
21:13broad range anywhere from sort of
21:16impression projects to projects.
21:17Working on changing the culture of
21:19EA and this isn't this, isn't it?
21:22By any means at it, you know,
21:25for instance,
21:25we have three separate committees at
21:27at at the Connecticut looking to to
21:29work on racial disparity issues and
21:32implementing anti racist practices.
21:34So there's a lot of stuff going on,
21:36but one of the primary points I want
21:39to make is most of these projects
21:41are what I think of as bottom up
21:44quality improvement in what I mean
21:47by that is a provider at Villa
21:49Connecticut is identified a problem
21:51in care and is working to investigate
21:53that further or develop solutions
21:55or evaluating those solutions.
21:57And this can be contrasted to something I
21:59think of as top down quality improvement.
22:02And also I'll discuss sort of the
22:05differences here as we go on.
22:07Great,
22:08so that's bottom up quality improvement.
22:11But what we're talking about now is this.
22:14This idea of top down and what is
22:16that in the first thing we need to
22:18know is that VA is a nationwide
22:21integrated healthcare system.
22:23So VA has a central office in
22:25Washington and what they do produce
22:27policy and make budget decisions.
22:29But really,
22:29the responsibility for care and
22:31the oversight of care is at the
22:33regional and facility level.
22:34Much of the policy driven out of
22:37central office is trying to ensure
22:39the quality of care at all the 100.
22:4240 different facilities.
22:43One of the primary ways they do
22:46that is that they push out a host
22:48of metrics that are designed to
22:50track that quality in these metrics
22:53are essentially designed.
22:54They use data from our electronic
22:56medical record that is centrally
22:58processed and then scores on
23:00these metrics are pushed out to
23:02the 140 different VA facilities.
23:06Great. So one of these quality
23:09met quality metrics look like,
23:11so you may have heard the term hetas and he
23:14just stands for healthcare effectiveness,
23:17data and information set.
23:18And these are national metrics that
23:21can be used to compare the quality.
23:24Across different health
23:25care facilities in the US.
23:27Not just VA, but VA has added
23:30extensively to these metrics and
23:32calls them strategic analytics for
23:34improvement and learning or sale.
23:36And so one of the main takeaways of
23:39this talk should be if you're into
23:41really bad acronyms that you need to
23:44go into the quality improvement check
23:47because that's it's full of them.
23:49But sale metrics are the primary
23:52way that be a central office
23:54monitors the quality of care.
23:56And theoretically,
23:57these metrics represent central office policy
24:00priorities for VA over here on the left.
24:02This is not an eye chart,
24:05it's just, it's just a list
24:07of the mental health quality,
24:09metrics within sale,
24:10and there's about 30 of them.
24:14Great.
24:14But wait, there's more.
24:16There's way more Sovyet pushes out
24:18way more metrics, and there are
24:20hundreds of metrics you can see.
24:21Just some of them here.
24:23And this brings me to another point,
24:25I want to make, which is there is a major
24:28difference between quality monitoring.
24:30Yeah,
24:30with using these metrics and
24:32trying to improve care with these
24:34metrics and so you need a lot of
24:36data streams to monitor care,
24:38but to improve care,
24:40you really usually just focus
24:42on sort of a small part or a
24:45couple of metrics to improve.
24:47In individual aspect of care.
24:50Great, so how does VA Connecticut do on sale?
24:54This is called a target plotter.
24:56Radar plots in so within the sale metrics
24:59that are within the mental health sale
25:02metrics that there are three domains.
25:04I've got them highlighted in
25:06red here and from a cop quality
25:08monitoring standpoint via Connecticut
25:10does very well in these metrics,
25:13especially our access metrics.
25:15And to some extent our
25:16continuity of care measures.
25:18But of course there's
25:20always room for improvement.
25:22And for instance,
25:23within this a continuity of care
25:25domain over here on the left there
25:27are 16 separate metrics within that
25:30and it in looking at these metrics
25:32we have identified that two which
25:34evaluate antidepressant treatment
25:35longevity for patients with depression.
25:37The two of those metrics that do
25:39that are really kind of dragging down
25:42our continuity of care and sort of
25:44adding to our middling scores on that,
25:47and I want to talk you through what
25:50we've done to try to rectify that.
25:53Great,
25:53so this metrics I'm showing you
25:56here measures where their patients
25:58diagnosed with depression who are
26:00started on anti suppress antidepressant
26:02have that continued out to six
26:04months and so the background for
26:06this metric is based on a wealth
26:09of research research showing that
26:11antidepressant treatment for people
26:13depression should be continued for
26:15most patients out to six months
26:18in order to prevent relapse.
26:20So this figure is showing that
26:22on average over the
26:24last five years. Three years,
26:26about 53% of via Connecticut patients
26:28with depression have had their anti
26:30depressant continued out to six months,
26:32whereas the average for for VA is 63%.
26:35So on average we're running about
26:38a 10% deficit and so this brings
26:40me to one of the main points here,
26:43which is I'm pretty sure without
26:45this data from central office that
26:48compares us to other VA facilities,
26:50we really wouldn't be able to identify
26:52this issue as an individual system.
26:55And certainly it would be very
26:57difficult for an individual provider
26:59to identify this trend if they didn't
27:01have this type of comparative data,
27:03and so that's the first point.
27:05I want to make is that there's a
27:08difference between sort of top down
27:10and bottom up quality improvement.
27:12Top down quality improvement really
27:14relies on quality monitoring and that
27:16quality monitoring allows us to identify
27:18gaps we would not otherwise see,
27:20and so a second point I want to make
27:23here is that the second point about the.
27:26Top down quality improvement is the
27:28issue of buying and so getting buy
27:31in for an issue that is shown to you.
27:33Kind of from the outside or is
27:35not intrinsically developed.
27:36It's more difficult to get that buy in OK
27:38and so that that's kind of a main issue.
27:41I want to.
27:43I want to point out. Good.
27:46So, so we get the data.
27:48The data shows us a problem we
27:50get by and we decide to focus on
27:53it and it via Connecticut.
27:54What we did is formed a group to
27:56look at this problem specifically,
27:58we did three major things we dug into charts.
28:00We talked to providers and then
28:02we discussed this issue with VA
28:04Central office experts and from that
28:06we developed kind of this list of
28:08root causes and I've got the three
28:10primary root causes up here and
28:11I'll just run through them here.
28:13So first there's an extended
28:15interval between when medicated
28:16anti depressants were started.
28:17And then when we are able to
28:19follow up with patients on that,
28:22second thing is that we have frequently
28:24care transition care transitions and
28:26then a lot of people in those transitions
28:29end up sort of falling through.
28:31The cracks are dropping out of care.
28:33Thirdly,
28:34this problem seems to localize to
28:36really high workload and relatively
28:38low resource treatment locations
28:39within V8 Connecticut.
28:41OK,
28:41so now now for another issue related
28:43to a top down quality improvement
28:45we get heck of a lot of data.
28:47We have access to world experts,
28:49but this still the data is not
28:51the the answer.
28:52It's it's digging into the data
28:54and understanding how the data
28:55applies to your specific context,
28:57which is really important.
28:58Second thing I want to say is is
29:01in the end a root cause is really
29:03just a best guess so we can sort
29:05of look at all this data and
29:07come up with these root causes,
29:09but they're not smoking guns
29:10so we don't have any
29:12smoking gun. Proof that these three
29:14issues are really the whole story,
29:15and at some point we have to take it on
29:18faith and go with with with with what
29:20we with what our gut says is that the
29:23three main issues are. Good alright?
29:26So so after identifying root causes we
29:28said about coming up with solutions.
29:30We identified several different potential
29:32solutions and I'd map them out here
29:35on the X axis we have, you know,
29:37sort of the continuum of effectiveness,
29:39and then on the Y act access we have
29:41sort of a difficulty of implementing
29:44and as you can see,
29:45there's no free lunch and in this
29:47case there certainly isn't a free
29:49lunch in that the easy solutions
29:51probably aren't all that effective,
29:53and the effective solutions are
29:55probably hard to do or expensive.
29:57And this brings me to my last point,
29:59which is. Economics of solution making.
30:02Even though antidepressant treatment
30:03longevity is really important,
30:05we want all our patients who are
30:07diagnosed with depression on on
30:09adequate dose in for a length of time.
30:12We can't pour all our resources into
30:14solving this problem and so we need
30:17leaders that could make decisions
30:19and make priorities as to where
30:21we're going to focus our efforts.
30:23And So what we did as a group as we
30:27chose three of these solutions and so.
30:30There there are the three.
30:32OK,
30:32so we started with some general
30:34provider education in the short term,
30:36and then we're going to add some academic
30:38detailing visits by Angie Boggs,
30:40who is our clinical pharmacist
30:41in for a long term solution.
30:43We're going to work to get a care
30:45manager in place in these high workload
30:47areas to do some follow up Contacts.
30:50After antidepressants are start and so
30:52we just kind of started this process.
30:54So maybe in the future I can
30:56come back and tell you how we do.
30:59Good, so in conclusion,
31:01so conclusions are via Connecticut is
31:03a hotbed of Qi, primarily bottom up,
31:05which means it's driven by a bunch
31:07of caring providers who care about
31:09where they work and want to change the
31:11system in which in which they work.
31:13I told you about one specific project
31:16within that that is kind of more
31:18top down and their specific some
31:20specific issues with top down Qi.
31:22First is that by in it may be more
31:24difficult to get by in for top down Qi
31:27than it is for intrinsically developed.
31:30Identify problems next.
31:31We have a lot of data.
31:33We have a lot of resources but
31:35it still takes work to apply that
31:37to your specific problem and then
31:40when you look into your problem and
31:42you do root cause analysis,
31:44there's nothing magical about that.
31:46And in the end it might be just your
31:49best guess as as to what's going on.
31:51And finally,
31:52there's usually no silver bullet solution.
31:54It's more like a shotgun approach
31:56to solution making and you have
31:59to make decisions about.
32:00Where and how to allocate your
32:03resources, so I appreciate it.
32:06I'm over over to utilize.
32:27I think doctor Hermes emu you
32:29handed over to Doctor Var Server.
32:31I'm up next, so I might I might
32:33go unless you want to go to Paris.
32:36Sorry bout that. No
32:38no. It's all. It's all good.
32:39It's all good. Just
32:41checking fired up John. Don't
32:43go and government going alright
32:45here we go really nice to be here.
32:48Thanks everyone thanks
32:49Doctor Sonia conductor.
32:50Leave putting this together for.
32:51I'm going to talk a little bit
32:53about the unique UI challenges and
32:55opportunities we have at CMH C as
32:57a public academic partnership for
32:59Community Mental Health Center.
33:01And I'm going to go through the
33:03example this step and and outcomes
33:05oriented learning health system model,
33:07which we've been working on
33:08for a number of years now.
33:10For those that don't know,
33:12steps are first episode psychosis,
33:14clinical research service founded at CMAC.
33:16In 2006,
33:17by the notary who's mentored a lot of
33:19the work that you're gonna see here today,
33:22and there's our funders.
33:25OK, so I'm going to start with
33:28an excuse qis MHC can be really
33:30challenging and it's probably
33:32going to seem less polished than
33:35what you've seen so far today.
33:37And here's an example,
33:39so I want to take you through
33:42what I might have been doing this
33:45morning at CMAC if I wasn't here.
33:48Speaking with you all today.
33:50So here's everyday clinical care at CMH C.
33:53We have wits REHR widths,
33:55communicates with their enterprise.
33:57Data Warehouse generating reports
33:59for Demas who we work for.
34:01But then there's also a legacy database
34:03which generate sports reports for CMS
34:05and then and then the Joint Commission.
34:08Then we have a nice you know
34:10Microsoft Suite of resource is to
34:12keep everything ticking along.
34:14Sounds pretty reasonable.
34:15However,
34:16which is partially implemented by by Dima,
34:19so we still do have a parallel
34:21physical chart,
34:22so we're still interacting with that,
34:24and that obviously needs to
34:26be scanned to the database.
34:28Fine, we can put up with that.
34:30Unfortunately there are some
34:32other legacy databases that are
34:33available for certain services
34:35depending on what you're looking at.
34:36Some of our services go to deduct instead.
34:39OK,
34:39will fall back into the model and
34:42then shout out to Dan Shetler.
34:44Are a QA director.
34:44We want to we want to get some good
34:47visualizations to get some utilization data.
34:50So we want to pull in tapped into Tableau.
34:52But this is what the data flow looks like in.
34:56In order to get some good
34:58visualizations going.
34:59But then Tableau helps
35:00you with visualizations.
35:01That doesn't help you with data capture,
35:04so Luckily enough,
35:05I work in a research clinical research
35:07clinic that has red cap implimented.
35:09So we've got some good data
35:11capture resource is there and
35:13it can generate reports for the
35:15funders so that that went OK.
35:17But way to colleagues about
35:19to send you an email.
35:21Unfortunately they send that email to your
35:23Yale outlook instead of your demas outlook,
35:26which is a completely separate login.
35:28So you have to toggle across.
35:30Uh,
35:31give
35:31me Doctor Cahill. Sorry to interrupt,
35:33can you put this in Presenter View?
35:36Yeah I can. I can.
35:40Perfect thank you.
35:42Thanks, Trisha. So we have to.
35:44We have to toggle across but OK,
35:46forget about it.
35:47Let's go on a video conference instead.
35:50So we jump on Yell Zoom,
35:52but during the course of our conversations
35:55we start talking bout a CMAC patients.
35:57So policy Demas from Dima says
35:59we need to jump onto DEMAS teams
36:01instead which currently freezes.
36:03Then we need to download a blank
36:06admission template for the client
36:07that's on the DEMAS Intranet.
36:09Unfortunately we don't have remote desktop.
36:12Access for the Internet,
36:13but Luckily there's a copy
36:15on your box I'm moving.
36:17I'm moving faster here if we want
36:19to communicate Phi on that template
36:22we have to use Zix secure email.
36:24I want to sign a nursing
36:26order for this client,
36:28so I see whether there with Laura
36:30Home Care that has an online portal
36:33for signing the Care orders.
36:35Unfortunately,
36:35this client is one of is with one of the
36:3916 other agencies that we work with,
36:41so we have to use fax for that next job.
36:45I need to look at some lab work so we
36:48look at Hartford Healthcare for lab work
36:51either on the portal or via via fax.
36:54Unfortunately,
36:54there's no lab works there.
36:56It seems that the clients opted to
36:58use quest in the community instead,
37:00so we log on to Quantum instead
37:02to look at that next job,
37:04put in medication refill.
37:05So we put that into RX NT.
37:08But we need to print off the
37:10orders into the chart.
37:11It looks like we're prescribing clause Appin,
37:13but also Ativan, so I also log into
37:17the closet in REM system CTP&P.
37:19Oh no, the patients in the ER,
37:22but Luckily we have read only
37:24access to young Haven Epic,
37:26so we can log in there.
37:28So that's a fair summary I
37:30think and hope to send you.
37:32Correct me if I'm wrong of our currency.
37:35MHC information ecology.
37:38So I hope that's all clear to everyone.
37:43So as you can see,
37:44it's hard to do conventional Qi at CMAC.
37:47Nevertheless, we have a lot of strength here,
37:49and I want to highlight here,
37:51and I'm not going to go through
37:53each of these for brevity.
37:55There's a few highlights here that's
37:57stood out to me over the years,
37:59either because I've had the pleasure of
38:01being involved with some of these efforts,
38:03working with some of these individuals,
38:05or they've really spoken to really salient
38:07narratives that that's around them.
38:08I mean, you have you have quite
38:11structured Qi processes here.
38:12For for the Joint Commission,
38:13but you also have things like.
38:16We have a cross country ski
38:18team for our snow preparedness,
38:20forgetting forgetting physicians on site.
38:23I also want to shout out to Will Rutland,
38:27so as a PG three he notice to a
38:29real gap in in bridging meds between
38:32the only Haven hospital system in
38:34our CMAC pharmacy and as you know,
38:37as a resident can,
38:38he bridged the two systems of
38:40care and put in place an epic best
38:43practices advisory for CMAC Pharmacy,
38:45which which has been has been
38:47triggered 31 times since its inception,
38:49but I'll let you peruse the
38:52other examples here.
38:54But as you can see,
38:55it takes a village and I could certainly
38:57be critiqued here that some of these
38:59examples stressed stretched the
39:00definition of Qi initiatives a bit.
39:02But what they do is capture the
39:04spirit of CMH.
39:05See, we all mark in,
39:06and we strive for excellence in
39:09our in our mission.
39:11So we've established informatics
39:12is a challenge for us,
39:13but we are mission driven and our strength,
39:16so we have a community rich and dedicated,
39:18caring, smart,
39:19creative and motivated individuals
39:20and we have an access to an array
39:23of resources and expertise as
39:24well as community partners,
39:25some of whom are also presenting here
39:28today who are willing to help us out.
39:32So traditional Qi is hard to do.
39:34It's MHC.
39:35We've seen some encouraging narratives today,
39:37but how do we know,
39:39objectively that we are doing a good job?
39:43So what other models of Qi are available
39:46that could help us so one model could
39:49be seeding or joining and outcomes oriented,
39:52learning health system,
39:53and I've thrown up a couple
39:55of definitions of of that.
39:57Their outcomes oriented learning
39:58health system would focus on core.
40:00Or outcomes.
40:02Not processes of care,
40:04so it allows.
40:06The reality of of a community mental
40:09Health Center to do what it does best
40:12was keeping an eye on what we agree.
40:16We need to be doing.
40:17Ultimately for the population
40:19with serving the core outcome,
40:21shipset should be derived from and
40:23continuously reviewed from multi stake
40:25in multi stakeholder input to ensure
40:27it remains meaningful for the population.
40:29Were trying to serve and the
40:32Institute of Medicine guides us here.
40:34They they talk about an
40:36LHS thriving when science.
40:37Infomatics incentives and culture
40:39aligned for continuous improvement.
40:40And so I just wanted to expand on that a
40:44little bit. So this is how we've been
40:47thinking about it at step as sort of
40:49four pillars of a model learning health
40:52system for continuous quality improvement.
40:54So science rigorous methodology.
40:55Essentially you want to
40:57get your measures rights,
40:58but you want to capture the value of
41:00qualitative as well as quantitative data.
41:03You want to Orient around a core dynamic
41:05set of multi stakeholder derived outcomes.
41:07As I've mentioned,
41:08I've put the next one in brackets
41:10because this is something that
41:12we're sort of adding to this
41:14definition as a future direction,
41:16but integration.
41:17To support multi directional
41:19knowledge generation and translation,
41:21can we plug learning health systems
41:23into basic science research
41:25and therapeutics development?
41:27Next informatics we really want to
41:29minimize the burden to operators.
41:31As you can see from our sort
41:34of data data flow ecology,
41:36we want to try to minimize as much as
41:38possible parallel entry into systems and
41:41try to create opportunities for passive
41:43and opportunistic data collection.
41:45We want to securely and ethically support
41:48interoperability and integration of
41:49applications and multiple databases,
41:51and we want to be agile,
41:53user centered and collaborative
41:55in our design and development
41:57of mathematics systems.
41:58And one idea would be embedding embedding
42:02dashboards into everyday clinical workflow.
42:04In terms of building incentives
42:06and Doctor Hermes spoke a little
42:09bit to this today at the VA,
42:11we want to protest the buy
42:13in of our operators,
42:14not just the managers.
42:15So we want to empower the user to reflect,
42:19learn,
42:19and improve while we're working
42:21around these these measures,
42:22we want to offer support and the
42:24tools to solve those problems,
42:26and we want to value autonomy and
42:29individualism wherever possible.
42:30Whilst we are benchmark working
42:32outcomes and trying to to ensure.
42:35Ensure consistent quality across our
42:37systems of care and Lastly culture.
42:39I always enjoy being reminded of this.
42:42Quote Culture eats strategy for breakfast.
42:45You know,
42:45we wanted to develop a culture of inclusion,
42:49responsiveness,
42:49respect and humility around Qi.
42:51We want to form a nonpunitive supportive
42:55community for continuous learning of all.
42:57And we want to engender hope for
43:00improvement and elevates successes.
43:02And that's really at the core
43:04of a learning health system.
43:06It really wants to foster these
43:08water cooler conversations that
43:10generate creativity and then
43:12support rapid cycles of innovation.
43:16So I want to elevate.
43:19That the work of the nursery and
43:21Laura Levine Sykes at step they've
43:24recently launched the Connecticut early
43:26Psychosis Learning Health Network,
43:28which is is seeking really to extend
43:31steps impacts statewide through
43:33a local learning health system.
43:35You can see from this slide and
43:38I won't go through all of it.
43:41This is this is Doctor Sykes slide.
43:44There's a real emphasis on supporting
43:47with education and training.
43:49If you want to learn more, there's a.
43:51There's a link at the bottom there,
43:53and I encourage you water to
43:55check out the website,
43:56but this is what's happening locally in
43:58Connecticut from from step extending
44:00into this learning health system model,
44:02and also want to acknowledge the funders
44:04there in the bottom right corner.
44:08So a busy slide. I apologize,
44:10but we realized that we wanted to
44:12in order to develop and outcomes
44:15oriented learning health system model.
44:17In this day and age we need to
44:20support it with a digital media.
44:22So what does that mean?
44:24It means having an application,
44:26a data system,
44:27a database that facilitates the
44:28integration of multiple data sources
44:30and create sort of reflective space.
44:33For diffuse providers,
44:34diffuse clinics to sit and reflect
44:36and come up with these ideas.
44:38So we applied for some funding to build.
44:41A prototype for this and it's it's
44:44gone through a few iterations.
44:46As you can see over over the
44:48years we were asked to present
44:50this prototype by Bob Hines,
44:52Senator Preparatory Meeting for a
44:54series of NIMHRA phase for the for
44:57what's now called the Eppinette
44:59project that's now started rolling.
45:01So that stands for early
45:03Psychosis intervention network,
45:04so that is essentially modeled as a
45:06nationwide learning health system,
45:08specifically for the first episode,
45:10psychosis services and steps.
45:12Part of that.
45:13So the group is currently funded
45:16to implement our learning health
45:18system model in two of the
45:21eight national eppinette hubs.
45:23So I just wanted to last couple of slides.
45:27This is what happen.
45:29It looks like nationally,
45:31there's eight regional hubs.
45:33There's 101 early psychosis clinics
45:35across 17 States and then there's
45:38the eppinette data coordinating
45:40center and their harmonized accord.
45:42Outcomes set which is starting to be
45:45collected across across the network.
45:47So this is one of the hubs that were
45:50involved with the eyes of John Cain
45:52and Double Robinson at Northwell.
45:54It's called yeah Streeter network.
45:56There are 12 clinics,
45:58one of which is step right there
46:01looking out the back of that cluster.
46:04And then the second network
46:06is called AC Eppinette,
46:07so it's six larger academic sites.
46:10The PII is Alumbrera at Indiana,
46:12and we have the pleasure of working
46:15with this network too. So last slide.
46:20What could be the next steps?
46:23So can we possibly extend
46:25this LHS infrastructure?
46:26We restart,
46:27submerge in it and get it right
46:29to create new opportunities for
46:31knowledge generation and translation?
46:33And specifically can we extend
46:35it vertically upwards into really
46:37capturing the knowledge that
46:39exists in our wider community?
46:41Wider stakeholders,
46:42people with lived experience
46:43lay knowledge that there exists.
46:45Can we also extend it vertically
46:47downwards to integrate into the basic
46:50clinical science collaborations by
46:52market development in therapeutics?
46:54And then.
46:54Extending in these other directions
46:57with can we scale up?
46:59Can we scale up through the open
47:01net network and then potentially
47:03could we generalize,
47:05generalize to other severe mental illness?
47:07And that's where I'll end and
47:10thank you and feel free to.
47:13To get in touch and long awaited
47:16Doctor Rosa over to you Sir.
47:19Thank you doctor Cahill.
47:25Alright um. So good morning everybody,
47:28so I'm going to be talking about
47:30the residency curriculum and
47:32the transformation we've made
47:33around the quality improvement
47:35in patient safety curriculum for
47:37residents over the past few years.
47:39Really, the when this started
47:41five or six years ago,
47:42the focus on quality improvement
47:44in patient safety in the curriculum
47:45is mostly reserved for the Pgy
47:47four year sort of after people
47:49had gone through basic clinical
47:51and other kinds of education,
47:52the idea was to help them
47:54optimize the way that they thought
47:56about the clinical practice,
47:57and I think based on some feedback that
47:59we got in some AC GME survey results,
48:02I'm going to share there was a
48:03significant effort and energy
48:05thord revitalizing the curriculum.
48:06I'm going to talk about that
48:08and show some of the work.
48:10Product from that effort.
48:11Over the past few years.
48:17So in 2015 every year,
48:19the AC Jimmy doesn't annual site survey,
48:21both residents and faculty,
48:22and it shows 15 the scores of the residency
48:25in these particular areas were not up to
48:27the standards that we were hoping for.
48:30So every year they ask questions about
48:32whether residents participate in quality
48:33improvement and patient safety activities.
48:35And as you can see here,
48:37the score here was 67% of
48:39residents indicated that they did,
48:40which was below the National Service
48:42or the national average at the time,
48:44another area is around. Resident.
48:47But their practice habits.
48:48Now this is different or distinct from
48:51receiving feedback and supervision.
48:52I think our residency program does
48:54a great job of providing residents
48:56with supervision opportunities,
48:57but this is really looking
48:59at more hard objective data,
49:00sort of quantifiable metrics that
49:02residents could look at and only 1/3
49:04of residents at the time reported that
49:06they were receiving that which was
49:09significantly below the national average.
49:15The residency program director,
49:16along with the GC, convened a
49:18task force to look at the Quality
49:21Improvement education across the.
49:26His work in step at the time he
49:28was one of the associate Program
49:30Director's and he was responsible.
49:33The systems based practices and problem
49:35based learning and improvement elements
49:37of the curriculum that I now oversee,
49:39and so he put together a group that had
49:41broad multisite representation and also
49:43had resident representation as well.
49:55Here in residency with a stepwise progression
49:58it for more senior residents to try.
50:00I'm sure residents were acknowledging
50:02this participation in the survey to give
50:04us credit for the work we were doing.
50:06To increase the routine practice habit,
50:08data feedback through implementing
50:10an EMR driven mechanism for providing
50:12residents data about their work.
50:14So I'll talk a little bit about
50:17some examples of how we did that.
50:19And then to it we can enhance the
50:22Experiential Qi activities for the
50:25residents at the clinical sites.
50:27So this is what the curriculum
50:29looks like now.
50:30So again, as I said before,
50:32is primarily located in the Pgy
50:33four year several years ago.
50:35Now we really do have this stepwise
50:37progression through the residency,
50:38so in residents pgy one year
50:40we just start to talk about
50:41quality improvement as a concept.
50:43We introduce them.
50:44The idea that they work in a system
50:46and that as interns they are one
50:48cog in a large complicated machine
50:50that's coming to lead to health
50:52care outcomes for their patients.
50:54We introduce the idea that
50:55there if there's an error.
50:57Even though we want to attribute
50:58it to individuals,
50:59usually it's a systems error,
51:00not just an individual error,
51:02and get them thinking about those ideas.
51:05In the Pgy two year we start to introduce
51:07them to the basics of quality improvement.
51:10Things like a plan,
51:11do study, act cycle.
51:13That's the PDS acronym.
51:14We give them some tools to use and some
51:17introduction to quality science and also
51:19talk about Barry barriers in quality
51:21improvement and how to avoid them.
51:24In the Pgy three year we start to
51:25help them apply quality improvement
51:27ideas to their clinical work.
51:29How to think about actually
51:30running a Qi project?
51:31How do we measure quality and just this year,
51:34Doctor Lee through her great
51:35leadership was able to actually
51:37secure a grant that allowed our
51:38residents and participate in a
51:40quality improvement simulation lab,
51:41which was a really unique opportunity.
51:43And then in the Pgy,
51:44four year for residents for all residents,
51:46we think about how to apply Qi and
51:48quality science to their clinical
51:49medicine and for those who are really
51:51interested in some specialization,
51:53we do have some Chief of Qi positions both.
51:56The VA in it.
51:57Yellow Haven hospital.
52:01The next big undertaking for us was
52:03thinking about how we were going
52:05to give residents this practice.
52:07Performance feedback.
52:08So for anyone who went through
52:10the residency before with this
52:12transformation that I'm describing
52:13may remember that in the past,
52:15what was expected of residents is that
52:17at the end of their pgy three year
52:20they were going to gather up a random
52:22sampling of their clinical charts.
52:24They were going to identify some
52:26national metric like metabolic monitoring
52:28for patients on anti psychotics.
52:30And they were going to be expected to.
52:32Randomly audit ten of their charts.
52:34See how close they were to that metric and
52:37then in the beginning of their pgy four year,
52:39bring the data back to their
52:41peers and presented the class.
52:43What we often found is that residents
52:45ability to do this was limited.
52:47Sometimes they would switch clinical sites
52:48from the Pgy three to the Pgy four year,
52:50and so they no longer had access
52:52to the charts if they didn't think
52:54to do this proactively,
52:55they got preoccupied and it was
52:56just a really onerous experience for
52:58the resident was a lot of effort.
53:00They had to expend to do this work.
53:02I think we identified in this work group
53:04that you know in the data age we now live in,
53:07that there are ways that we should
53:08be able to do a lot of this work
53:11for the residents and provide them
53:12the data so that they can then.
53:14How do I change my practice
53:17in response to this data so?
53:19We looked at all the clinical sites to see
53:22what was the one centralizing force there.
53:24'cause again the residents are
53:26rotating at all different sites,
53:28doing different rotations and what we
53:30realize is essentially all residents
53:31at some point during their residency
53:33are going to interact with the Yellow
53:36Haven hospital system and usually
53:37it through some on call experience.
53:39So obviously a lot of our residents also
53:42rotate their an inpatient experiences
53:43and so we can use the epic EMR as
53:46a way of designing a mechanism for
53:49providing them quantifiable objective.
53:50Eat up about something and the
53:52place we decided to start was around
53:54their prescribing practices.
53:54We thought again that was something really
53:57centralized to what the work that they do.
53:59Recognizing that a pgy one is going
54:00to have a lot less autonomy than a pgy
54:03two or a pgy three or a pgy 4 about
54:06the prescribing that they're doing.
54:07But still,
54:08it's a reflection of the practice and
54:11the work they're doing in the residency.
54:14So I'm going to show you here some examples.
54:16So this was our first iteration of a
54:19prescriber profile and this is for an
54:21individual resident and essentially
54:23what we do is every resident gets
54:25generated their own individual
54:26prescriber profile that's shared
54:28with them privately so that their
54:30peers don't necessarily see that
54:31what they're doing.
54:32But then we also share with
54:34the whole class cumulative
54:36data about the prescribing practices
54:37of all the residents in their peer
54:40group so that they can see and compare
54:42where they stand amongst their peers.
54:45So that as they advance through the
54:46residency, they can try to be more
54:48thoughtful and reflective of their own work,
54:50and if they see that as a pgy two,
54:52they realize they they've
54:53really prescribe clozapine,
54:54much less than their peers,
54:56maybe as a TTY,
54:57three in their outpatient setting.
54:58That's something they want to think about
55:00when the opportunity presents itself.
55:02And what we found is that this prescriber
55:05profile practice has actually been
55:06a Qi project within a Qi project.
55:08And I'll show you as every year
55:10that we've done this,
55:12we've gotten feedback from the residents
55:14about additional medications to
55:15include other factors to think about
55:17in different ways to present the data.
55:19So here I'll show.
55:20This was our second year in which
55:22we not only looked at the the
55:25medications they were given,
55:26but we started to look at their diagnosis
55:28of the patients who received the medications.
55:31So you'll see the colors are different
55:33and at the bottom the legend shows
55:35anxiety disorders,
55:36psychosis, etc.
55:36So they can think about not only
55:38the locations where they were
55:40prescribing the medications,
55:41but for what primary indications.
55:44We then became even more complicated as we
55:46started to add more and more medications,
55:48and so the formatting of this went
55:50from being a vertical to horizontal
55:52as it was hard to capture the
55:54data in any other way.
55:57They then got even more complicated as we
56:00continue to add more factors to think about.
56:03And then a couple of years ago,
56:05residents started suggests that
56:06really we ought to be thinking about
56:08socio demographic factors as well,
56:09and so we added race and ethnicity is
56:12another factor to think about in our
56:14prescribing practices as well as age.
56:15So you'll see here, the different
56:17columns represent different races,
56:18and then the color coding is based
56:20on the age of those for whom
56:22the medications were prescribed.
56:27We also started to add in PRN so
56:29the previous things I showed were
56:30just about standing medication.
56:32So we started to allow residents
56:34to look at the PRN medications
56:36that were prescribing and also
56:37whether they were prescribed in an
56:40oral format versus an IAM format.
56:42So you know from the residence.
56:43As I said, we've gotten a lot of
56:45feedback that this has been very useful,
56:47and it's been helpful,
56:48and it's provide a space for
56:49some discussions of their on
56:51call experiences where a lot of
56:52this work is taking place.
56:54And as I said,
56:54we really tried to modify these every
56:56year based on the feedback we get.
57:00So you can see that as a result of this work,
57:03we have steadily improved,
57:05were not yet on our goal, but we have
57:07improved significantly in some ways.
57:09So as far as participation in Qi
57:11and patient safety activities,
57:12we've gone up from 67% to 77%.
57:14Consistently.
57:14We're still not quite at the national
57:16average, but we're getting closer.
57:18And I think some of the reasons
57:20for that have to do with some of
57:22the challenges that John and others
57:24highlighted about involving resident
57:26just engaging in Qi activities
57:27in our cadre of clinical sites.
57:29But it's been really nice to
57:31see is that providing data about
57:32practice habits where we were so
57:34far below the national average.
57:36We're now actually exceeding the
57:37national average significantly,
57:38so I think these results reflect
57:40that residents really appreciate the
57:42efforts that have gone into this.
57:44This work has also led to some
57:46scholarship which has been really exciting.
57:49So two residents this year Ignacio Sardinian,
57:51Terrell Holloway, amongst many others,
57:53published a paper based on this
57:55data looking at racial ethnic
57:57differences in resident prescribing.
58:00In a couple of years ago,
58:01another outcome of this was a prior resident,
58:04Akhil Gupta developed yet
58:05another quality improvement data
58:07metric that we could utilize,
58:08which was looking at the disposition
58:10outcomes for patients who present to the CIU.
58:13So you'll see here,
58:14the blue represents patients who
58:15are recommended for admission.
58:17The purple patients who are recommended
58:19for observation and the green
58:20patients who are recommended for
58:22discharge and essentially the slight
58:24coloration differences within the blue,
58:26purple,
58:26and green are the differences between
58:28what the resident recommended versus
58:29what ultimately happened to the
58:31patient based on the attending decision.
58:33So again,
58:34we do a similar process where residents
58:35can see their individualized data,
58:37and then they can see where they
58:38stack up compared to their peers.
58:42We also look at this what we call
58:44treat and release data to see how what
58:46percentage of the patients they see that
58:48they choose to discharge are representing
58:50to the cious within seven days. And.
58:56That's been another really interesting
58:58way that we've been able to look at
59:01the the there practice in a real,
59:02objective, objective, quantifiable way.
59:05So I think that is all I have for today,
59:07so I will pass it back to Doctor Cerny Ack.
59:11Thank you, I want to leave enough time
59:14for questions and so now people will
59:16we have a few but people could add so
59:19I'm going to be as quick as possible
59:21and really decrease the comments.
59:23So just hot take on each one at
59:25first was extraordinary in and I
59:27think it speaks to heterogeneity
59:28and excellence in the Department.
59:31You know, you heard from the major
59:32sites and it just really extraordinary
59:34and very creative work being done.
59:37So here we go. In the case with Doctor Lee.
59:41One of the things that really
59:42impressed me in the mania consensus
59:44group was not only was it a team,
59:46but included resident.
59:47And so I think that's an extraordinary
59:50model about an issue that everybody faces,
59:53but also that really the team based
59:56work we always talk about that.
59:58But to see that, really.
01:00:00So much in place,
01:00:03including residents is just extraordinary.
01:00:06And with doctor Hermes.
01:00:09I guess what impressed me the most
01:00:11was taking that top down data and then
01:00:13like trying to figure out the details
01:00:15about how you get to the number you
01:00:17get to and how you can improve that.
01:00:19An having been in the position of that
01:00:22raining down on me on a daily basis,
01:00:24it's just really great to see that and
01:00:26it improves veterans health and so and
01:00:29I think the the by an issue of like
01:00:31why are we doing this is because it's
01:00:33been shown to be an effective thing.
01:00:35And here's how we can improve.
01:00:37That was just a great example.
01:00:38I'm John.
01:00:39I'll be answering calls from Demis
01:00:41later on today about the slides,
01:00:44and so I'll be sure to forward them to you,
01:00:47but I would say first of all
01:00:49it's a CMAC thing.
01:00:50We acknowledge realities of the
01:00:52situation and we work with it,
01:00:54and I think one of the things that
01:00:57came through in your presentation
01:00:58was that you know you work with what
01:01:01you've got an you can do work anywhere,
01:01:04and the excellence of CNBC.
01:01:05And I would say all of Demas
01:01:08in working in a challenging.
01:01:10Technological environment.
01:01:12And then I would say for Doctor
01:01:14Waters presentation two things.
01:01:16One is,
01:01:16I think it's wonderful when you
01:01:18have the infrastructure that
01:01:20and you can plug in questions.
01:01:22So age, race things like this,
01:01:24like the infrastructure exists and
01:01:25so now you can query it in ways that
01:01:28you consider particularly relevant.
01:01:30And suggestions coming from other directions.
01:01:32The other is I would say it's
01:01:34just the weirdest thing,
01:01:35being old enough in the
01:01:37Department just to see.
01:01:38So I had an idea when I
01:01:42was in attending an 87.
01:01:44We're at 91 when I discharge a lot
01:01:46of people and someone come back
01:01:48and someone and I can never figure
01:01:50out like how to predict that.
01:01:52And I think one of the things you know
01:01:54that things are showing with the resident.
01:01:56It's not to show people
01:01:58you know the because you're
01:01:59discharging so many people.
01:02:01So many people are coming back
01:02:02or this is what you're doing bad.
01:02:04It's actually to see someone who or
01:02:06several people who violate that rule
01:02:08that we had was increased discharges.
01:02:10Increased re admissions that you know.
01:02:12Is there someone in that group that's
01:02:14actually got what we would call a good eye?
01:02:17I'm that they can break free
01:02:19of the constraints that I had,
01:02:20that I would always see that you
01:02:22know you increased discharges.
01:02:23Re admissions go up too.
01:02:25So it's not to just tell people what
01:02:27they're doing wrong by any means,
01:02:29and that wasn't the suggestion to the groups,
01:02:31but it is to actually identify best
01:02:33practices and one that deviate in a
01:02:35good way and could actually teach
01:02:37a lot of other people information.
01:02:39And it is so hard to figure out like
01:02:41I don't know how you would unless you
01:02:44got this massive amount data about
01:02:46people doing their evaluations in the ER.
01:02:48And so to all of you,
01:02:51I thank you very much for these
01:02:53presentations.
01:02:54Very thought provoking presentations
01:02:56and let's see what we've got in
01:02:59terms of questions. Um?
01:03:02Trisha, why won't you help me with this?
01:03:05I'm sorry.
01:03:06I mean that's fine, let's do.
01:03:12Amazon scary let me
01:03:14see I think one was data about people
01:03:17receiving metrics for prescribing
01:03:19medications for addiction at the VA.
01:03:23That's from Doctor O'Malley to Eric.
01:03:28Yeah, so great the the.
01:03:31Up short stories we do great at that, so
01:03:33this is that that is that that is a metric.
01:03:36We are sort of on top of. I don't.
01:03:38I don't know what our numbers on,
01:03:40but you know so so one thing I didn't share
01:03:43is that you know VA push will push out these
01:03:46metrics to us and then and then raid us.
01:03:49Give us a Z score based on the the VA
01:03:51average and so whether you're however many
01:03:55standard deviations above or below the mean,
01:03:57and that's how they figure out
01:04:00you know what what,
01:04:01what color you get right,
01:04:03and you don't want to be read so,
01:04:06but weird full in the green on map 4,
01:04:09four OUD&AUD. Oh yeah. The
01:04:13other question, Doctor Sarniak is from
01:04:16Doctor O'Malley and it's for Eric.
01:04:18Does the VA have metrics for
01:04:21prescribing medications for addiction?
01:04:23Just ask that one.
01:04:24Sorry bout that. I'll just
01:04:26explain for the crowd so that we have sort
01:04:29of two main metrics that we work off of.
01:04:32Whether Matt or medication assisted
01:04:34therapies prescribed for OUD or au D so
01:04:37so we have two metrics that we work off.
01:04:39We're doing good on those.
01:04:43Great Na, I guess.
01:04:45A comment from Jennifer's IG
01:04:48and I'm very interested in
01:04:51safety issues with regards.
01:04:53Artie, I'm sorry.
01:04:54I'm old enough.
01:04:54I don't understand the RT.
01:04:57I don't think it's related to
01:04:59know the EMR records right?
01:05:00Yeah, so I know that Doctor Cahill
01:05:03presented kind of all the complexities
01:05:05of the EMR as sort of a joke.
01:05:08Like hey look, what we have to deal with
01:05:11and this is in the background and and look,
01:05:14you know we were able to
01:05:16get some work done anyway.
01:05:18Which is amazing.
01:05:19It is amazing, but my interest is actually
01:05:21approaching that head on and saying no,
01:05:24the EMR in and of itself is a safety problem.
01:05:28And so I've been active in our
01:05:30local epic optimization Committee
01:05:32at the Yale New Haven, you know?
01:05:35Or the Department of Psychiatry,
01:05:37but some of the initiatives have done
01:05:39have affected, sort of all of you.
01:05:42New Haven for example.
01:05:45People get vital signs taken.
01:05:47Sort of anywhere in the hospital
01:05:50that's now universally seen instead
01:05:52of segregated out somewhere so that
01:05:54nobody knows 'cause it's sort of sitting
01:05:57in an electronic box somewhere, and.
01:06:00It also just like there was an
01:06:02error where if if social history
01:06:04wasn't entered in then it said none.
01:06:07So for example it would say number
01:06:09of children none when it was meant
01:06:12to say not entered.
01:06:13So there was actual misinformation
01:06:15across the board because of our EMR.
01:06:17And so I've,
01:06:18you know,
01:06:18worked with the committee that has been
01:06:21really nice enough to listen to me
01:06:23as this part time outpatient psychiatrist.
01:06:25I raised my hand.
01:06:27I point out these things and they
01:06:29work on it and they fix them.
01:06:31An I think it's been really helpful
01:06:33for patient quality and safety,
01:06:35so when you put up things like
01:06:37that diagram of a joke about,
01:06:39you know I have to deal with this EMR
01:06:42where this one talks to that one that
01:06:44one text to this one, this one toxin.
01:06:47It's impossible.
01:06:47I actually take that really seriously.
01:06:49Sorry to have no sense of humor,
01:06:51but I think that that's a real
01:06:54problem in healthcare and I would be
01:06:56interested in finding other people who
01:06:58see that as a safety quality problem.
01:07:00Actually working on fixing that.
01:07:01Or publishing data about it?
01:07:03Or Anne Anne, I'm not sure.
01:07:05Kind of how to go about that.
01:07:07It's just something that I've
01:07:08noticed in my in my clinical care.
01:07:10So that was sort of what my comment was.
01:07:14Well, thanks for the comment.
01:07:15I John, can I give you one minute reply
01:07:18'cause we have a few other questions I
01:07:21want know. Thank you so much for
01:07:23that comment. I mean I think humor
01:07:25is a the psychodynamic members of this
01:07:28group. Will I hope?
01:07:29Support me and saying that humor is
01:07:32a mature defense mechanism and it is
01:07:34not meant to imply that I don't take
01:07:36this seriously and I would love to
01:07:38work with you along along those lines.
01:07:41So thank you for your comment
01:07:43and I look forward to.
01:07:45To working with you. Great,
01:07:47I'll just send out my email address
01:07:50so anybody can contact me if
01:07:52you're interested. Thank you.
01:07:53Both Ann from Doctor Carmen Parker
01:07:56to Doctor Wasser as we collect data
01:07:58that may reveal concerning racial
01:07:59bias and diagnostic and prescribing
01:08:01habits for faculty and residents.
01:08:04Have we yet entered conversations of
01:08:06supporting those with concerning trends?
01:08:09So Tobias, can you give us 2 minutes?
01:08:11Yeah, sure. So I think it's a
01:08:13really great question, Carmen.
01:08:16So it's complicated.
01:08:16I would say by in a lot of different ways,
01:08:19so one we really and I didn't get into this,
01:08:22but we really, really try hard when
01:08:24we present this information to be
01:08:26clear that this is not about judgment.
01:08:28This is not about some people
01:08:30are good and some people are bad,
01:08:32and I'm appreciative that even the language
01:08:34you're using is thoughtful and careful.
01:08:36But I think one thing I want to be
01:08:38very mindful of is that we're not
01:08:40sending the message to a resident
01:08:42that they're doing something bad.
01:08:44The second factor that really
01:08:45complicated is that.
01:08:46A lot of the choices that the residents
01:08:48are making in prescribing these settings
01:08:50are not wholly independent choices,
01:08:52so one it obviously can be
01:08:53influenced by their attending,
01:08:54but two it can also be really heavily
01:08:56influenced by community practices,
01:08:58so a lot of people you know these choices
01:09:00are being things that are being continued.
01:09:02Some of their seeing a CI you,
01:09:04they're just continuing their outpatient
01:09:06meds or an inpatient unit or wherever so.
01:09:09It's it's not.
01:09:10I think I would be careful about
01:09:12interpreting racial bias that we see
01:09:15in the prescribing as necessarily
01:09:17solely reflective of the residents.
01:09:20Choice as as not as more.
01:09:21Being a multi factorial and kind
01:09:23of complicated at the same time.
01:09:25I think we do have to address that.
01:09:27We see really desperate findings
01:09:28for in certain individuals to help
01:09:30them acknowledge that their findings
01:09:31are really different and how do
01:09:33we support them through that.
01:09:34So I think this paper was only recently
01:09:36kind of coming to fruition and I'm
01:09:38still wrestling with it so I know
01:09:40if you or anyone else is interested
01:09:42in this area has ideas or how to
01:09:44address this in the kind of careful,
01:09:46thoughtful way we'd like to,
01:09:47I'm all ears.
01:09:50Thanks, I I guess I would add 2.
01:09:53I didn't hear you mention faculty in that,
01:09:57and so I think Doctor Parkers question.
01:09:59There's still half. That to be addressed.
01:10:05Something that worked for I want to make
01:10:07sure just because there was a question
01:10:10from Doctor Goldenberg to Doctor Hermes,
01:10:12our patient populations at different VA
01:10:15sufficiently similar to compare across sites.
01:10:17I saw you answered in a text,
01:10:19but just so that everybody can hear it. Oh
01:10:23yeah, great so it's a great question, Matt.
01:10:26The so would you know I I talked about
01:10:29VA pushing out metrics and you know
01:10:32thanks for giving that analogy of sort
01:10:34of having data rain down on you 'cause
01:10:37it that's what it feels like sometimes.
01:10:39Thankfully, when we're compared
01:10:41against other facilities for a lot
01:10:43of the metrics they are weighted
01:10:45according to the facilities complexity.
01:10:47So we are. We are compared to other
01:10:50like facilities like Boston,
01:10:51another sort of larger academic Villiers.
01:10:53And to some extent.
01:10:55That characterization takes into account,
01:10:56you know, patient mix as well.
01:10:58So it's not. I don't think it's perfect,
01:11:01but it gives you a.
01:11:02It's much better than trying
01:11:04to do this in the dark.
01:11:07So yeah, thank you.
01:11:13Any other questions? We have attrition.
01:11:17We have two minutes, is that? Yeah, it looks
01:11:20like all the questions and chat are
01:11:22done and I don't see any hand sprays.
01:11:25So unless any come up now.
01:11:28OK, well give it a second and just to finish.
01:11:32I would say minute when I said it early,
01:11:36I think you now have a an idea of
01:11:39some of the work being done in
01:11:41the Department and we are very
01:11:44interested in future opportunities
01:11:47to highlight clinical practice.
01:11:49And so how we think about that?
01:11:52And then again, you saw, I mean,
01:11:54the excellence is just uncovered
01:11:56in in this kind of conversation
01:11:58exists throughout the Department,
01:12:00and so we would be very interested in
01:12:03any opportunities to further highlight
01:12:06kind of clinical work that people
01:12:08are doing in our vast Department.
01:12:10I would like to thank all the presenters,
01:12:14extraordinary job on pretty short
01:12:16notice and again thank you all,
01:12:18thanks specifically to Doctor Lee for.
01:12:21I got to be the face of this.
01:12:23She did all the work,
01:12:25so thanks again and thanks to everybody.