Article Text

  1. M. S. Horton,
  2. M. Conde
  1. The University of Texas Health Science Center at San Antonio, San Antonio, TX


Background The Institute of Medicine's 2001 report Crossing the Quality Chasm describes a health care system delivering care to patients below expectations set forth from evidence-based medicine. ACGME responded by requiring residency programs to teach residents the skills needed to analyze their own practice patterns to improve the quality of care that is delivered to patients the core competency, practice-based learning improvement (PBLI).

Methods Eleven internal medicine categorical housestaff rotated on the ambulatory care outpatient month between July and October 2005. The housestaff were introduced to the concepts of performance measures, quality improvement, and tools such as clinical reminders. Each resident was then given a list of diabetic patients from their patient panel to perform a chart review of 5 random patients. The following items are examples of data collected for each patient: age, duration of diabetes, tobacco use, pneumovax, aspirin use, results of last foot exam.

Results The housestaff identified in their five diabetic patients consistent areas in need of improvement in order to propose a commitment to change. These proposals were grouped into two categories: specific provider behavior and systems issues. Twelve instances of specific provider behavior and 7 system issues were noted. For specific provider behavior, three housestaff acknowledged the need to provide their patients with aspirin. Seven housestaff stated improvement in history and physical examination skills were needed. Inquiring into the time insulin is taken by the patients, their reasons for noncompliance, and completion of the monofilament foot exam are examples of these skills. Issues with the health care system could be further categorized into decreased awareness of institutional resources or delays with consultants. For instance, several residents did not realize that patient visits did not require a physician face to face visit but could be done with a telephone call or a visit to an RN. They were also not aware of diabetic specialty clinics or diabetic education classes.

Conclusion With the realization in the 21st century that the health care delivered is of poorer quality than should be, organizations such as the ACGME have required implementation of quality improvement initiatives. In this project, housestaff acknowledged areas of their own behavior, knowledge, and skills that need to be improved but also barriers of the health care system that result in patients not receiving optimal care. Evolution of this curriculum will continue to occur as the residents will reanalyze their patient panel to determine if their commitment to change directed them toward closing their own quality chasm.

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