Internal Medicine Resident Longitudinal QI Project
A. OUTLINE & DUE DATES
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1. Understand the basics of PSDA cycles (Plan, Do, Study, Act)
 Take required pre-quiz: “UNM Internal Medicine Pre-QI Quiz” (DUE OCTOBER 30, 2014)
 Read and complete background and instructions sections of this document
 Complete online tutorial
2. Complete cycle 1 (6 months: October 2014 – March 2015)
 Start cycle 1 on October 1st, 2014
 Finish cycle 1 on March 31, 2015
 Complete cycle 1 worksheet
 Complete cycle 1 database
 Submit cycle 1 worksheet & database to QI chief (DUE APRIL 1, 2015)
 Take required post-quiz: “UNM Internal Medicine Post-QI Quiz” (DUE APRIL 1, 2015)
3. Start cycle 2 - this cycle will be completed in R2 year (6 months: April 2015 – September 2015)
 Start cycle 2 on April 1, 2014
1. Complete cycle 2 (6 months: April 2014 – September 2014)
 Continue cycle 2 from April last year
 Finish cycle 2 on September 30, 2014
 Complete cycle 2 worksheet
 Complete cycle 2 database
 Submit cycles 1 & 2 worksheet & database to QI chief (DUE OCTOBER 30, 2014)
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2. Complete cycle 3 (6 months: October 2014 – March 2015)
 Start cycle 3 on October 1st, 2014
 Finish cycle 3 on March 31, 2015
 Complete cycle 3 worksheet
 Complete cycle 3 database
 Submit cycle 3 worksheet & database to QI chief (DUE APRIL 1, 2015)
3. Start cycle 4 (6 months: April 2015 – September 2015)
 Start cycle 4 on April 1, 2015
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1. Complete cycle 4 (6 months: April 2014 – September 2014)
 Continue cycle 4 from April last year
 Finish cycle 4 on September 30, 2014
 Complete cycle 4 worksheet
 Complete cycle 4 database
 Submit cycles 3 & 4 worksheet & database to QI chief (DUE OCTOBER 30, 2014)
2. Complete cycle 5 (6 months: October 2014 – March 2015)
 Start cycle 5 on October 1st, 2014
 Finish cycle 5 on March 31, 2015
 Complete cycle 5 worksheet
 Complete cycle 5 database
 Submit cycle 5 worksheet & database to QI chief (DUE APRIL 1, 2015)
B. COMPLETION OF PDSA CYCLES THROUGH RESIDENCY
At the conclusion of your residency you will have completed 5 PDSA cycles. All resident QI projects will be
graded as pass/fail. You must submit all 5 PDSA cycles in order to graduate from the program.
PDSA cycle timeline
PDSA 1 (complete during intern year – due in April)
PDSA 2 (complete at beginning of R2 year – due in October)
PDSA 3 (complete during R2 year – due in April)
PDSA 4 (complete at beginning of R3 year – due in October)
PDSA 5 (complete during R3 year – due in April)
Intern year
 You must complete the pre-quiz before starting project
 You must complete and submit cycle 1
 You must complete the post-quiz after cycle 1
 You must start cycle 2
R2 year
 You must complete cycles 2 and 3
 You must start cycle 4
 You must implement a different intervention than that which was used in your intern year.
Meaning you cannot use the exact same intervention used during intern year for your R2 PDSA
cycles. You may, however, use your initial intervention as a springboard for a new idea or variation
on your original intervention.
 You must also use a new series of patients for this intervention.
R3 year
 You must complete cycles 4 and 5
 You can continue to use your prior intervention from cycles 3 and 4, however, you must refine your
intervention to hopefully improve your results
 You can continue to use the same patients from cycles 3 and 4 or choose a different set of patients
if you wish
C. GOALS & OBJECTIVES
The required longitudinal QI project is part of an ongoing QI curriculum during residency which includes QI
lectures at Thursday school, QI morning reports and QI journal club. The objectives of this project are:
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Increased awareness of health care systems and how to incorporate resources to optimize
patient care (system based practice)
Experience in investigation & evaluation of your patient care
Experience problem solving to improve the care you provide (Problem based learning and
improvement)
Improved knowledge of guideline/standard of care based practice (JNC8 or ADA guidelines)
Knowledge, experience, and exposure to QI methodology
Evaluation of data derived outcome measures and continuous process improvement
(PDSA)
Experience in translating guidelines into practice
Improved management of chronic diseases
Experience with implementation of Evidence Based Medicine into practice
D. BACKGROUND
1. Why are we doing this?
Per ACGME requirements, residents are required to “perform a longitudinal continuity clinic project
involving evaluation of that resident’s panel of patients and using performance data derived from their
panel.”
2. What are we trying to do?
The goal of this project is to implement small changes to your clinic practice and evaluate the
effectiveness of those changes. In doing so, you will adhere to ACGME requirements, learn about
implementing quality improvement projects and hopefully make an impact on your clinic and patients.
This will be accomplished using Plan, Do, Study, Act (PDSA) cycles.
3. What is a PDSA cycle/what are some online tutorials?
For an introduction on PDSA cycles, please watch this online video from the national quality center
(http://www.nqcqualityacademy.org/tutorial13/). The entire video is helpful, but the explanation of
PDSA cycles begins on slide 15.
Additionally, the Institute for Healthcare Improvement (IHI) has an excellent web tutorial on “How to
Improve” using PDSA cycles (http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx). In
particular please review the following sections: setting AIMS, establishing measures, selecting changes,
testing changes and implementing changes.
The most important things to remember from the video and web tutorial are how to determine the goal
(AIM) of a project, creating an intervention (CHANGE) and how to measure the intervention (MEASURE)
as well as how PDSA cycles work.
4. What do I need to do?
For this project we are focusing on management of chronic disease and implementation of
guidelines/standards of care into your practice. The chronic diseases that will be focused on are diabetes
and hypertension.
If your clinic is at 1st choice or UNM (SW mesa, 1209, NEH) – you will focus on DM2
If your clinic is at the VA – you will focus on HTN
For UNM and 1st choice clinics:
From your resident panel, patients with uncontrolled DM2 will be identified for you. You will then
review baseline A1Cs and select 5 patients (or more if you would like) for a proposed intervention. You
will review guidelines for treatment of DM2 (ADA standards of care) and select a standard of care you
would like to implement into your clinic (AIM). Then, with the help of a clinic mentor, you will
implement your proposal using PDSA methodology (CHANGE). At the end of each cycle, you will
compare baseline data (MEASURE) to data after implementation (e.g. A1C before and after intervention)
Cycles will be 6 months in duration .This project will continue throughout the duration of your residency
(R1-R3). During this process you will submit completed PDSA worksheets to the QI chief for evaluation
and to ensure these projects are completed.
For VA clinics:
From your resident panel, patients with uncontrolled HTN will be identified for you. You will then review
baseline blood pressure and select 5 patients (or more if you would like) for a proposed intervention.
You will review guidelines for treatment of HTN (JNC 8) and select a standard of care you would like to
implement into your clinic (AIM). Then, with the help of a clinic mentor, you will implement your
proposal using PDSA methodology (CHANGE). At the end of each cycle, you will compare baseline data
(MEASURE) to data after implementation (e.g. blood pressure before and after intervention).
Cycles will be 6 months in duration .This project will continue throughout the duration of your residency
(R1-R3). During this process you will submit completed PDSA worksheets to the QI chief for evaluation
and to ensure these projects are completed.
5. How do I get started?
Please read the PDSA cycle instructions detailed below.
6. What guidelines/standards of care do I use?
Recommended guidelines are attached to the email and can be found on the resident wiki
(http://unmimresident.pbworks.com) under Required Ambulatory QI Project, however, they are:
DM2 – ADA Executive Summary: Standards of Medical Care in Diabetes 2014
HTN – JNC 8
You may choose alternative guideline implementation but this must be discussed with an attending
prior to doing so.
7. Is there an example of this?
See the attached “PDSA worksheet (example).” In this example, the UNM resident looked at the ADA
guidelines and found that patients with DM2 needed “quarterly follow-up.” The resident then decided
on a small intervention - to personally call the patients to remind them of appointments - to help ensure
patients met the standard of care for quarterly follow-up. By doing this intervention, the resident’s AIM
was to lower A1C average by 20% in those patients which the resident called.
After completing a PDSA cycle, the resident found this intervention had not met the residents AIM and
decided on a different approach to achieve that AIM. The resident then did a need PDSA cycle (PDSA
cycle 2) and then reviewed the data.
8. Can I work in a group?
You can a form a group to develop an intervention and determine how to implement the intervention at
your respective clinic. However, each resident must complete a worksheet and database and each
resident must use their own patients from their panels.
9. What is the required survey?
In an effort to improve the required QI project residents will be required to take a pre-quiz before
starting the project and a post-quiz after each PDSA cycle. This will help guide the program and give us a
forum for feedback and improvement. Currently, only interns will be required to take the pre and post
quiz assessments. Please see the outline for quiz times and due dates.
The quizzes are required but will be anonymous. You will be given a unique identifier via email that
corresponds to your name. A list of all interns and their identifiers will be stored by an independent
party who will keep track of those who have completed the quizzes. The quiz graders will only see the
identifier and will not know the name of the quiz taker.
10. What is the website for the required survey?
PRE-quiz: “UNM Internal Medicine Pre-QI Quiz”
https://www.surveymonkey.com/s/NYNRLFV
Post- quiz: “UNM Internal Medicine Post-QI Quiz”
https://www.surveymonkey.com/s/NB5PKQV
11. Where can I find a list of patients for my intervention?
Please contact the following individuals for your respective list of patients:
SW Mesa:
Alisha Parada, MD or
Anita Sanchez
1209:
Jessica Bigney, MD or
Lorraine Martinez
NEH:
Allen Adolphe, MD
VA :
Heather Brislen, MD or
Greg Fotieo, MD
1st Choice:
Shaun Aries, MD
12. What if I have questions?
Please email the QI chief with any questions you may have. Additionally, your clinic mentor can also help
answer questions. Many residents have found that other residents may serve as resources for their
project.
E. PDSA CYCLE 1 INSTRUCTIONS
PRE-PLAN - INTERNS ONLY
 Complete required online pre-quiz
 Complete online video and web tutorial about PDSA methodology
 Identify a clinic attending that can serve as a mentor for your project
 Review sample PDSA worksheet
PLAN
 Gather your list of identified patients for intervention (see #11 on background for details)
 Review recommended guidelines for your respective clinic
o DM - ADA standards of care
o HTN - JNC 8
 Decide which guideline/standard of care to implement
 Define your goal (AIM)
 Discuss with attending plan and how to implement
 Obtain and review baseline clinic data
 Select 5 patients (or more) for intervention
 Begin patient database form
 Complete “PLAN” portion of PDSA cycle worksheet
DO
 Implement your project into your clinical practice (CHANGE)
 Record observations, obstacles and complications on PDSA cycle worksheet
STUDY AND ACT
 Record 6 month data on the patient database form
 Analyze baseline and 6 month data (MEASURE)
 Complete remainder of PDSA worksheet
 Evaluate if your aim was met:
If No: Identify specific changes that need to be implemented to meet your aim
If Yes: Discuss how you can broaden the scope of your project (add additional guidelines/standards
to your practice, expand to other providers)
Regardless: Identify obstacles/complications and discuss ways to avoid these for next cycle. Record
your analysis & discussion on PDSA Worksheet.
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Submit your completed PDSA cycle worksheet and patient database form to the QI chief by the
designated time under the “Outline” portion of this document
Complete required online post-knowledge survey – INTERNS ONLY
F. PDSA CYCLE 2 INSTRUCTIONS
PLAN
 Review prior data from PDSA cycle 1 and find ways to improve intervention or ways to improve
implementation
 Complete “PLAN” portion of PDSA cycle worksheet
DO
 Implement your project into your clinical practice
 Record observations, obstacles and complications on PDSA cycle worksheet
STUDY AND ACT
 Record data on the patient database form
 Analyze baseline, 6 month and 12 month data
 Complete remainder of PDSA cycle worksheet
 Submit your completed PDSA cycle worksheet and patient database form to the QI chief by the
designated time under the “Outline” portion of this document
 Complete required online post-knowledge survey – INTERNS ONLY
G. PDSA CYCLE 3 & 4 INSTRUCTIONS
Essentially, cycles 3 and 4 function in a similar manner as cycles 1 and 2. Therefore, the instructions from
cycles 1 and 2 apply for cycles 3 and 4.
However, you must implement a different intervention than that which was used in cycles 1 and 2.
Meaning you cannot use the exact same intervention used previously. You may, however, use your
initial intervention as a springboard for a new idea or variation on your original intervention.
You must also use a new series of patients for this intervention.
H. PDSA CYCLE 5 INSTRUCTIONS
Cycle 5 is unique in that it not linked to a second component. The goal of cycle is 5 is to refine you
previously used intervention from cycle 3 and 4 to hopefully improve your outcomes.
You can continue to use your prior intervention from cycles 3 and 4; however, you must refine your
intervention.
You can continue to use the same patients from cycles 3 and 4 or choose a different set of patients if
you wish.
PDSA Worksheet
Resident name:
PDSA cycle #:
Start date:
End date:
Plan
PDSA
Cycle
Outline
1. What is the identified problem?
2. What is the aim?
3. What is the specific component of
the guidelines used?
4. What is your current
improvement process?
Attending/Advisor:
Do
Carry out small scale test
of change with the goal of
meeting the aim by
implementing the chosen
standard of care
component into practice.
PDSA cycle #:
Start date:
End date:
Study
Gather data and
analyze impact of
change
Implement plan into clinic
practice for those
identified patients
Briefly describe your plan
for the implementation of
the intervention.
Cycle #
1.
Baseline data:
2.
1st 6 months data:
3.
4.
Cycle #
1.
2.
3.
4.
2nd 6 months data:
Act
How do you interpret
these results?
Was your goal met?
If not why?
If your goal was met,
then are you meeting
national standards?
What can you add to or
improve to help meet
your goal or meet
national standards?
Patient Database
UNM Clinics
Resident Longitudinal Continuity Clinic Quality Improvement Project
Please record which patients you are following and their HgA1c at baseline, 6 months, and 12 months and
then calculate the average HgA1c of the panel.
Resident name:
Attending/Advisor:
PDSA cycle number:
Start date:
End date:
Patient
Name
Patient
MRN
Baseline
HgA1c
Average HgA1C at baseline:_____
6 months
HgA1c
12 months
HgA1c
Average HgA1C at 6 months: _____
Notes
Average HgA1C at 12 months:_____
Patient Database
VA Clinics
Resident Longitudinal Continuity Clinic Quality Improvement Project
Panel database sheet: Please record which patients you are following and their BP at baseline, 6 months, and
12 months and then calculate the average BP of the panel.
Resident name:
Attending/Advisor:
PDSA cycle number:
Start date:
End date:
Patient
Name
Patient
MRN
Average BP at baseline: _____
Baseline
BP
6 months
BP
12 months
BP
Average BP at 6 months: _____
Notes
Average BP at 12 months:_____
PDSA Worksheet (EXAMPLE)
Resident name: Goot
PDSA cycle #:1
Start date: Oct 1
End date: March 30
Plan
PDSA
Cycle
Outline
1. What is the identified problem?
2. What is the Aim?
3. What is the specific component of
the guidelines used?
4. What is your current
improvement process?
Attending/Advisor: Jernigan
Do
Carry out small scale test
of change with goal of
meeting the Aim by
implementing the chosen
standard of care
component into practice.
PDSA cycle #:2
Start date: April 1
End date: September 30
Study
Act
Gather data and
analyze impact of
change
How do you interpret
these results?
Was your goal met?
If not why?
If your goal was met,
then are you meeting
national standards?
What can you add to or
improve to help meet
your goal or meet
national standards?
For my PDSA project, I will
ensure quarterly follow up
appointments and personally
call these patients to inform
them of their appointment. I
will assess my baseline
average A1c values for these
7 patients and compare
results every six months. My
goal is to lower the average
A1c of these 7 patients by
20% in six months.
(September/October
through March/April)
Baseline data:
Average A1c for the
identified 7 patients in
my panel was 11.8%
My aim was not met.
I identified medication
compliance and lack of
time during clinic visit to
educate patients as a
barrier for improvement.
I will add a follow up
phone call one week after
each quarterly visit and
discuss, encourage, and
educate these patients to
improve med compliance.
For the second PDSA cycle, I
will ensure quarterly follow
up and a follow up phone
call dedicated to discuss DM
education on medication
compliance. My aim will be
to decrease A1c by an
average of 20% in these 7
identified patients from their
average baseline average
A1c of 11.8%. (April/May
through
September/October)
2nd 6 months data:
After 2 PDSA cycles
(12months) the average
A1c was 9.1%.
Implement plan into clinic
practice for those
identified patients
Briefly describe your plan
for the implementation of
the intervention.
Cycle# 1
1. I identified 7 patients with poorly
controlled DMII (A1c>9) that have not
had adequate follow up. I will use these
patients in my PDSA project.
2. Improve the average of the identified
patient panel A1c by 20% over the next
6 six months.
3. According to Standards of Medical
Care in Diabetes – 2012 (page s18),
uncontrolled DMII needs follow up at
least quarterly
Cycle# 2
4. I will ensure quarterly follow visits and
call the identified patients to ensure
awareness of next appointment (the 7
patients with A1c >9%)
1. Poorly controlled DMII, A1c not at
goal, I identified lack of quarterly follow
up and educational time about
medication compliance as barriers for
me not meeting my aim.
2. Goal A1c 9.4 (20% decrease form
baseline A1c)
3. Implementation of quarterly follow
up (page S18) and education (page S16)
4. I will ensure quarterly follow up with a
reminder phone call for these patients,
and I will add a follow up phone call
after each quarterly visit to educate and
encourage medication compliance
1st 6 months data:
After six months, the
average A1c was 10.0%,
the goal average A1c
was 9.4%.
My aim was met. I plan to
discuss ways to enact this
project on a larger scale
and problem solve ways
for this to be sustainable
on a large scale.
I plan to continue this
PDSA cycle for the next 12
months and complete 2
more cycles.