Wksp 307_Mariotti - Alliance for Academic Internal Medicine

Ambulatory Redesign in 

Residency Training 

PCMH Model 

APDIM 

Spring 2011 

Jennifer Mariotti, DO, FACP 

Workshop / Presentation 

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■ 

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Goal - Provide an individualized map for residency practice and 

ambulatory educational reform grounded in quality improvement 

Template provided 

– Work through the document as we discuss different topics 

– Consider your program / experience 

• Action plan on potential changes / learnings 

– Map out your tangible “to do” next steps 

Collaborative learning 

– Open forum / sharing of ideas and concepts 

Change your current framework 

– Cause you to think differently about your residents ambulatory experience 

– Reflect honestly and openly 

• Training environment and the culture for improvement

■ Key areas? 

Clear Expectations 

■ One major take away? 

■ Review of our learnings / literature 

■ Tools utilized / Resources 

My Background 

■ Related Experience 

– Associate Program Director 

• Internal Medicine 

• PD – Osteopathic Internship 

– Medical Director – Residency Clinic 

• PCMH / Residency Collaborative Participation 

– Quality Leader 

• Department of Medicine - LVHN 

• IHI OS GME Interest Group Facilitator

■ 

Overview 

National call for residency redesign - ambulatory education 

■ Key element - Develop a core model – 

– Quality improvement culture within residency practice 

– Achieve high quality clinical outcomes in an educational environment 

■ 

How do you do this? 

– Integrate residents into the quality improvement mechanism 

• Achieve sustainability 

– New models of resident scheduling 

– Continuity of care / Modified open access 

– EMR implementation 

– Patient centered medical home (PCMH) model concepts 

• Certification – Should you / Why would you / When 

– Key quality data metrics – Resident considerations 

– Integration of PBLI and SBP competencies 

– Balance / navigate system change vs. educational opportunities 

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Charting Course - Roadmap 


– Changes in practice of medicine 

• Chronic care / population p management – Separate outpt / inpt 

– Work hour restrictions 

– Shortage of PCPs 

– Increasing focus on patient safety 

Educational Experience 

– Dysfunctional residency practices 

– Poor clinical experiences 

– Low ambulatory primary care matriculation 

– Emphasize inpatient medicine / Ambulatory is an “add on” 

– Strong use of “clinics” 

• Primary venue for ambulatory medicine 

• Common – dysfunctional settings 

The “ICU” of ambulatory care 

1 Meyers F et al.Redesigning Residency training in internal medicine: The Consensus Report AAIM Redesign Task Force. Academic Medicine. 2007;82(12):1211-1219. 

2 Fitzgibbons J,et al. Redesigning Residency education in Internal Medicine: APDIM position paper. Annals of Internal Medicine. 2006;144(12):920-926. 

3 Batalden P,et al General Competencies and Accreditation in Graduate Medical Education. Health Affairs. 2002; 21(5):103-111. 

4.Holmboe E,et al. Reforming Internal Medicine Residency Training: A Report from SGIM JGIM. 2005;20:1165-1172. 

5 Keirns C. et al. The unintended consequences of training residents in dysfunctional setting. Acad Med. 2008;83:498-502.

Quality Improvement 

“Every system is perfectly designed to get 

the results it gets” 

■ 

■ 

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Mechanism for Change 

QI Committee 

Practice Transformation 

– DRIVER: On your own, Collaborative, Consultation 

Working group 

– Residency versus Practice 

• Focus defines the members 

Regular meetings 

– Leader – QI experience / ownership 

• Integrates with Residency / Practice / Faculty 

Prioritize projects 

– Start small and grow as you develop 

– Complete full PDCA as a group 

• Encourages sustainability 

– Tangible metrics / monitor and showcase


■ Resources 

– Infrastructure – People / Knowledge 

• Faculty / key leader development 

• Tools for QI 

– Lean methods / A3 concepts / etc. 

– Resources – 

» IHI open school 

» ACMQ – American college of medical quality 

» APDIM 

»TJC 


■ Resources 

– Infrastructure - Team 

• Key areas should be represented 

• Want engagement (sometimes opponents are best) 

• Multiple residents / consistent presence 

• Faculty – Core if possible 

– Ensure consistent and productive meetings 

• Define goals together / need a safe culture


■ Resources 

– I/S needs 

• Analyst / Support liaison 

– Key to success – need strong relationship 

• Database for enterprise information 

• Business Intelligence tools for analysis 

• Understanding of data management in system 

■ 

Redesign - What do you do? 





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– Balance / navigate system change vs. educational opportunities

Ambulatory Redesign 

■ Structure – People 

– Workforce distribution / Operational structure 

■ Process: 

– Scheduling Model (*Specific Linear Order) 

• Resident Schedule 

– Team Model 

• Patient Schedule – Open Access model 

– Continuity 

Scheduling 

■ Core Structure – Residency 





– Continuity

Question 

Does your program follow the traditional 

one clinic session / week model? 

■ Yes 

■ No 

Question 

Are you satisfied with that model? 

■ Yes 

■ No 

■ Don’t know

Resident Scheduling 

■ 

■ 

■ 

Separate inpatient and outpatient 

Strengthen ambulatory exposure / emphasis 

– Make outpatient medicine IMPORTANT 

Immersion training 

– Long block versus weekly concept 

• Year long; 4:1; 4:2 Model 

– Example template - Review 

■ 

Model selection depends on inherent program 

requirements / needs 

Example Long-Block Schedule 

1 Warm E, et al. The ambulatory long block; An ACGME EIP. JGIM 23 (7); 921-6.

Example 4:1; 4:2 Schedule 

1 Mariotti J et al The 4:1 Schedule; A novel template. JGME. 12/10; 541-7. 

2 Shalaby M et al. Developing new models of ambulatory training. AAIM Insight 8:3. 12-17. 

The Details - 

Inpatient Team Structure

4:1 Theory - CMO Matrix 

Context Mechanism Outcome 

Separation of inpatient and 

outpatient experiences for 

the residents 

Residents would have 

dedicated weeks in clinic 

Residents wouldn’t have to 

work in both venues at 

once 

Extra time in clinic would 

allow residents to learn 

about the clinic process 

- Less internal conflict 

- Less frustration 

- Less “tense” environment 

- Better work satisfaction 

- More focused learning 

- More efficient care 

- More effective care 

- Better satisfaction 

A complicated schedule - 

Residents split into five 

different cohorts 

Residents wouldn’t be 

pulled to clinic 

More “slots” for patients 

Resident staggering 

They would have more 

focused time on rotations 

- Enhanced continuity 

- Overlap on inpatient care 

-“Team”-feel in clinic 

-Tougher to find “switches” 

- Better rotation education 

- More time with preceptors 

4:1 Schedule Results 

Educational Environment Learnings 

• Better sense of “team” in clinic 

• No pressure to “get out of clinic” 

• Allowed residents to focus on clinic patients 

• “Immersion” model resident engagement 

in change / improvement efforts 

• Cons: 

• Difficult for short term follow up 

• Requires a team model for cross coverage

Immersion Training 

(Ambulatory Block) Outcomes 

■ Consistent research findings 

– Satisfaction improved 

• Residents, patients, faculty 

• Enhanced ownership and engagement 

– Quality Measures improved 

– Continuity / No-Show rates improved 

■ PD / Resident perspective article 

1 Warm E, et al. The ambulatory long block; An ACGME EIP. JGIM 23 (7); 921-6. 

2 Mariotti J et al The 4:1 Schedule; A novel template. JGME. 12/10; 541-7. 

3 Shalaby M et al. Developing new models of ambulatory training. AAIM Insight 8:3. 12-17. 

4 Thomas K et al. Alternative approaches to ambulatory training: Resident and PD perspectives. JGIM 24(8):904-10. 

Open Collaborative Discussion 

■ Other scheduling models?

Scheduling 






– Continuity 

Question 

Does your outpatient resident practice function 

in a team model? 

■ Yes 

■ No 

■ Don’t know

Question 

If you don’t currently use a team model, did you 

try it in the past and find it didn’t work? 

■ Yes 

■ No 

■ Don’t know 

Team Development 

■ Clinical model 

– Team development 

• Three core resident teams (a, b, c) 

– (+/-) Staff linkage 

• Delineation of administrative work 

• Patient panels defined * Referenced later 

– Dedicated preceptors per team 

• Allowed for Attending continuity 

• 3 residents:1 faculty ratio 

– Selected faculty practice at site

Ambulatory Scheduling 

■ Clinical model 

– 6 sessions of clinic, 3 sessions other ambulatory 

LVPP 

Team schedule 

Session Monday Tuesday Wednesday Thursday Friday 

AM AB BC AC BC AB 

PM AC AC Education AB BC 

Ambulatory Scheduling 

■ Each team 

– All within same 4:1 cohort 

– Integration of PGY years 

– Separate clinical “space” 

■ Consideration for staffing linkage

1 Hern T. Patient Care management teams: improving continuity, office efficiency, and teamwork in a residency clinic. JGME. 09/09. 67-72 

Provider Team Model 

■ Research Findings 

– Improvement in ratings of: 

• Learning opportunities 

• Quality of teaching 

• Job satisfaction 

• Employee Autonomy 

• Staff roles 

• Staff attitudes toward residents 

– Patient care management teams 

• Continuity it of patient t 

care 

• Office efficiency 

• Team communication 

– Essential for continuity – Residency model 

1 Roth L, Effects of implementation of a team model on physician and staff perceptions of a clinic’s organizational and learning environments. FMed, 2009; 41(6):434-9. 

2 Hern T. Patient Care management teams: improving continuity, office efficiency, and teamwork in a residency clinic. JGME. 09/09. 67-72 

3 Kennedy f. Implementation of an open access scheduling system in a residency training program. FMed 2003; 35(9):666-70


■ Team model considerations 

Scheduling 






– Continuity

Question 

Are you familiar with the concept of an open 

access model (or a modified open access)? 

■ Yes 

■ No 

■ Maybe 

Question 

Does your outpatient resident practice schedule 

using an open access model (or modified)? 

■ Yes 

■ No 

■ Don’t know

(Modified) Open Access 

■ 

■ 

■ 

■ 

Defined: “Doing today’s work today” 

Element of PCMH (access) 

Scheduling model 

– Traditional Open Access – 

• Appointments are open 48 hours prior 

• No advanced booking 

– Modified Open Access – 

(Preferred in GME due to limited availability) 

• Some advance appointments 

– 5 week follow up / 2 week continuity / 24 hr prior acute 

• Consistent ambulatory scheduling allows for continuity 

– An appointment is an appointment – focus is on continuity 

A REMINDER SYSTEM is the key for chronic population continuity! 

– How this reminder system functions can define the success of open 

access model 

■ Benefits: 

Modified Open Access 

– Allows for acute changes in schedules 

• Necessary with residency demands 

– Decreases no – show rates 

• No-Show rate – Cut in ½ 

– Consistent t experience across practices 

• Optimizes educational exposure 

– More patients seen / session

Open Access Model 

■ Tangible Process 

– Have resource handouts on how to 

transition 

Open Access Model 

■ Research Findings 

– Charges / revenues increased 

• Visits per FTE, lower no show rate 

– Total monthly volumes – increase 

– Improved satisfaction 

• Patient / Provider 

– Reduce appointment delays 

– Improved patient-PCP match 

1 Kennedy J. Implementation of an open access scheduling system in a residency training program. FMed 2003; 35(9); 666-70 

2 Belardi F. A controlled trial of an advanced access appointment system in a residency family medicine center. Fmed 2004;36(5):341-5

Modified Open Access 

(Continuity Focus) 

■ Need assigned preferred providers – 

– How many have assigned panels? 

• What size panel for your residents? 

• How do you maintain assignments? 

– Reports Run / Excel management / EMR assistance 

• Correct assignment is INTEGRAL to assessing continuity with 

a provider – Requires oversight! 

– Continuity – priority with chronic conditions 

• Reminder system / preferred provider system can be 

structured to optimize your resident experience 

■ 

A helpful method to integrate PCMH principle 

(primary provider) within GME context 

Patient / Provider Continuity 

■ Are you able to maintain continuity 

between providers and patients? 

– Yes 

– No 

– Not sure

Patient / Provider Continuity 

■ Do you measure continuity? 

– Yes 

– No 

– Not sure 

Continuity 

■ Discussion on barriers to continuity 

■ Discussion on how you make it work

■ MMCI 

Continuity Measurement 

■ Provider Index 

■ Patient Index 

■ Chronic condition patients vs. everyone 

■ Continuity is necessary for provider 

population data to be “meaningful” 

1 Darden, P. Comparison of continuity in a resident versus private practice. Peds 2001;108;1263-1268 

2 Breslau N. Continuity Reexamined: Differential impact on satisfaction with medical care for disabled and normal children. Medical Care April 1982;Vol XX, No 4; 347-359 

3 Morgan E et al. Continuity of care and patient satisfaction in a family practice clinic. J am Board Fam Pract 2004;17:341-6. 

Continuity Research 

■ Increased satisfaction 

– Patient / Provider / Staff 

■ Decreased resource utilization / costs 

■ Decreased ED utilization 

■ Improved chronic disease recognition 

■ Decreased hospitalizations 

■ Improved clinical outcomes 

1 Saultz J, et al Interpersonal continuity of care and patient satisfaction: A critical review. Annals of family medicine. 2004;2(5):445-451. 

2 Becker M, et al A field experiment to evaluate various outcomes of continuity of physician care. AJPH. 1974;64(11):1062-1070. 

3 Raddish M,et al Continuity of care: Is it cost effective? Am J Managed care. 1999;5:727-734. 

4.Rosenblatt R,et al The effect of the doctor patient relationship on ED use among the elderly. Am J Public Health. 2000;90:97-102. 

5.Gill J,er al The effect of continuity of care on ED use. Arch Family Medicine. 2000;9:333-338. 

6.Koopman R, et al. Continuity of care and recognition of diabetes, hypertension and hypercholesterolemia. Arch Internal Medicine. 2003;163:1357-1361. 

7 Gill J, Mainous A. The role of provider continuity in preventing hospitalizations. Arch Family Medicine. 1998;7:352-357. 

8.Cabana M, Jee S. Does continuity of care improve patient outcomes? The journal of family practice. 2004;53(12):974 - 980.

Continuity Research 

■ Chronic care patients 

– Continuity means the most 

■ Acute care 

– Continuity less important 

■ Team based continuity ~ way forward 

– Need to balance fast access and ability to 

consult a known and trusted doctor 

1 Mainous A. Advanced access, open access, and continuity of care: should we enforce continuity? FMed 2009;41(1):57-8. 


■ Open Access considerations 

■ Continuity considerations

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Structure 

– EMR Tool 

Process / Workflows (*Specific Linear Order) 

• Simple usage / information entry 

– Workflow learning 

• Focusing entry of data (meaningful locations) 

– OBS fields / trackable fields 

• Report Generation / Data Audit / Feedback 

• Clinical Decision support tools (meaningful use) 

– Templates / Clinical reports

EMR 

■ What status is your practice with EMR? 

– Not implemented, no plans to do so 

– Not implemented, gearing up soon 

– Implemented < 1 yr ago 

– Implemented 2-5 yrs ago 

– Implemented >5 yrs ago 

EMR 

■ If implemented, how do you feel about 

EMR? 

– Hate it! 

– Necessary Evil, some pros and cons 

– Love it! 

– Not sure

■ First Year 

EMR Utilization 

– Simple usage / information entry 

• Workflow learning 

– Ensure workflows are defined (standard) 

• Review information with residents regularly 

– Difficult to expect learners to navigate 

Clinical Decision Support tools at this 

stage

EMR Implementation 

■ Second Year (meaningful use) 

– Focusing entry of data 

• Meaningful locations 

– OBS fields / trackable fields 

– Report Generation 

• Requires continuity * if using population data 

– Highly recommend individualized feedback 

– Data Audit / Feedback 

• Focuses residents on where to enter data to get “credit” 

– Will discuss at PCMH tenets / PBLI

EMR Implementation 

■ Second – Third Year 

– Utilization can move further 

• Clinical Decision support tools 

– Meaningful use 

• Templates / Clinical reports 

– Asthma / Lipids / Preoperative / etc. 

– Educational Tool 

• Solidify EBM guidelines / concepts 

• Guide treatment algorithms

EMR Positive Considerations 

■ Positive Considerations: 

– Personal teaching files 

– Performance reporting 

• Outcome / Procedure tracking 

– Documentation 

• More detail usually reported 

• Electronic history prompts optimized 

Peled J. Do electronic health records help or hinder education? PLOS Medicine. May 2009; 6(5); 1-5. 

EMR Educational Tool 

■ Research 

– Point of care education 

• New knowledge best assimilated when 

learned in context 

• Electronic order sets / template notes 

– Computerized CDS system 

• Any system to assist in decision making 

– Research, QI education and core 

competencies 

1 Keenan C. EMRs and their impact on resident and medical student education. Academic Psychiatry 2006;30:522-527

EMR Research / Attitudes 

■ Observations / Learnings 

– EMRs bypass synthesis of clinical information 

• Attending knows all the case elements 

• Prevents learners from presenting patient data in words 

– Creates an educational exercise 

– Could cause unprocessed information transfer 

– EMR is a distractor 

• “Staring into a screen” 

• Less interaction among patients / faculty 

• Faculty swiftly click through a chart to answer questions 

rather than pose them to learner 

– Robs them of questions that occur to a more seasoned 

clinician 



■ Observations / Learnings 

– Copy and Waste 

• Potential source of error / waste in EMR 

– “Readily available security” 

• Not checking data in advance because quick 

access is possible 

• Prevents opportunities to explore things on 

their own 

Peled J. Do electronic health records help or hinder education? PLOS Medicine. May 2009; 6(5); 1-5.


■ Challenges / Barriers to EMR adoption 

– Time it takes to enter information 

• Paper compared to EMR 

– Requires exact diagnosis / exact lab testing 

– Double work – paper then EMR 

– Intrusion on the patient / provider interaction 

– Potential impact on quality documentation 

• Could be worse if time is an issue 

• Ensuring note is “accurate” 

– Not documenting what wasn’t done 

• Strongly monitor the use of templates! 

1 Ilie V. et al. Paper versus Electronic: Challenges associated with physicians usage of EMRs. Proceedings of the 40 th Hawaii IC on Social systems - 2007 

EMR Educational Considerations 

■ Educational Elements: 

– Faculty should actively avoid referring to source 

data during presentations 

– Faculty / learner / patient interactions should be 

fostered in conducive environment 

• Encourage face to face encounters 

– Copying and pasting 

• Could be banned 

Peled J. Do electronic health records help or hinder education? PLOS Medicine. May 2009; 6(5); 1-5.

EMR Educational Considerations 

■ Educational Elements: 

– Learners (Students / GME) should be 

encouraged to actively check labs prior to 

presentations 

– Incorporate teaching of EMR specific 

communication to learners 

• Introduce computer / adjust geography / 30 

second rule / share data with patients 


■ EMR Usage 

Open Discussion 

– Discussion on Educational benefit 

– Goal – 

• Educational development versus system 

redesign for Quality integration 

i 

– Opportunities for data / audit feedback


Data considerations for resident learners: 

■ 

■ 

■ 

Ensuring resident’s personal data / data ownership 

– Will likely need team model for some metrics (pop based) 

– Continuity is critical before data can be delivered 

Point of care data metrics – alternative for GME 

learners 

– E.g. – foot exams / DM patient 

• Staff education / performance of monofilament 

• Resident performance and assurance of completion 

• Can review data and ensure done on all patients each week 

Population management versus individual 

management 

– Each carries different considerations 


General data considerations: 

■ Process versus Outcome data metrics 

– Did they “do” the right thing? 

• DM Foot exam 

• Vaccination completion 

– Flu / Pneumovax – DM patients 

• Preventive maintenance 

– Mammography tracking 

• Can be facilitated by EMR / prompting / clinical decision 

support tools


■ Process versus Outcome metrics 

– Did they achieve a better “outcome” 

• Enhanced glucose control 

– Better HbA1C control in a population 

» Truly measure after a “process” change 

» Clinical case mgr involvement 

• Patient satisfaction / Provider satisfaction 

– Satisfaction surveys / Press Ganey surveys 

• Decreased no – show rates 

– Implementation of open access, use of no-show letters, 

defined protocol that was enforced, enhanced 

communication with patients (call center), notification on 

entering practice

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■ 













■ Structure 

– Patient Centered Medical Home 

■ Process = System change ~ Practice-wide QI 

mechanism 

– Population management 

– Performance reporting / PBLI 

– Balance of education versus system support

PCMH 

Is your residency practice certified? 

■ Yes 

■ No, but working on it 

■ No, no plans right now 

■ Not sure 

Patient Centered Medical Home 

AAFP, AAP, ACP, AOA: March, 2007 

■ Personal Physician 

■ Physician directed medical practice 

■ Whole person orientation 

■ Care – coordinated and/or integrated 

■ Quality of care / culture of patient safety 

■ Enhanced access to care 

■ Payment Reform 

http://www.pcpcc.net/

■ Are you doing it 

BUT… 

SYSTEMATICALLY? 

– And 

ARE YOU GETTING PAID FOR IT? 

- And 

ARE YOUR LEARNERS INVOLVED? 

PCMH – Associated with: 

■ Better outcomes 

■ Reduced mortality 

■ Fewer preventable hospital admissions 

■ Lower utilization 

■ Improved patient compliance 

■ Lower medicare spending 

Evidence of Quality Summary Report, 2009 (PCPCC)

National Committee for Quality 

Assurance (NCQA) 

■ PPC – PCMH Recognition 

– Level 1, 2, and 3 

■ NCQA supported by 

– AAFP / AAP / ACP / AOA 

– Washington based not-for-profit 

healthcare QI organization 

The Joint Commission 

■ Primary Care Home Option 

– Accreditation of ambulatory health care 

organizations 

– Working with Medicare / Medicaid / Insurance 

carriers to ensure standards will allow for 

recognition as PCH provider 

■ Starting in July 2011 

– Standards to be released in November ‘10, final 

standards in March ‘11 and on-site surveys in 

July ’11.

PCMH Focus 

■ Application process 

– Online survey to upload documents 

– 9 part process to accreditation 

• PPC 1 - Access and communication 

• PPC 2 - Patient tracking and registry 

• PPC 3 – Care management 

• PPC 4 – Patient self-management support 

• PPC 5 – Electronic prescribing 

• PPC 6 – Test tracking 

• PPC 7 – Referral tracking 

• PPC 8 – Performance reporting and improvement 

• PPC 9 – Advanced electronic communication 

PCMH Focus 

■ Application process 

– Documentation supporting performance 

– Includes: 

• Protocols / policies 

• Data reports (% demographics on charting, % 

active problem list, etc) 

– EMR is integral with this area 

• Screen shots of EMR / examples of 

documents that show protocols used 

• Population management reports / how used

PCMH Focus 

■ Collaborative insights 

– PAFP Family medicine residency 

collaborative 

• ~30 residency programs in state 

– Tandem PA-Governor collaborative 

– Shared resources / documents 

– Coaching provided / guidance 

– Goal – application submission 

PCMH Focus 

■ 

■ 

Resident involvement 

– In application process – limited # of resident champions 

– Should ideally be through core QI / PI mechanism in 

practice or through feedback related to initiative 

PCMH process facilitates QI / PI to occur – resident 

integration should be downstream of actual 

certification process but in the middle of the change 

efforts themselves 

– Understanding of process and certification is encouraged


■ Learner involvement observations 

PLAN / DO 

– Group project / Strong faculty mentorship 

– Develop an infrastructure to allow them to be a 

member and not have to “lead” the team 

– “Buy in” to the project 

– Consistent interaction with lead faculty to guide 

observations and progress 

– Interactions allow for experiential learning 


■ Learner involvement observations 

CHECK (DATA) 

– Needs to be “specific” 

• Provide the residents with key directions on where and 

what needs to be done 

• For example – review this excel file and perform X 

– Needs faculty mentoring 

– Data management / interpretation 

– Chart reviews 

– Database maintenance


■ Learner Involvement 

ACT 

– Feeding back data / changes to occur 

– Consistent communication key 

– If personal initiative – have residents be 

the ones to deliver the message 

PCMH Focus 

■ Do I NEED to certify my residency 

practice as a PCMH? 

– Proactive approach – health care reform 

reimbursement model 

– Core concepts of practice transformation 

are the ultimate t goals 

• Areas that are emphasized align well with 

Residency Ambulatory Redesign 

– Can be used as a model / reason for reform

PCMH Tenets & 


• PPC 1 - Access and communication 

– Scheduling / Modified Open Access Model 

• PPC 2 - Patient tracking and registry 

– Assignments of Preferred Provider / EMR Reporting 

• PPC 3 – Care management 

– System support providing population management 

• PPC 4 – Patient self-management support 

– Resident involvement in group visit education 

• PPC 5 – Electronic prescribing 

– EMR Provided 

PCMH Tenets & 


• PPC 6 – Test tracking 


• PPC 7 – Referral tracking 


• PPC 8 – Performance reporting and improvement 

– Data feedback to residents / PBLI / SBP 

• PPC 9 – Advanced electronic communication 


d 

■ EMR can be viewed as independent 

educational tool as well

PCMH Certification Assistance 

■ Collaborative Support 

– State Sponsored / ACP / IPIP 

■ ACP Medical Home Builder 

– acponline.org/medicalhomebuilder 

■ Consultants 

■ TransforMED 

– http://www.transformed.com/ 

Balance System Change vs. 

Educational Development 

■ Hand-in-Hand Model 

■ System redesign is future of primary care 

– Chronic Care Model 

– Learning how to change a larger system 

■ Teaching residents how to navigate 

– Use Clinical Decision Support Tools 

– Focus on medicine and allow system to support 

the other “tasks” 

• “Tasks for Staff / Decisions for Physicians” 

– (Dr. Warning)

Personalized Template 

■ What kind of QI mechanism do you 

have currently in your practice? 

– Who is your identified leader of QI? 

■ Check off areas that you might find 

helpful 

■ Map out your action plan for follow up 

■ Concepts / Ideas – “Take-away” 

Thank you for your time! 

■ Questions / Thoughts

Wksp 307_Mariotti - Alliance for Academic Internal Medicine

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