![The Ambulatory Long Block: A University of Cincinnati Educational Innovations Project Eric J. Warm M.D., Brian Revis M.D., Sara McCune M.D., Jennifer Ernst, M.D., Yvette Neirouz, M.D., Tiffiny Diers M.D., Bradley Mathis M.D., Gregory Rouan M.D. PATIENT SATISFACTION CLINICAL QUALITY RESULTS LONG BLOCK MICROSYSTEM ABSTRACT BACKGROUND: Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting OBJECTIVE: Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients METHODS: We created the ambulatory long-block as part of the ACGME’s Educational Innovation Project. The long-block occurs from the 17th to the 29th month of residency, and isayear-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. Long-block residents follow approximately 120-150 patients, have office hours 3 half-days per week, and are responsive to patient needs (by answering messages, refilling medications, etc.) daily. Otherwise, long-block residents rotate on electives and research experiences with minimal overnight call. Residents receive extensive instruction in chronic illness care, quality improvement, and inter-professional teams RESULTS: The long-block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. There has also been a trend towards decreased emergency department visit rates and no show rates. Additionally, the long-block resulted in a robust multi-source evaluation that identified high, intermediate, and low performing residents, and suggested specific formative feedback for each CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement ,[object Object]](https://image.slidesharecdn.com/warmuniversityofcincinnatiabimfoundationforumposter-100730111600-phpapp02/85/The-Ambulatory-Long-Block-1-320.jpg)
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The Ambulatory Long Block
- 2. Resident scores have improved the most
- 3. Satisfaction dips immediately after a long-block ends but then rebounds (above)
- 4. This may represent breaking and reforming of therapeutic relationships
- 5. The large team is broken up into mini-teams
- 7. In 2007, the nursing staff transitioned from a mostly medical assistants to all RN and LPN level staff to provide case management
- 9. This historical bias towards the inpatient setting has led to dysfunctional ambulatory training settings
- 10. Many residents receive little support for ambulatory chronic illness management, improvement science, or interdisciplinary teamwork
- 11. The end result of these combined deficiencies has been characterized as the “training/practice gap” – few internal medicine graduates leave residency with the skills needed to function effectively in the ambulatory setting
- 12. The practice uses an electronic medical record (Centricity) and a disease registry (MQIC)
- 13. Residents receive extensive EMR training
- 14. Residents and nurses then have a pre-clinic “huddle” to review the patients that will be seen , and decide on an efficient plan for the day
- 15. Prior to each clinic session, residents review the EMR, prepare a progress note, and make a list of things that must be done during the session
- 17. Each long- block class has shown significant increases in in-training exam scores from PGY-2 to PGY-3
- 18. Our residency is in the upper quartile for passing the ABIM certification examination
- 19. The University of Cincinnati internal medicine residency program consists of 108 residents (69 categorical) based in a large academic health center
- 20. The categorical resident ambulatory practice is an urban safety-net practice located next to the main teaching hospital
- 21. Residents are responsible for approximately 19,000 ambulatory visits per year
- 22. 58% of the patients have hypertension and 32% have diabetes; only 1% have private insurance
- 23. Residents rated their ambulatory clinic experience low during exits interviews, reported little time for learning in the ambulatory setting due to difficulty balancing ward and ambulatory duties, and reported a lack of personal reward the ambulatory setting
- 24. The practice also had poor patient-doctor continuity, poor clinical quality markers, poor patient satisfaction, and poor staff satisfaction
- 25. The initial data from the first long-block showed significant improvement for many process measures and intermediate outcome measures of care
- 27. The entire team meets weekly to review data and solve problems; an open agenda is set by all team members
- 28. Every meeting starts with a patient story
- 29. Residents receive individual reports monthly
- 30. Each report includes a ranking on each measure compared with peers
- 34. Residents are given a rank for each data point compared to peers in the class, and this data is reviewed with the chief resident and program director over the course of the long-block
- 35. The table above shows that in a long-block class the MSF demonstrates residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%)
- 36. Each high, intermediate and low performing resident had a least one aspect of the MSF significantly lower than the other, and this serves as the basis of formative feedback during long-block
- 37. Residents receive radar graphs (figures A-C, below) as part of their evaluation
- 38. Focus is given to lower scored measures (furthest from the center of the radar graph)