RightCare Rounds Toolkit

RightCare Rounds is an educational initiative that incorporates evidence-based discussion in the format of a case presentation to promote appropriate patient care. This program aims to help clinicians recognize and prevent overuse and underuse, while taking into consideration social contexts and patient preferences. This toolkit provides step-by-step instructions for how to implement RightCare Rounds in any institution.
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Implementation Guide

(a) Goals of the Conference 

At the conclusion of this program, RightCare Educators will be able to:

Organize/lead:

  • Implement RightCare Rounds within an existing educational time slot
  • Facilitate a RightCare Rounds session
  • Promote implementation across specialties and at neighboring institutions

Take action/make change:

  • Promote institutional culture of right care where the goal of medicine is to provide the best possible care at lowest burden to patients
  • Help clinicians recognize and avoid overuse/underuse before it occurs
  • Address barriers to accessing good care
  • Identify opportunities for improving quality of care
  • Measure outcomes and assess impact (e.g. new protocols or programs in place stemming from RightCare Rounds)
  • Improve patient safety
  • Consider drivers of overuse/underuse
  • Review benefits and harms of common health interventions
  • Recognize patient preferences as a key element of evidence based care

 

At the conclusion of this activity, RightCare Rounds participants will have:

  • Considered drivers of overuse/underuse
  • Reviewed benefits and harms of common health interventions
  • Recognized patient preferences as a key element of evidence based care
  • Uncovered opportunities for improving quality of care

 

(b) Step-by-step instructions

Quick facts about implementing RightCare Rounds:

  • It takes 30 minutes to 1 hour to discuss a case
  • The program can take place in a variety of contexts (ideally within an existing educational time slot):
    • Morning Report
    • Noon conference
    • Pre-clinic conference
    • Grand Rounds
    • Morbidity & Mortality Conference

 

i. How To Get Started 

How do we select a case?

Instances of overuse and underuse are a daily occurrence in hospitals and clinics everywhere. The best cases are those where tests or interventions were omitted despite a strong evidence base for their use, or where seemingly reasonable ones were provided that were nevertheless unnecessary because the evidence for their use is absent or weak, or where the patient’s preferences or whole life situation were not honored. Cases of near misses or actual harms would be particularly important but not essential. In other words, cases of malpractice or obvious errors are not appropriate for this conference. Often times medical overuse is built into the health care system, for example, requiring pre-operative testing before a low risk procedure like cataract removal. The trouble with such unnecessary testing is that the best evidence indicates it does not benefit patients, yet any test has the potential to cause harm. Another example might be daily blood work in the hospital leading to anemia or obtaining cardiac stress testing in a low risk patient leading to a false positive and harm from coronary angiography.

Examples of inappropriate, though common, health interventions are listed within the Choosing Wisely campaign; many others have been identified through the Do No Harm Project, or have been published in the Teachable Moments Series in JAMA Internal Medicine.

Common examples where harm may occur from overuse:

  1. Screening tests. “All screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost.” – Sir Muir Gray
  2. Older patients, especially those who are not ill.
  3. Incidental findings on imaging or labs – that is, seeming abnormalities in patients with no symptoms of the disease in question.
  4. Diagnosis and treatment of mild abnormalities (e.g. A1c of 6.5%, blood pressure of 145/88, asymptomatic bacteriuria, subclinical hypothyroidism).
  5. Preference misdiagnosis – when the patient expresses regret about a past test or treatment decision. This may indicate that they were not fully informed of the potential downsides of testing or treatment when the decision was originally made. Many patients opt for less testing and treatment when fully informed and experience less regret after the decision has been made.
  6. Pre-operative testing that is unlikely to change management.
  7. Treating to an arbitrary target (e.g. blood pressure, lipids, bone density, inflammatory markers, hemoglobin, TSH, A1C).

 

Who should be in the room? 

Clinicians and trainees from any of the allied health professions.

 

How to obtain support?

Natural allies for new programs aimed at changing institutional culture can often be found in other trainees, faculty – especially medical educators, and program directors.

 

How to explain why this is different and important?

Messaging is key as we try to nudge healthcare in a more rational, patient-centered direction. Though excess financial cost is an important issue in health care systems across the world, the motivation for RightCare rounds is to rejuvenate our professionalism by considering ways to provide the best possible care for our patients in the emerging new delivery system by incorporating a “360 degree view” of the patient.

 

Where to find a mentor?

We suggest identifying junior faculty (who may have more time to help you) and medical educators within your institution who are sympathetic to concepts of improving ‘value’ through reduction of overuse or underuse. Residency program directors are important to engage early in the process to ensure access to an existing educational time slot. We have found that engaging senior clinicians/leadership early in the process is not mandatory for success.

 

ii. How To Run RightCare Rounds

As RightCare Rounds utilizes the case presentation format, the basic structure should not feel significantly different from a typical educational conference such as morning report or noon conference.  Similarly, details of the key clinical events and a discussion of the evidence to support the best possible care of patients ought to be incorporated and thought about in advance. These points are often best presented via PowerPoint or a similar platform.

A notable departure from traditional educational conferences is the focus on care that was well intended, but nevertheless missed opportunities for care, or provided care that was unneeded or unwanted. Additionally, careful reflection on how we can do better going forward, whether that be by better engaging patient preferences, understanding the social contexts or the myriad other drivers of overuse and underuse, will all be potential focal points of discussion. When appropriate, inviting the patient to share their perspective in person could be especially valuable.

A cause and effect diagram, i.e. a fishbone diagram (similar to the one in the attached sample presentation), can be useful to facilitate discussion. RightCare Rounds should always be safe and conducted professionally, emphasizing humility in the challenges of providing best care for our patients.

 

Morning Report/Noon Conference/Ambulatory Adaptation (30 min):

Preparation:

  • Conference date is arranged by chief resident or other RightCare champion
  • Case of medical overuse/underuse is identified by presenter 1-2 weeks in advance of conference

Structure of the presentation:

  • Timeline: Outline/timeline of case is presented, including relevant details regarding patient preferences and social/cultural/system contexts
    • What happened? What are the key details so we can understand the relevant context of the story?
  • Clinical course: Clinical course is discussed among participants, e.g. potential alternative diagnostic or management strategies to achieve RightCare
  • Clinical evidence: Brief review of evidence, summarizing known risks and benefits from diagnostic or therapeutic intervention(s) in question
    • What is “better” according to this patient’s preferences/goals of care?
    • What resources do we actually have available?
    • What would the best evidence suggest? Can we quantify the absolute benefits and harms of the relevant diagnostic or therapeutic interventions at hand?
  • Overuse/underuse: Particular instance of overuse/underuse and potential harm or near harm is cited by presenter along with evidence supporting its occurrence
    • What went wrong? In other words, what was the instance (or instances) of overuse or underuse? Was there overtesting, overdiagnosis, overtreatment, or a preference misdiagnosis? If underuse occurred, what was it? Often overuse and underuse are linked—an overuse of technology with an underuse of listening. Was there a failure to clarify goals of care, resulting in a late referral to hospice, for example?
    • Describe the burden or harm to the patient, e.g. physical, emotional, and/or severe financial harm
    • Describe the medical evidence supporting the assessment that overuse or underuse may have occurred.
    • Remember: overuse and underuse are common occurrences, typically well-intended, seemingly reasonable, and even the standard of care sometimes
  • Drivers: Drivers of overuse are considered, e.g. systems or cognitive factors
    • How could the drivers of care be modified?
  • Future improvements: Presenter proposes alternative way forward to ensure RightCare for similar cases in the future, group considers opportunities for quality improvement
    • What would RightCare for this patient look like?
    • What can we do for patients like this next time?
    • What systems can we put in place to do better?
    • What are the barriers to change? Who can help?

 

Grand Rounds/Morbidity & Mortality Conference Adaptation (60 min):

Preparation:

  • Conference date arranged by local GR/M&M organizer on suggestion of RightCare champion
  • Case of medical overuse/underuse is identified by presenter three months in advance of conference
  • Members of entire care team are invited to Rounds
  • Extensive research of medical chart, particularly of frequent admissions/readmissions
  • Interviews of members of care team, including subspecialists, nursing professionals, medical assistants, orderlies and others. Interviews of patient and family when appropriate

Structure of the presentation:

  • Timeline: Outline/timeline of case is presented, including relevant details regarding patient preferences and social/cultural/system contexts
    • What happened? What are the key details so we can understand the relevant context of the story?
  • Clinical course: Clinical course is discussed among participants, e.g. potential alternative diagnostic or management strategies to achieve RightCare
  • Clinical evidence: Brief review of evidence, summarizing known risks and benefits from diagnostic or therapeutic intervention(s) in question
    • What is “better” according to this patient’s preferences/goals of care?
    • What resources do we actually have available?
    • What would the best evidence suggest? Can we quantify the absolute benefits and harms of the relevant diagnostic or therapeutic interventions at hand?
  • Overuse/underuse: Particular instance of overuse/underuse and potential harm or near harm is cited by presenter along with evidence supporting its occurrence
    • What went wrong? In other words, what was the instance (or instances) of overuse or underuse? Was there overtesting, overdiagnosis, overtreatment, or a preference misdiagnosis? If underuse occurred, what was it? Often overuse and underuse are linked, with an overuse of technology and an underuse of listening. Was there a failure to clarify goals of care, resulting e.g. in a late referral to hospice?
    • Describe the burden or harm to the patient, e.g. physical, emotional, and/or severe financial harm
    • Describe the medical evidence supporting the assessment that overuse or underuse may have occurred.
    • Remember: overuse and underuse are common occurrences, typically well-intended, seemingly reasonable, and even the standard of care sometimes
  • Drivers: Drivers of overuse are considered, e.g. systems or cognitive factors
    • How could the drivers of care be modified?
  • Future improvements: Presenter proposes alternative way forward to ensure RightCare for similar cases in the future, group considers opportunities for quality improvement
    • What would RightCare for this patient look like?
    • What can we do for patients like this next time?
    • What systems can we put in place to do better?
    • What are the barriers to change? Who can help?

 

iii. What To Do After

  • A summary of issues surfaced out of the conference in various categories (e.g. poor evidence base, poor interprofessional communication, lack of needed health system resources, inadequate outpatient follow-up, etc.), local culture driving a given practice
  • Possible remedies:  of local processes of care or of communication, of knowledge, of training
  • Review and discussion of summary with mentor
  • Report out to residency leadership or hospital administration, when relevant
  • Report out to Lown Institute for our records (attached post-surveys)
  • 3 or 6 month follow up presentation of action items to a scheduled RC Rounds event (public accountability)
  • Note that these cases and discussions are perfect fodder for a publishable paper, for example, in JAMA Internal Medicine.

 

(c) Measuring success