The Center of Excellence is a training pathway with the outpatient rotations primarily based at the Louis Stokes Cleveland VA Medical Center. This program began in 2011 when the Louis Stokes Cleveland VA Medical Center received a $5 million federal grant to offer physicians and nurse practitioner learners a novel and visionary approach to health care in the 21st century. It has several curricular components: training in the six sigma and other performance improvement tools-leadership in quality improvement care; interdisciplinary team-based care; proactive care; real-time patient feedback; humanities in health care and virtual health care. Contact: Simran.Singh@VA.gov
Length of training: 3 years
Setting: University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veteran Affairs Medical Center
Description and defining characteristics: The Center of Excellence (COE) residents participate in an innovative program primarily based at the VA called Transforming Out-Patient Care (TOPC).
In January 2011, the Louis Stokes Cleveland VA Medical Center received a five million dollar federal grant to offer physician and nurse practitioner learners a novel and visionary approach to healthcare in the 21st century. In collaboration with the Frances Payne Bolton School of Nursing and supported by the VA Office of Academic Affiliations, this Center of Excellence will prepare residents and nurse practitioner students to work in new models of care that demand teamwork and patient centered care. Students will be offered novel educational opportunities to build on current strengths in the curriculum as well as acquire new skill sets.
The outpatient clinical experience at the Louis Stokes Cleveland VA Medical Center serves a diverse patient population of varying age and medical complexity with oversight by dedicated faculty who are selected on academic merit and proven commitment to clinical education. In this environment, trainees manage patients in collaboration with pharmacists, psychologists, and registered nurses. Emphasis on chronic disease management is provided via traditional office visits, shared medical appointments, tele-health communication, and through utilization of locally-developed diabetes, chronic kidney disease and heart failure disease registries. The Louis Stokes Cleveland VA Medical Center will have fully implemented the PACT (Patient-Aligned Care Team) model (synonymous with patient-centered medical home) which provides dedicated interdisciplinary team members to enhance patient care and provider and patient satisfaction.
Training in Six Sigma and Other Performance Improvement Tools: The Center of Excellence is excited to partner with faculty from the Case Weatherhead School of Management to provide trainees with the skills and tools necessary to implement performance improvement into the everyday care of patients. Learners will have the opportunity to receive training in management skills such as Six Sigma taught by Weatherhead faculty.
Leadership in Quality Care Improvement: Learners will become competent in leading and incorporating quality measures and performance improvement into the delivery of health care. Specific to the Center of Excellence, residents and nurse practitioner students will have access to chronic disease registries and will be provided various opportunities to learn how to use these tools effectively for panel and population management, and improve safety and quality at the system level.
Interdisciplinary Team-Based Care: Learners in the program will engage in a team-based model for health care delivery. As members of a PACT team, residents and nurse practitioners will work collaboratively with RNs, LPNs, social workers, pharm-Ds, health psychologists, as well as dedicated administrative support for a specified panel of patients. The goal of this model is to provide comprehensive patient care while enhancing provider and nursing staff satisfaction.
Humanities in Health Care: Learners will engage in a narrative health care course which will include predesignated reading assignments of relevant popular press and movies as well as discussion of these readings/videos at regular meetings led by members of the Department of Bioethics and Case Western Reserve University. Additionally, the Lois Stokes Cleveland VA Medical Center has partnered with the Cleveland Museum of Art to develop an Art in Health Carecurriculum as well as with the Allen Memorial Library to provide a historical perspective to the practice of medicine and nursing.
Virtual Healthcare: Learners will partake in a robust curriculum which will emphasize the role of emerging technologies in non-face to face care of the patient. This will include different perspectives on maximizing telephone management opportunities, utilization of telehealth resources already available through the VA system (home monitoring systems) as well as secure messaging via e-mail.
3 months of COE
1 month of vacation
1 month of elective (0.5 months during COE time, 0.5 months during wards time)
1 month of Geriatrics
0.5 months of primary care
0.5 months of FCM (Fundamentals of Clinical Medicine)
0.5-1 months of night float
0-0.5 months of Jeopardy
0-0.5 months of urgent care at the VA
1 month of ICU
4-4.5 months of wards
6 months of COE
1 month of vacation (0.5 months during COE time, 0.5 months during wards time)
2 months of elective (1 month during COE time, 1 month during wards time)
0.5-1 month of night float
1.5-2 months of ICU
2-3 months of wards
3 months of COE
1 month of vacation
3 months of elective (1 month during COE time, 2 months during wards time)
1 month of DACR (Day Acting Chief Resident)
0-0.5 months of VACR (VA Acting Chief Resident)
1-1.5 months of ICU
0-0.5 months of urgent care at the VA
3-4 months of wards
Center of Excellence pathway experience by Leland Hull, MD
While I initially chose this track because of my interest in primary care/general internal medicine, after being a part of the program I would recommend it to anyone regardless of their future career plans. The program allows for an intensive outpatient experience with true continuity for your patients. The schedule rotates so you do three months of inpatient rotations rotating with three months at a time of outpatient continuity clinic. During your clinic rotations, you have full responsibility over a panel of patients that you share with another resident. Residents develop a patient panel that we not only see in clinic, but can proactively manage active issues. For example, I have a panel management half day each week during which I can sort through my patients and identify all of my uncontrolled diabetic patients to either schedule follow-ups, adjust medications with telephone encounters, or contact in other ways.
You will work in a team with a dedicated RN and LPN for each team, so that you develop experience delivering patient care via a VA PACT Team model (the VA's version of the Patient-Centered Medical Home), integrating your care with nurses, psychologists, nutritionists, and pharmacists. You also get to do subspecialty clinics during your clinic months and develop a relationship with subspecialty mentors. Finally, the program includes a quality improvement curriculum, and each resident works on a longitudinal quality improvement project to be presented at the Institute for Healthcare Improvement national meeting during their third year.
What I like most about COE is the relationships I have been able to develop with my patients, and in turn, I feel like this has given me a confidence to take ownership over my patients. I enjoy having dedicated time not to just see patients but to think about their problems. I have the chance to make an initial diagnosis in the clinic -- to be the person who works up the adrenal adenoma or who helps the person with an uncontrolled HbA1c on the sometimes difficult path to glycemic control, rather than reading about these problems on a patient's problem list. The Quality Improvement curriculum is also robust and a special part of this program, and because we work on our QI projects longitudinally we can truly see the effects in the clinic as we go through our residency. I would recommend this program to any incoming intern, regardless of future plans.