Health Professions Education

Using a Healthcare Matrix to

Assess Patient Care in Terms
of Aims for Improvement
and Core Competencies John W. Bingham, M.H.A.
Doris C. Quinn, Ph.D.
Michael G. Richardson, M.D.
Paul V. Miles, M.D.
Steven G. Gabbe, M.D.
n 2001, the Institute of Medicine (IOM) presented a

I compelling case for its claim that the difference

between the “health care we have and the care we
could have” represents much more than a gap, but
Article-at-a-Glance
Background: In 2001, the Institute of Medicine (IOM)
rather a chasm,1 and that the health care quality chasm recommended six Aims for Improvement; the dimen-
persists alarmingly unchecked.2,3 Unfortunately, a chasm sions of quality describe a health care system that is safe,
also exists between the medical education that we have timely, effective, efficient, equitable, and patient cen-
and that which we could have.4,5 The IOM identified tered. In 1999, the Accreditation Council of Graduate
“reform of health professions education critical to Medical Education (ACGME) adopted six core compe-
enhancing the quality of health care in the United tencies that physicians in training must master if they are
States.”1 to provide quality care. A Healthcare Matrix was devel-
The challenge is to create a system in which the fol- oped that links the IOM aims for improvement and the
lowing are true: six ACGME Core Competencies. The matrix provides a
■ The care of every patient has the potential to improve blueprint to help residents to learn the core competen-
the care of all patients yet to come cies in patient care, and to help faculty to link mastery of
■ Competencies are integrated into the routine practice the competencies with improvement in quality of care.
of daily care Healthcare Matrix: The Healthcare Matrix is a con-
■ Decision making regarding care of the patient is guid- ceptual framework that projects an episode of care as an
ed by the best evidence available interaction between quality outcomes and the skills,
■ The quality of health care is positively related to the knowledge, and attitudes (core competencies) necessary
quality of medical education. to affect those outcomes. For example, an anesthesiolo-
The IOM recommended that to address the chasm in gy resident used the Healthcare Matrix for a complex 18-
health care quality, all health care organizations, profes- hour episode of care with a life-threatening situation.
sional groups, and private and public purchasers pursue Ongoing Work and Research Agenda: Collecting and
six Aims for Improvement in health care.1 These “dimen- analyzing a series of matrices provides the foundation
sions of quality” describe a health care system that is for systematic change in patient care and medical edu-
safe, timely, effective, efficient, equitable, and patient cation and a rich source of data for operational and
centered. improvement research.

98
February 2005 Volume 31 Number 2
 In 1999, the Accreditation Council of Graduate without experience in quality improvement.8 For these
Medical Education (ACGME) focused on the shortcom- reasons, and acknowledging the dependency of quality
ings of graduate medical education (GME) and set the medical education on the presence of quality medical
following goals: care and improvement, we introduce a formative
■ The content of graduate education is aligned with the approach to the presentation of the core competencies
changing needs of the health system to residents, which in turn is having an effect on the fac-
■ Residency programs use sound outcome assessment ulty and their patient care.
methods for both the residents’ and programs’ achieve-
ment of educational outcomes6 The Healthcare Matrix
The ACGME adopted six core competencies that The Healthcare Matrix (Figure 1, page 101) is a
physicians in training must master if they are to provide response to the challenge of linking all six competencies
quality care. The American Board of Medical Specialties mandated by ACGME with the realities of the current sys-
(ABMS) has adopted these same competencies as the tem of medical education, which is usually more focused
basis for the standards of certification and maintenance on the acquisition of medical knowledge. It is a conceptu-
of certification for all specialty boards,7 making this al framework that projects an “episode of care” as the large
framework equally valuable for all practicing physicians. and complex picture that it is yet provides a glimpse into
This article introduces a Healthcare Matrix that links the interaction between quality outcomes (IOM Aims for
the IOM Aims for Improvement and the six ACGME Core Improvement) and the skills, knowledge, and attitudes
Competencies. The matrix provides a blueprint to help (ACGME Core Competencies) necessary to affect those
residents to learn the core competencies in their daily outcomes. The matrix is intended to make readily appar-
work of caring for patients and to help faculty to link ent the tight linkage between competencies and outcomes.
mastery of the competencies with improvement in quali- The first row (Patient Care) is meant to be an assess-
ty of care. The matrix also provides a framework for edu- ment of the quality of the care. For example, was care
cators to use in curriculum and program redesign. Data safe? If the answer is “yes,” this is written in that cell.
collected in completing the matrix can be used to gener- Was care timely? If it wasn’t, the cell gets a “no.” Next,
ate new knowledge for operational and outcome for each column that receives a “no,” the four specific
improvements and research for both resident education ACGME competencies (medical knowledge, profession-
and the delivery of care. alism, system-based practice, and interpersonal and
communication skills) are examined in terms of their
Challenge of Teaching and Assessing contributions to the care of the patient. Finally, subopti-
the Core Competencies mal performance is synthesized into the implementation
Teaching and evaluating the core competencies essential of improvement strategies (practice-based learning and
for quality health care is an evolutionary process without improvement).
a prescribed formula.6 Most academic institutions Two examples are provided to illustrate our pilot work
have focused on identifying summative assessment with the Healthcare Matrix in two different resident
tools to evaluate residents’ acquisition of the compe- learning settings. A facilitator [D.C.Q.] first attends a typ-
tencies, which presumes that the competencies are ical case or mortality and morbidity (M&M) conference
being taught and learned effectively. In reality, teaching and documents the presentation and discussion on a
and assessing the less formally defined competencies— blank matrix framework. She then shares the matrix with
professionalism, communication and interpersonal the group as a means of discussing the six competencies,
skills, systems-based practice, and practice-based highlighting what was missed of the competencies.
learning and improvement—has been problematic Sometimes the matrix is sent to the resident for addition-
even for experienced clinicians and educators. Teaching al reflections (see Example 2, page 103). Eventually, the
system-based practice and practice-based learning and residents will use the matrix to prepare their case pre-
improvement has been especially daunting for faculty sentations and M&M conferences. The most beneficial

99
February 2005 Volume 31 Number 2
 Healthcare Matrix for a Patient with Pregnancy and Disseminated
Intravascular Coagulopathy

Figure 1. The use of the Healthcare Matrix to analyze a complex episode of care that took place in the course of 18 hours
and involved a life-threatening situation is described in Example 1. The most important cells are outlined. ACGME,
Accreditation Council of Graduate Medical Education; IOM, Institute of Medicine; IV, intravenous; OR, operating
room. The IOM dimensions of care and the ACGME Core Competencies are explained in the legend for Figure 2.

100
February 2005 Volume 31 Number 2
learning comes from the residents having to think about effectiveness of teams, systems (protocols for con-
each cell as it relates to their presentation. sultation and crisis prevention and management), and
practice-based improvement. In fact, although the DIC
Example 1. Anesthesiology Resident was a life-threatening development, these other system-
The first example presents the learning experience of related factors lay at the heart of this near miss.
a resident who used the Healthcare Matrix to analyze a Considering the patient’s age and parity, it must be
complex episode of care that took place in the course of argued that the catastrophe was not completely averted
18 hours and involved a life-threatening situation. The because her fertility was permanently sacrificed.
matrix prompted the resident and other team members The case formed the basis of an extended resident
to look beyond the compelling medical issues to explore learning exercise. The attending asked the resident to
the significance of competencies and dimensions of care write a detailed account of the peripartum course,
that represented the real threats to life in this case. including all clinical details, events, team communica-
Ultimately, this exercise led to consideration of process tions, and time line. The resident was also to compile an
changes designed to improve care. exhaustive list of “important learning topics and issues
A senior anesthesiology resident and her supervising prompted by reflection of the details of this case (no par-
attending [M.R.G.] were summoned urgently in the ticular order).” The attending anesthesiologist per-
middle of the night to provide anesthesia for a young formed the same exercise independently.
mother who had delivered a healthy term infant an hour The resident’s list of learning topics was as follows:
earlier. Postpartum bleeding necessitated uterine explo- 1. DIC—what is it?
ration under anesthesia. Initial assessment revealed 2. DIC in pregnancy—what are the causes?
hypovolemic shock and continuing vaginal bleeding but 3. Fibrinolysis in DIC (significance of an in vitro
only a single intravenous (IV) line. A call to the blood clot test)
bank revealed that no blood was immediately available 4. Local anesthetic toxicity
because the patient’s blood sample had been received 5. Postpartum hemorrhage with regional anesthesia
only five minutes earlier. Suspecting disseminated versus general anesthesia
intravascular coagulopathy (DIC), the anesthesia team 6. Pulmonary edema secondary to massive transfusion/
immediately placed a large-bore IV and began aggressive volume resuscitation
resuscitation with IV fluid and type-specific but 7. Hypocalcemia from massive transfusion
uncrossmatched blood products. Within 15 minutes the 8. Blood-tinged epidural aspirate—significance?
patient’s vital signs stabilized and her symptoms of 9. Carboprost, misoprostol, and methylergonovine
shock resolved. During the next 1½ hours, she under- maleate-indications and uses
went a life-saving peripartum abdominal hysterectomy, 10. Third-spacing—can specific IV fluids prevent it?
with > 5 liters of blood loss and a total of 7 liters of IV 11. Arterial-line indications—use with massive trans-
fluid and 31 units of various blood products transfused. fusions or not?
She subsequently experienced pulmonary edema on the 12. Who needs a type and cross? Why does it take 30
first postoperative day, a further decrease in hematocrit minutes?
(requiring additional blood transfusions), and sympto- Of the 12 learning points, all but one (point 12)
matic hypocalcemia due to massive transfusion, yet was focused entirely on the intersections between the com-
discharged home on her fourth postoperative day. petencies medical knowledge and patient care and the
This highly complex episode of care was replete with dimensions effectiveness and safety—representing only
learning points in all core competencies and dimensions 4 of the 36 cells of health care. Learning point 12 includ-
of care—medical knowledge and patient care issues ed the Systems/Timeliness cell.
(chorioamnionitis, pathophysiology and treatment of The attending physician inserted his recollections
DIC, massive transfusion, and so on), professionalism/ into the resident’s narrative, focusing especially on the
ethical issues, equity, timeliness of communication, team interaction and communication issues omitted

101
February 2005 Volume 31 Number 2
 from the resident’s draft. He then asked the resident to to enhance learning in a psychiatry resident case
use the Healthcare Matrix to discuss the individual com- conference. In the matrix for this example (Figure 2,
petencies and dimensions and the implications of the page 104) the resident’s additional content is initialed
intersecting cells. He explained how this episode of care [WH]). The psychiatry residents now use the matrix
and other episodes of care could be viewed in terms of to prepare their case conference presentations, and the
each of the cells, with reflection on what was done and program director uses it to ask questions during the pre-
how the various facets of care contribute to the out- sentations. Two lessons learned by the residents are that
come, and ultimately consideration of what was done not all cells need be filled in and that it is helpful to bor-
well and what was suboptimal and could benefit from der the most important cell(s) in red.
improvement.
The resident returned a matrix that was much richer, Creating and Reinforcing a Culture
now including entries in 17 of 36 cells (Figure 1). The of Learning
resident chose to use this case for a one-hour, depart- The matrix is intended to help consider patient care in
mental senior resident case presentation identifying the terms of the IOM Aims and the ACGME Core
learning points she wished to include. Approximately Competencies rather than make these dimensions add
two-thirds of her presentation focused on the scientific on to an already compressed duty-hour week. Faculty
and clinical aspects of normal and abnormal homeosta- use the matrix to enhance the learning experience for
sis, and the management of DIC. The final third of her every resident. We are slowly creating an environment
presentation centered on the systems, communication, where learning can occur with other members of the
and team issues that contributed to the near-catastroph- team, where data are gathered and reviewed, and where
ic outcome, introducing these by way of the Healthcare decisions are made in a collaborative manner rather than
Matrix model. During the 15-minute discussion period, in an environment characterized by “embarrassment,
questions and comments offered by faculty and resi- blame, shame and sometimes humiliation”9 for the resi-
dents in attendance concerned the many cells represent- dents. This new learning environment represents a shift
ing the intersections of competencies (especially in culture that acknowledges the resident as part of a
communication, systems-based practice, professional- system of care, in which he or she learns in and about
ism, practice-based learning and improvement) and the system of care.
dimensions of care (especially safety, timeliness, patient- The matrix provides a common framework for evalu-
centeredness, equitability, effectiveness). ating and improving patient care across all disciplines.
The resident’s presentation of this case prompted the For example, pediatrics residents are teaming up with
obstetrical anesthesiology faculty to partner with the the nursing staff and managers to improve the residents’
obstetricians and obstetric nursing staff to improve the continuity clinic. The residents had identified many sys-
team’s processes involved in responding to urgent tem issues in care of a child with asthma, and when they
obstetrical situations. During a debriefing interview with brought this to the attention of the nursing manager, she
one of the authors [D.C.Q.], the resident reflected on the stated that a team was already working on those issues.
learning exercise and the matrix’s usefulness in con- The pediatric residents were then invited to be part of
tributing to her learning. The resident viewed the Matrix the process flow team. When the matrix was used to ana-
as pivotal to opening her eyes to the many competencies lyze suboptimal outcomes associated with femoral vein
other than medical knowledge which are critical to opti- cannulation, faculty and residents established a multi-
mal healthcare delivery. Based on this presentation, the disciplinary team to decide on orders, policies, and pro-
Department of Anesthesia will use the Matrix to frame cedures for venous cannulation.
M&M conferences.
Ongoing Work and Research Agenda
Example 2. Psychiatry Resident The Healthcare Matrix is being used in a variety of set-
In a second example, the Healthcare Matrix was used tings and is the focus of a research agenda.

102
February 2005 Volume 31 Number 2
Healthcare Matrix for Care of a Patient with Schizophrenia (and
Auditory Hallucinations)

continued

103
February 2005 Volume 31 Number 2
 Healthcare Matrix for Care of a Patient with Schizophrenia (and
Auditory Hallucinations), continued

1 Safe: Avoiding injuries to patients from the care that is intended to help 8 Medical Knowledge about established and evolving biomedical, clinical,
them. and cognate sciences (e.g. epidemiological and social-behavioral) and
2 Timely: Reducing waits and sometimes harmful delays for both those the application of this knowledge to patient care.
who receive and those who give care. 9 Interpersonal and communication skills that result in effective informa-
3 Effective: Providing services based on scientific knowledge to all who tion exchange and teaming with patients, their families, and other
could benefit and refraining from providing services to those not likely health professionals.
to benefit (avoiding underuse and overuse, respectively). 10 Professionalism, as manifested through a commitment to carrying out
4 Efficient: Avoiding waste, including waste of equipment, supplies, ideas, professional responsibilities, adherence to ethical principles, and sensi-
and energy. tivity to a diverse patient population.
11 System-based practice, as manifested by actions that demonstrate an
5 Equitable: Providing care that does not vary in quality because of per-
sonal characteristics such as gender, ethnicity, geographic location, and awareness of and responsiveness to the larger context and system of
socio-economic status. health care and the ability to effectively call on system resources to
provide care that is of optimal value.
6 Patient-Centered: Providing care that is respectful of and responsive to
12 Practice-based learning and improvement that involves investi-
individual patient preferences, needs, and values and ensuring that
patient values guide all clinical decisions. gation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvement in patient
7 Patient care that is compassionate, appropriate, and effective for the care.
treatment of health problems and the promotion of health.

Figure 2. This Healthcare Matrix was used to enhance learning regarding the case presented as Example 2. The most
important cells are outlined. ACGME, Accreditation Council of Graduate Medical Education; IOM, Institute of Medicine;
Dx, diagnosis; EBM, evidence-based medicine; CAPOC (Child/Adolescence psychiatric outpatient care); Tx, treatment;
ETOH, alcohol; PCP, primary care physician; TNCARE, Tennesee’s Medicaid managed care system; HC, health care.

Multiple Uses in Different Specialties Enhancing Personal and Professional Development

The Healthcare Matrix is being piloted at Vanderbilt Dreyfus and Dreyfus10 teach us that novices benefit
University Medical Center and elsewhere in many special- from algorithms and structured approaches to learning.
ties, including not only anesthesiology, psychiatry, and Residents learn heuristics from textbooks, mentors, chief
nephrology but also emergency medicine and internal residents, faculty, and others. For example, all students
medicine–ambulatory. It is also being used as a frame- learn to take a complete history and perform a thorough
work for transforming traditional M&M conferences into physical examination, a time-consuming process. When
Morbidity and Mortality and Improvement conferences. they know more about patient assessment, students are
The Children’s Hospital at Vanderbilt University Medical able to perform a focused version of the “history and
Center has created a structure titled Performance physical.” Likewise, the resident struggles with this
Management and Improvement (PM & I) that includes use matrix at first, but with experience becomes more facile
of the matrix for team learning. We have some positive with the tool, taking less time to complete matrix cells.
preliminary data on how the matrix is helping to expand The matrix provides a valuable technique for the
the context of learning for the residents and faculty but clinician-educator to zero in on the aspects of care that
more data will be gathered to further validate the tool. are most important in the presentation of a given case.

104
February 2005 Volume 31 Number 2
 At the conclusion of an episode of care, a resident and competencies, the resident will provide faculty with his
his or her attending physician debrief with the following or her portfolio and the learning/reflections related to
questions, which address all cells in the matrix: patient care. We are developing an electronic portfolio to
1. Was care for this patient as good as it could be? accommodate required data (duty hours, procedures, and
2. What improvements in the competencies of the res- so on) and data from the Healthcare Matrix.
ident and faculty and changes in the system of care
would result in improved care for the next patient? Research Agenda
Although a completed matrix provides a large amount The Healthcare Matrix provides a framework for clini-
of information, focusing learning at the “cell” level keeps cians and teams to improve care of patients. Collecting and
the learner from feeling overwhelmed with all the dimen- analyzing a series of matrices provides the foundation for
sions of care. It is useful to ask “Relative to this patient systematic change in patient care and medical education,
condition, what knowledge do physicians need to know as well as a rich source of data for operational and
to improve patient safety?” or, “What cell or few cells improvement research. We are planning a qualitative
had the greatest impact on this outcome, and why?” research project in which examination of the completed
Completing the matrix cells should itself teach all the matrices for each specialty will help identify the “quality
core competencies. As learners seek to improve the sys- characteristics” important for each specialty. We hope to
tems, they will become competent in practice-based be able to identify evaluation tools appropriate for each
learning and improvement. A recent article by Ogrinc et specialty. We are now tracking data over time from cells
al.,8 which describes a framework for teaching medical from matrices completed by ambulatory medicine resi-
students and residents about practice-based learning and dents to create a balanced set of measures to assess
improvement, should help residents use the matrix. progress in patient care and resident education. J

Documenting Learning
John W. Bingham, M.H.A., is Director, Center for Clinical
A completed Healthcare Matrix documents the ability
Improvement, Vanderbilt University Medical Center,
to reflect on outcomes for a patient or panel of patients Nashville, Tennessee; Doris C. Quinn, Ph.D., is Director,
in terms of the gap between the care provided and the Quality Education and Measurement Center for Clinical
care that could be provided and encourages reflection on Improvement; and Michael G. Richardson, M.D., is
how this knowledge can be used to improve care. As Associate Professor, Department of Anesthesiology. Paul V.
improvements in care are made, patient outcome can be Miles, M.D., is Vice President and Director of Quality
Improvement, American Board of Pediatrics, Chapel Hill,
compared to assess their effectiveness. The matrix also
North Carolina. Steven G. Gabbe, M.D., is Dean, Vanderbilt
provides a useful basis for documenting formative feed- University Medical Center. Please send requests for reprints
back as part of a summative evaluation. Instead of the to Doris C. Quinn, Ph.D., [email protected].
faculty having to decide if the learner demonstrated the

References
1. Institute of Medicine: Crossing the Quality Chasm. Washington, 5. Institute of Medicine: Health Professions Education: A Bridge to
D.C.: National Academy Press, 2001. Quality. Washington, D.C. National Academy Press. 2003.
2. Kerr E.A., et al.: Profiling the quality of care in twelve communities: 6. Accreditation Council of Graduate Medical Education (ACGME):
results from the CQI study. Health Aff (Millwood). 23(3):247–256, 2001. The project: Introduction. http://www.acgme.org.
May–Jun. 2004. 7. Nahrwold D.: The changing role of certification for physicians. ABMS
3. Joint Commission on Accreditation of Healthcare Organizations: Reporter, 11, Spring 2002. Available at http://www.abms.org.
Weaving the Fabric: Strategies for Improving Our Nation’s Healthcare. 8. Ogrinc G., et al.: Framework for teaching medical students and resi-
Oakbrook Terrace, IL: Joint Commission, 2003. http://www.jcaho.org/ dents about practice-based learning and improvement, synthesized
about+us/public+policy+initiatives/weaving+the+fabric.htm (last from a literature review. Acad Med 78:748–756, Jul. 2003.
accessed Dec. 10, 2004). 9. Shine, K.: Crossing the quality chasm: The role of postgraduate train-
4. AAMC Executive Council: AAMC policy guidance on graduate med- ing. Am J Med 113: 265–267, Aug. 15, 2002.
ical education: assuring quality patient care and quality education. 10. Dreyfus H., Dreyfus S.: Mind Over Medicine. New York: Free Press,
Acad Med 78:112–116, Jun. 2003. 1982.

105
February 2005 Volume 31 Number 2