Summary: A decade ago new competencies for graduate medical education called for residents to learn to how work within larger health care systems and to measure and establish processes to continually improve their performance. Since then, several innovative programs on both the undergraduate and graduate levels have begun to teach health care quality improvement through didactic instruction and hands-on experiences, and a few have shown that physicians in training are able to improve care processes. Still, more work needs to be done to clarify the goals of quality improvement training, evaluate its effectiveness, and make measurement and improvement part of professional behavior.
By Martha Hostetter
Over the last decade, several high-profile reports have called for reform of medical education. From these reports, a consensus has emerged that it's not enough for medical students, residents, and other trainee health care professionals to be taught the biomedical sciences and fundamentals of evidence-based care; clinicians also need to know how to deploy their knowledge in the messy, real world of hospitals and clinics. This means knowing how to work collaboratively with other health professionals, communicate effectively with patients, navigate a complex and changing care system, manage scarce resources and reduce waste, and be accountable for their performance. It also means identifying and understanding their panel of patients—for example to ascertain the prevalence of diabetes—so they can effectively manage care. Just as crucial, they also must know how to measure and improve the quality of their care.
Recognizing the importance of these goals, the Accreditation Council for Graduate Medical Education (ACGME), which accredits medical residency programs, in 1999 adopted six competencies for graduate medical education, including two that were new to most educators. The first, which falls under the rubric of "practice-based learning and improvement," requires residents to demonstrate the ability to investigate and evaluate their care of patients, appraise and assimilate scientific evidence, and continuously improve patient care. The second, a systems-based practice competency, requires residents to demonstrate their awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal care.2
While acknowledging the challenges of addressing these new requirements, many medical educators also recognized their value. As they saw it, medical education programs were not preparing students to cope with the systems-based problems they would encounter. "Knowing what to do and wanting to do the right thing were necessary but not sufficient," says Linda Headrick, M.D., M.S., senior associate dean for education at the University of Missouri–Columbia School of Medicine.
Headrick became convinced of the need for medical education reform back in 1990, after she took part in a study of ways to teach residents how to screen for lipid disorders. In the study, residents received three different, progressively more intensive levels of guidance: some heard a standard lecture only; some received this education, as well as generic reminders of the lipid screening guidelines on each eligible patients' chart; and a third group received the education and timely information about what to do for each patient, based on care guidelines. Surprisingly, all residents performed about the same: those who received detailed feedback about their patients were no more likely to screen for lipids when recommended than other residents, and there was no correlation between how well residents performed on an exam testing knowledge of lipid disorders and what they did for their patients.
A resident survey suggested the real problem: there were many barriers to lipid screening, including time constraints and confusion over the test ordering form. "This experience led me to the need for quality improvement training—to create systems that help people deliver the right care at the right time," Headrick said.
This year's 100th anniversary of the Flexner report—which called for a scientific approach to medical education and spurred changes in teaching institutions throughout the U.S.—is prompting renewed scrutiny of medical education and demands for more and faster reform. In this issue of Quality Matters, we look at how far we have come in integrating quality improvement into medical training, and what more needs to happen to ensure physicians are prepared to provide safer, more effective, higher-quality care.5
Early Attempts at Change
Residency programs across the nation have responded to the new graduate medical education competencies by hiring additional teaching staff or retraining faculty; adding elective or required courses on patient safety, quality improvement, health care systems, and related topics; and developing hands-on projects to give residents opportunities to learn how to measure and improve care processes. Still, programs have struggled to incorporate the new competencies into crowded curricula and clinical schedules. Many have developed short and/or elective courses that fail to provide the practical, longitudinal experiences required for improvement cycles. And some educators struggle to convince residents of the value of quality improvement training.
For their part, medical schools have been slower than residency programs to develop quality improvement curricula—perhaps because the Liaison Committee on Medical Education, which accredits undergraduate medical schools, requires medical schools to provide information on how quality improvement and patient safety are incorporated into curricula, but does not provide official standards for accreditation. And because medical students have short rotations, it can be difficult for schools to create meaningful opportunities for their students to take part in clinical improvement projects. Still, in a recent survey, the majority of medical schools reported that quality improvement was part of their required curricula. M. Brownell Anderson, M.Ed., senior director of educational affairs at the Association of American Medical Colleges, says that medical schools do so by incorporating learning goals into existing courses and clerkships, rather than teaching discrete courses on improvement techniques.
Some innovative programs—on the undergraduate and postgraduate levels—are attempting to bridge the gap between medical education and practice by providing meaningful opportunities for their students to engage in performance improvement.
One of the most comprehensive is the Leadership Preventive Medicine Residency, based at Dartmouth-Hitchcock Medical Center. In this two-year program, residents from multiple clinical specialties receive didactic training in data management, leadership, and improvement skills and also spend time in a public health agency. In addition, says Tina Foster, M.D., M.P.H., its program director, faculty coaches work closely with residents to develop and carry out long-term improvement projects. "[Residents] spend the first year of training in a series of structured rotations, which help them to identify a patient population of interest, explore that population's current processes of care and outcomes, identify gaps in care and explore change ideas, and propose a practicum," she says. "The second year is spent in leading an inter-professional group in improving care for that population." One recent practicum resulted in an 80 percent reduction in the time that lapsed between ordering antibiotics on an inpatient medicine unit and administering them. In another, a resident developed a tool for documenting and improving the discussion around advance directives among frail elders; the tool has since been adopted by all primary care practices in one community. A third resident's practicum resulted in an eightfold increase in compliance with hand hygiene in a low-performing unit, with continued progress after the practicum ended.
Beth Israel Deaconess Medical Center, in Boston, launched a quality improvement elective for its medical residents in 2000, in conjunction with the Stoneman Center for Quality Improvement, the hospital's quality improvement research institution. In 2006, the course became mandatory. During the three-week rotation, residents investigate a recent medical error or complaint, perform a root-cause analysis, and propose solutions. In addition, they choose from a predetermined list and work through the Plan-Do-Study-Act cycle to try to improve a particular care process. Anjala Tess, M.D., associate program director for the residency program, cites several processes that were changed as a result of this work, including a new heparin dosing regimen and systems for patient handoffs and discharge. Other clinicians have come to view the residents as a resource, and often suggest improvement projects for them to pursue.
Given that quality improvement is a team sport, many programs seek to build collaborations among trainee physicians, nurses, pharmacists, and other health professionals. In work supported by the Josiah Macy, Jr. Foundation and the Institute for Healthcare Improvement, the University of Missouri School of Medicine in Columbia partnered with the School of Nursing to have undergraduate medical and nursing students work together to reduce falls among hospitalized patients. The students do risk assessments, provide patient education, and make recommendations on how to decrease the number of falls. In addition, first-year medical students take a four-week course with nursing, respiratory therapy, pharmacy, and health management students in which they analyze an adverse event and propose improvements. Johns Hopkins University offers a program in which residents partner with nurses on a quality improvement project during a three-month course.
Some schools seek to involve students in the community, thereby helping them understand the broader health care system and the social and environmental factors that play a role in health. At Hofstra North Shore–L.I.J. School of Medicine, which will begin its inaugural academic year in 2011, first-year medical students will serve as emergency medical technicians as a way to give them early experience with patient care and in collaborating with other health professionals. At the Herbert Wertheim College of Medicine at Florida International University, medical students make home visits in care teams. In a trial program, medical students at the University of Connecticut School of Medicine conducted improvement projects at 24 primary care practices that resulted in improved care processes and better disease control for diabetes patients.
One of the longest-running programs, the V.A. National Quality Scholars Fellowship Program, offers two-year post-residency fellowships aimed at creating quality improvement leaders who will teach others and perform research to expand the knowledge base. The distance learning program is led by The Dartmouth Institute for Health Policy and Clinical Practice and has six training sites around the country; fellows participate in interactive video sessions and team-based improvement projects. Mark Splaine, M.D., M.S., director of the program, says that the program "takes advantage of the V.A.'s deep commitment to improving quality and measuring data." Since 1999, 69 fellows have completed the program, of which some 60 percent pursue work in academia and about a third stay in the V.A. system.
In 2008, the Institute for Healthcare Improvement launched the Open School to supplement the education of health professional students and faculty whose own academic institutions might not be moving quickly enough to include improvement skills into their curricula. "Things have changed a lot over the past decade," says Jonathan Finkelstein, M.D., M.P.H., a senior advisor to the Open School. "Most places have quality improvement on their radar screen, and some schools—albeit the minority—are doing sophisticated and extensive teaching in this area."
In addition to providing free resources and Web-based courses in quality improvement, patient safety, and leadership, the Open School encourages local action. There are some 250 Open School chapters based in universities and hospitals around the world that use IHI's support to kick-start improvement activities. For example, as part of their chapter efforts, Duke University medical students worked with faculty to plan a patient safety clinical class, and Fort Duncan Regional Medical Center participants implemented a program to reduce falls associated with medication.
Teaching Quality Improvement: Challenges Remain
Quality improvement training is still evolving, with innovative medical school and residency programs helping to lead the way. It's encouraging that even beginning medical students have proven they can contribute to clinical improvement efforts. Further work needs to be done to set clear learning objectives and integrate improvement techniques and approaches into core learning—not "special" coursework taught on the side. Such training must take place through the continuum of practice, from undergraduate to residency and continuing medical education.
In a review of quality improvement training programs, Romsai T. Boonyasai, M.D., M.P.H., assistant professor of medicine at Johns Hopkins School of Medicine, and colleagues found that most published curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence. Still, the researchers found little evidence that current educational methods have clinical benefits. Training programs need to set clear educational goals and establish benchmarks to evaluate their success.
Other experts say that quality improvement training should emphasize approaches and strategies, rather than facts. "Medical students are used to learning lessons and skills that will serve them well from one patient to another in any setting—medicine is based on the premise that we're all built very similarly," Finkelstein says. "But quality improvement is very context-based. Making surgery safer in a particular hospital is a very different problem than improving follow-up of chronic conditions in a community clinic. As with their biomedical skills, students can and should learn how to use performance data, systems thinking, and proven improvement techniques that will apply across problems and settings."
One such example is a program at St. Vincent’s Hospital, a teaching hospital affiliated with New York Medical College. The hospital engaged house staff at different levels in evaluating the delivery of care to patients with unexpected admission to the medical intensive care unit. Fellows critiqued the care of junior house staff, as well as themselves and their peers. Through this process, they gained exposure into root cause analysis. House staff also gained exposure to structured self-evaluation and case-specific clinical decision-making through a focused Morbidity and Mortality conference. This work led to development of new policies and procedures to address the frequency and documentation of vital signs in unstable patients and the criteria for escalation of care. As a result, the percentage of calls for patients who met the criteria for medical emergency response/critical care consult increased from 53 percent to 73 percent. The number of cardiac arrests on the general medical floor decreased from 3.1 per 1,000 discharges to .6 per 1,000 and the deaths on the medicine service decreased from 34 per 1,000 discharges to 24 per 1,000.
Experts agree that trainees need to learn by doing, and that the substance of their hands-on experiences matters. This means that medical trainees need to be carefully supervised in selecting and carrying out improvement projects. "As teachers, there are two ways we can approach the challenge of identifying QI opportunities that are doable while still important enough to be worthwhile," says Boonyasai. "One is to find the Goldilocks project (not too big, nor too small); the other is to provide students with off-the-shelf tools (such as clinician-friendly data or a catalog of ready-to-use process change tools) and access to QI consultants so that they can spend their time implementing and testing change instead of re-inventing the wheel."
Tess, of Beth Israel, adds that residents need to feel ownership in their improvement projects and sense that their work is valued by their institutions.
"There has to be real engagement with real improvement efforts for the program to work, and it takes time," says Foster of Dartmouth-Hitchcock Medical Center. "These are skills that can't simply be taught in a course, but that must be practiced and refined over time. As faculty, we don't necessarily know the 'right answer'; instead, we need to journey with the residents as they work to find solutions."
Finally, experts say, quality improvement training must become part of trainee physicians' professional behavior. Rosalie Phillips, M.P.H., executive director of the Tufts Health Care Institute, says that physician training should cultivate performance improvement skills as a "habit of mind"—an ingrained disposition that guides their daily decision-making. "One habit of mind needs to be, when you encounter a problem, you think: 'What in the system might be causing it?' and be ready to work through a root cause analysis and a Plan-Do-Study-Act process to address it."
Ultimately, it may require the "pull" of market demand for physicians who are versed in quality improvement techniques to encourage medical students and residents to seek out serious quality improvement training opportunities.
"Performance improvement should be part of the job description for physicians," says Headrick of the University of Missouri–Columbia School of Medicine. "It's a core professional value: we measure what we do, look at feedback, and try to improve. Quality improvement training gives you the tools to do that."
QUALITY IMPROVEMENT TRAINING RESOURCES
Institute for Healthcare Improvement Open School - An interprofessional educational community offering online courses, resources, and networking for those interested in acquiring skills in patient safety, quality improvement, teamwork, patient-centered care, and leadership.
Tufts Health Care Institute - Provides educational and training programs about improving and managing care to faculty, students, trainees, and practicing clinicians.
American Association of Medical Colleges, Integrating Quality Resources - Provides background on quality improvement theories, selected articles, and links to organizations and initiatives.
Academy for Healthcare Improvement - The Academy offers educational resources, including the Personal Continual Quality Improvement workbook, which can be used by health professional students to apply quality improvement tools to improve some process in their life.
Achieving Competency Today - Funded by the Robert Wood Johnson Foundation, this curriculum offers training to residents, graduate nursing students, and others in health care systems and quality improvement.
World Alliance for Patient Safety - This arm of the World Health Organization distributes the Guide to Developing a Patient Safety Curriculum in Medical Schools.
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 The American Board of Medical Specialties also adopted the six general competencies in 1999. Its 24 member boards now require physicians who wish to maintain their certification to demonstrate they are practicing according to the new competencies.
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