Addressing the Challenges in Teaching Quality Improvement

Challenges in Teaching Quality Improvement to Residents 

In this report, we focus on the quality improvement component of practice-based learning and improvement. For this study, “quality improvement” refers to the methods of improving processes of clinical care. “Systems” refer to bundles of related clinical processes and “systems improvement” refers to methods for improving these bundles.

Quality improvement training has been introduced successfully into several programs in family medicine, internal medicine, and surgery; however, many programs struggle to meet the following challenges.7, 8, 9, 10

Teaching Residents at Regions Hospital 

The curriculum for the residents in the University of Minnesota's Internal Medicine and Medicine–Pediatrics training programs includes a 3-month ambulatory care rotation. This rotation is based at Regions Hospital and its associated clinics. Regions Hospital is a Level I tertiary care hospital located in St. Paul, Minn, with a multispecialty staff of 500 physicians. The ambulatory care rotation includes experiences in several clinics, including Internal Medicine, Geriatrics, Dermatology, and Orthopedics. During the rotation, a half-day each week is devoted to a group project to improve performance in some area of clinical care. Project work groups consist of 7-11 residents.

The goal for each group is to pursue an improvement project and present the results to their peers and teachers. The residents learn:

The group is taught by a faculty member well grounded in quality improvement, as well as 2 respected clinicians. Overall guidance is provided by the head of Internal Medicine.

Each project begins with a discussion of quality improvement methods. This discussion focuses on the PDSA cycle, with special attention to setting of aims and measures and to using the small tests of process changes.19 In most cases, the short duration of the rotation does not permit the residents to proceed beyond planning a test of change.

The group is next asked to select a topic for improvement. They are provided with a list of past projects and projects currently underway at Regions Hospital and its clinics to convey the nature and scope of suitable projects. Residents may choose a topic on the list or devise their own. The topics chosen are listed in the Table.

Table. Quality Improvement Topics Chosen by the Residents (in Chronological Order 2005-2008)

	Resident teaching of ambulatory care topics to medical students
	Resident teaching of medical procedures to medical students
	Form, content, and timeliness of hospital discharge summaries
	Hand-off of patients from one resident group to another at change of shift
	Inpatient medication reconciliation
	Rapid access to information needed by residents to provide urgent inpatient care
	Prophylaxis against deep vein thrombosis in hospitalized medical patients
	Ambulatory care for patients with diabetes
	Inpatient care for patients admitted for exacerbations of chronic obstructive pulmonary disease
	Glycemic control for diabetic patients admitted to an inpatient general medicine service
	Ambulatory care for patients with chronic pain

The group reviews the medical literature to determine evidence-based practice for the chosen topic. Often, the residents appraise available clinical practice guidelines. When no guideline is available, they seek systematic reviews or carry out literature searches. They also can obtain unpublished reports on care processes used at other institutions.

The group sets an aim for improvement of the clinical process. As the residents write their aim statement, they also define one or more measures of success and learn that stating the aim and defining the measures are interdependent.

In most projects, the residents then proceed to measure current performance. In some cases, this measurement is strictly quantitative, for example, measuring the percentage of inpatients receiving appropriate drug treatment to prevent deep vein thrombosis. In a project aimed at improving resident-to-resident handoffs, baseline measurement was qualitative. Surveys and focus groups of residents revealed widespread safety concerns about the handoff process.

After measuring current performance, the group investigates its chosen clinical process. The residents devise a flowchart of the process using their own knowledge and interviewing other physicians and nurses who provide care. Gaining a full understanding of the clinical events normally requires a few iterations of interviews and information gathering. Some groups have used fishbone diagrams to understand processes more fully. The teacher introduces other quality improvement tools when they are suitable for understanding the process at hand.

The group next constructs a list of possible interventions and chooses 1 or 2 to test. Each group generates an initial list using structured brainstorming. The list is supplemented by revisiting the medical literature. The group then discusses the advantages and disadvantages of the items on the list, sometimes pausing to seek additional evidence on the effectiveness of interventions under consideration, and then multivotes.

A small-scale test of change is then planned. The group working on patient handoffs planned a revised patient census spreadsheet, which it piloted in one patient care area. A group working on diabetes care planned a pharmacist-staffed hypertension clinic.

Each project concludes with a formal presentation by the group to the department leaders, fellow residents, and medical students. Some of the care changes proposed by residents have been adopted in the hospital, for example, changes in care to prevent deep vein thrombosis.

Assessing Progress in Regions Hospital's Addressing of the Challenges 

The course has specific learner objectives, which are modest but clear. The objectives include gaining understanding of the whole PDSA cycle. However, the objectives are limited to the techniques of process improvement. They do not include acquiring organizational skills such as managing change in a medical group. ACGME does not require programs to teach these skills, but teaching them would add value.

Regions' program and several others have found time for training by scheduling it within an ambulatory rotation.14, 15, 17 However, the Regions program does not permit residents to experience all steps of the PDSA cycle.

The challenge to engage the residents was met by inviting them to choose their own topics. Regions Hospital continues to seek ways to engage the residents in learning the tools of quality improvement, which they commonly regard as unnecessary. The utility of structured brainstorming and multivoting is obvious to them. Flowcharting is less appealing. Fishbone diagrams and other tools are introduced when they promise to be useful, but occasions for introducing all of the tools do not arise in every project. Didactic sessions on tools have not been effective.

The residents readily acknowledge that they hear almost nothing about quality improvement in other portions of their training. Many residents have expressed interest in acquiring knowledge and skills in this area and have expressed delight about what they have learned. Others are puzzled by the silence of their clinical teachers. Others participate in the projects reluctantly; some are scornful, having inferred that quality improvement training is an unimportant accreditation requirement.

Fortunately, the Regions Hospital clinical setting provides good examples of excellent systems for clinical care and quality improvement work. In-house examples are supplemented by encouraging the residents to visit other clinics and hospitals nearby. Despite the successes, some residents have commented that they would prefer to work on actual quality improvement teams along with nurses, pharmacists, and administrators.

The course has been effective in conveying the connection between evidence-based medicine and systems improvement. After topic selection, each project proceeds to a review of the literature. When the group moves on to plan changes in care processes, residents clearly see that the purpose is to achieve reliable evidence-based practice.

Finally, assessment of resident competence is not well developed. Only group performance is assessed, not individual competence. However, the Regions program has set the stage for individual assessment by developing explicit objectives that could be used to define operational measures.

Actions Needed to Overcome the Challenges 

Regions Hospital continues to improve the training process with each new rotation, but challenges persist. For example, the program has yet to include hospital medical directors, nursing directors, and administrators in the training of residents in quality improvement. Another goal is to have residents participate directly in interprofessional improvement teams.

ACGME and ABIM can encourage better training by clarifying and strengthening their standards incrementally. The current ACGME curriculum requirement is stated in general terms.20 The ABIM certification examination does not include questions on systems improvement.21 There is no explicitly stated standard for program directors to use in determining whether residents are competent in practice-based learning and improvement.6 Improvements in medical school curricula also would be helpful. The current accreditation standards for US medical schools do not mention quality improvement methods.22 Teachers need to become more rigorous in evaluating the effectiveness of resident training.23

Medical education must be transformed. In the 20th century, science replaced clinical experience as the basis of medical practice. Now, systems thinking needs to be integrated into medicine. Students need to know that medical practice is a collaborative endeavor, requiring the input of many professionals working in systems that enable them to interact effectively. Teachers must convey that the excellence of individual clinicians and the excellence of clinical systems are intertwined and that these systems can be improved.