Innovating Graduate Medical Education at the Clinical Learning Environment: The Enhancing Quality Improvement for Patients Rotation.
In 2000, the Institute of Medicine (IOM) released To Err is Human and Crossing the Quality Chasm, the findings of which led the IOM to enunciate The 6 Aims for Improvement, defining quality health care as safe, timely, effective, efficient, equitable, and patient centered. (1) Following these reports, the Department of Health and Human Services published Federal Patient Safety and Quality Improvement; Final Rules, and the Association of American Medical Colleges (AAMC) responded with the AAMC Policy Guidance on Graduate Medical Education: Assuring Quality Patient Care and Quality Education. These policies and regulations were part of the impetus for the Accreditation Council on Graduate Medical Education (ACGME)'s creation of the Common Program Requirements, the Next Accreditation System (NAS), and the Clinical Learning Environment Review (CLER). (2,3,4)
Section VI of the ACGME Common Program Requirement, broadly titled The Learning and Working Environment, details expectations for residency education in the areas of patient safety (PS) and quality improvement (QI) (Table 1).
Additionally, the CLER program includes focus areas on QI/PS, encouraging resident participation in reporting and investigation of errors, unsafe conditions, and near misses, including involvement in interprofessional teams aimed at promoting safe care, improving systems, processes, and patient outcomes. (5,6) The implementation of these requirements has been addressed by training programs in a variety of ways such as didactic training, assignment of residents to existing programmatic and discipline-specific QI and PS projects, fostering de novo QI and PS projects, creation of QI/PS training blocks, and intermittently dispersing QI and PS training throughout residency. Training programs have identified the need to incorporate a combination of didactic training and experiential learning in order to reinforce QI terms and methodologies. Various approaches to experiential learning exist but have included outlining general strategies for improving quality, discussing substantive topics such as medication safety, encouraging resident engagement with hospital QI activities and case studies such as root cause analyses, as well as attendance at committee meetings. Additionally, residents have worked closely with faculty mentors to design and implement an independent study project that affects practice at the institution. (7) Overall residents have reported high levels of comfort by applying Practice Based Learning and Improvement (PBLI)-related knowledge and skills. Studies have concluded that a PBLI curriculum that is centered on practice-based quality improvement projects can fulfill the objectives of the ACGME competency while accomplishing sustained outcomes in quality improvement. (8)
In order to meaningfully address areas related to PS and QI in Section VI, the Learning and Working Environment, we created a collaborative elective resident rotation called Enhancing Quality Improvement for Patients (EQuIP). The elective is set within our primary teaching site, University Medical Center New Orleans (UMCNO) and is unique for its interdisciplinary, multimodality and interprofessional structure.
The EQuIP rotation curriculum was designed by the local subject matter experts involved with providing resident supervision. The rotation was designed as either a two week or a four week elective rotation, where funding is provided by the training program from already established hospital pay-lines. Daily rotational expectations are customized by the supervising experts based on the rotators and their other care responsibilities (eg. continuity clinic, program didactics, call schedule). Each resident has access to a where a day-to-day calendar of events is kept updated. Multiple educational modalities are employed including self-directed learning, small-group didactics, and experiential active learning activities. Residents on the rotation complete six Institute for Healthcare Improvement (IHI) modules throughout the course of their rotation (either two weeks or four weeks). (QI 102, 103, 104; PS 101, 102, 201) (9). They also participate in three didactic sessions covering quality improvement and patient safety concepts and methodologies, the relevance of QI/PS in graduate medical education, and clinical site specific specific committees, accreditation requirements and how these ft into the care that the residents and faculty are providing. Small-group sessions are held in the fields of QI/PS and include discussions about the completed modules as well as interactive reviews on the following topics: introduction to QI, PS, quality management and process improvement (PI), overview of UMCNO's Safety, Quality and Risk department, overview of the ACGME CPR, and the CLER focus areas in PS and QI, education in QI methodology, utilization of publicly reported databases for QI and PS information and the hospital's internal metric collection system and interprofessional oversightstructure called the Comprehensive Quality Management (CQM) committee. Experiential learning is achieved through: attendance and participation in hospital and medical staff committees, including the Comprehensive Quality Management committee; participation in currently operational PI workgroups and QI/PS projects (including but not limited to Trauma, Code Blue, Critical Care Committee, etc); and by participation in root cause analyses and disclosure reporting events. Participation in the daily Quality Huddle is also facilitated; the quality huddle is an interdisciplinary team which works to improve communication and resolves issues before they impact patient flow and safety. A sample schedule from an EQuIP rotation can be seen in Figure 1.
Figure 1: Sample Schedule for EQuIP Rotation Sample Schedule for EQuIP Rotation Monday Tuesday Wednesday 11/1 8:30 AM Quality Huddle 1:00 PM Patient Safety Rounds 11/6 8:30 AM 11/7 8:30 AM 11/8 7:00 AM Quality Huddle Quality Huddle Anesthesia/OR 1:00 PM 12:00 PM Committee Multidisciplinary IM Case Conference 8:30 AM Trauma Meeting 1:30 Quality Huddle UMCNO Quality Didactic 1:00 PM Lecture Medical Records Committee 1:00 PM Patient Safety Rounds 11/13 8:30 AM 11/14 8:30 AM 11/15 8:30 AM Quality Huddle Quality Huddle Quality Huddle 1:00 PM 1:00 PM Multidisciplinary Patient Safety Rounds Trauma Meeting 11/20 8:30 AM 11/21 8:30 AM 11/22 8:30 AM Quality Huddle Quality Huddle Quality Huddle 1:00 PM 12:00 PM 9:00 AM Multidisciplinary Pharmacy and Nurse Council Meeting Trauma Meeting Therapeutics Committee Meeting 11/27 8:30 AM 11/28 8:30 AM 11/29 8:30 AM Quality Huddle Quality Huddle Quality Huddle 10:00 AM 10:00 AM Transfusion Review Mock RCA Committee 12:00 PM SHIP Conference Monday Thursday Friday 11/2 8:30 AM 11/3 8:30 AM Quality Huddle Quality Huddle 12:00 PM 9:30 AM UMCNO Medicine Required EQuIP Committee Meeting Rotation Orientation 2:00 PM Grievance Meeting 11/6 8:30 AM 11/9 8:30 AM 11/10 8:30 AM Quality Huddle Quality Huddle Quality Huddle 1:00 PM 11:30 AM Multidisciplinary Stroke Committee Trauma Meeting 2:00 PM Grievance Committee 11/13 8:30 AM 11/16 8:30 AM 11/17 8:30 AM Quality Huddle Quality Huddle Quality Huddle 1:00 PM 2:00 PM 1:30 PM Multidisciplinary Grievance Committee GME Didactic Lecture Trauma Meeting 11/20 8:30 AM 11/24 11/25 Quality Huddle 1:00 PM Multidisciplinary Trauma Meeting 11/27 8:30 AM 11/30 8:30 AM Quality Huddle Quality Huddle 10:00 AM Transfusion Review Committee
Rotating residents are required to both perform a gap analysis as well as design a viable QI/PS project, then successfully present both to key stakeholders from administrative, nursing and physician groups. The presentation must demonstrate understanding of the core elements and tools (root cause analysis, flow charts, control charts, etc.), a succinct description of the project including scope; the case for change; objective, quantifiable performance measures; any pilot data, and goals to be achieved (future state). Residents must be able to identify potential barriers; and are asked to submit a draft timeline for completion of the project. (In accordance with the LSUHNO IRB Policies and Procedures Guidebook, the authors of this brief report deem this study exempt pursuant IRB policy number 5.20). Resident supervision is assigned depending on the activity but is consistently provided by QI/PS content experts among the faculty physicians, staff nurses or pharmacists, and hospital leadership personnel from the Quality and Risk departments.
The effectiveness of the EQuIP rotation in meeting its learning objectives is analyzed by comparison of pre- and post-rotation testing of 100% of participants; as well as by rotation effectiveness survey. Pre- and post-test questions were written by staff and faculty leadership involved with the EQuIP rotation. The pre-rotation exam is given on day one and the post-rotation exam is given on the final day of the rotation block. Questions are structured to determine knowledge of: core concepts of QI/PS processes; specific tools to devise an action plan; core principles of value based care; process for reviewing the qualification of a practitioner; and specific phases of a process improvement project. The rotation effectiveness survey asks aboutresidents' perceived enhanced knowledge in QI/PS and the degree of value obtained during EQuIP in preparing for future medical practice. Residents are asked to grade each item across a five-point scale ('1' equates to strong disagreement with attainment of knowledge; '5' equates to 'strong agreement' with attainment of knowledge of skills).
Finally, organizational impact of the rotation is also measured by monitoring the number of projects that have arisen from EQuIP. Project aims are archived and maintained in a searchable database of all resident-led projects, accessible to all residents and care providers. Projects can be searched by key word, by major heading or by project lead. Data is updated annually and progress in each project is assessed and reviewed.
Between 2014 and 2016, 41 residents from five medical specialties rotated on EQuIP. This included residents from pathology (15), radiology (9), internal medicine (9), emergency medicine (7), and neurosurgery (1). Taken as a percentage of the total resident complement, this equates to roughly 10% of all rotating residents, and residents ranged from second- to fourth-year of residency. This academic year, awareness of the rotation has grown and trainees from Nephrology, Pulmonary/Critical Care, and Plastic Surgery are also expected to participate. The pre- and post-rotation test results demonstrated significant improvement in rotating residents' knowledge of principles and processes of QI/PS/QM/PI (Table 2).
On the effectiveness survey, rotating residents rated every item at a score of '4' or higher, with an average rating of 4.35 (Table 3).
Review of the project database maintained by the EQuIP leadership revealed 85 distinct resident-led QI or PS project proposals over the course of the two academic years. Furthermore, the database revealed that rotating residents had submitted and presented nine poster presentations on their EQuIP work. Examples of these proposals include: Transition of Pediatric Patients to Adult Care; Reduction of Time of Specimen Placement in Formalin; and Improving CT Study Appropraiteness.
The interprofessional, multimodal, and interdisciplinary approach (comprised of physicians, nursing, and data/quality management analysts) modeled in EQuIP to teach residents about quality improvement and patient safety is both unique and effective. While participation by trainees has not extended to all learners in our environment (currently 10% participate), through increased awareness we are seeing more "buy-in" from program directors who have found thisrotation to be a valuable adjunct to their teaching methods. By structuring a curriculum in this way, residents were able to meet key learning objectives in all six ACGME core competencies including, but not limited to: advancing knowledge in key PS/QI concepts and tools (medical knowledge), defining care quality as a cost variable (medical knowledge), understanding epidemiologic risk factors and prevention strategies surrounding medical error (medical knowledge), reporting of PS events (medical knowledge), generation of ideas for enhanced care delivery systems (patient care, practice based learning and improvement and systems based practice), and confidence in effective communication strategy for us with the entire health care team (interpersonal and communication skills, professionalism, systems based practice). Added deliverables for resident rotations such as EQuIP include preliminary design of trainee- led PS/QI projects already vetted by institutional quality experts and stakeholders involved. And finally, health care organizations participating in educational programs such as EQuIP also benefit from expanded insight into which organizational areas perceived by residents to be in need of structured improvement projects, and by enhanced health care team coordination and communications that can ultimately drive improved outcomes.
Institutions interested in engaging in curriculum similar to that described in the EQuIP rotation, need to first detail their own learning objectives, and then identify their own local expertise in the areas of PS/QI. The collaborative nature of a rotation that involves nursing, physician and administrative leadership has the potential to be highly effective, but significant buy-in from all stakeholders must be ensured. Future development of the rotation would seek to incorporate feedback from the learners about the curriculum and expands its reach across the clinical spectrum to more specialties.
The EQuIP rotation at LSUSOM and UMCNO is a unique, interprofessional educational experience, for residents of a variety of disciplines. The rotation's combination of didactics, online educational modules, and practical experiences at the clinical learning environment is effective and prepares residents for future quality and safety challenges in practice. The rotation promotes meaningful participation in system wide initiatives aimed at organizational improvement, particularly in the areas of patient safety and quality of care delivery and has the potential to expand the scholarly activity portfolio of trainees and organizations. The EQuIP curriculum is readily adaptable to training programs of varying sizes and specialties with sufficient buy-in from program directors and hospital leadership.
(1.) Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
(2.) Federal Register / Vol. 73, No. 226 / Friday, November 21, 2008 / Rules and Regulations.
(3.) AAMC Policy Guidance on Graduate Medical Education: Assuring Quality Patient Care and Quality Education, Acad Med. 2003 Jan;78(1):112-6.
(4.) Weiss, KB, Bagian, J P, Wagner, R., Newton, R. (2014) CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment (Executive Summary). J Grad Medical Educ: September 2014, Vol. 6, No. 3, pp. 610-611.
(5.) Wagner, R., Patow, C., Newton, R., Casey, B., Koh, N. and Weiss, K. (2016) The Overview of the CLER Program: CLER National Report of Findings 2016. J Grad Med Educ: May 2016, Vol. 8.
(6.) Bagian, J., Weiss, K. On Behalf of the CLER Evaluation Committee (2016) Overarching Themes: CLER National Report of Findings 2016. J Grad Med Educ: May 2016, Vol. 8.
(7.) Weingart, S. N., Tess, A., Driver, J., Aronson, M. D. and Sands, K. (2004), Creating a Quality Improvement Elective for Medical House Officers. J Gen Intern Med, 19: 861-867.
(8.) Tomolo AM, Lawrence RH, Aron DC. A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum. Postgraduate Medical Journal 2009;85:530-537.
(9.) Institute for Healthcare Improvement. "Introducing the Improved IHI Open School Courses." Retrieved December 7, 2017 from http://forms.ihi.org/improved-courses
Fred Rodriguez, Jr., MD, Treva LIncoln, BA, C. Leigh Peters, and Murtuza Ali, MD are affiliated with Louisiana State University School of Medicine-New Orleans in New Orleans, LA. D. Blady, RN, E. Roslyn Pruitt, RN, and Robin McGoey, MD are affiliated with University Medical Center in New Orleans, LA.
Treva Lincoln can be reached at firstname.lastname@example.org.
Fred Rodriguez, Jr., MD, Treva Lincoln, BA, C. Leigh Peters, D. Blady, RN, E. Roslyn Pruitt, RN, Robin McGoey, MD, Murtuza Ali, MD
Table 1: Excerpts from the ACGME Common Program Requirements (CPR) for residents in the areas of patient safety (PS) and quality improvement (QI) Excerpts from the ACGME Common Program Requirements Core Requirements for Residents CPR Reference for Full Detail Active Participation in PS systems VI.A.1.a).(1).(a) Formal educational activities that promote PS-related goals, tools, VI.A.1.a).(2) and techniques Participation in PS activites that include analysis as well as VI.A.1.a).(3)(b) formulation and implementation of actions Training and experience in QI VI.A.1.b).(1)(a) processes Participation in interprofessional QI VI.A.1.b).(3)(a) activities QI: Quality Improvement PS: Patient Safety Table 2: Comparison of Pre- and Post-rotation Test Scores Comparison of Pre- and Post-rotation Test Scores Pre-Test Score (%) Post-Test Score (%) Average Score 61.11 80.00 Standard Deviation 18.75 20.58 Two tailed T-test P 0.0009 value Table 3: Resident Ratings on Post-Rotation Effectiveness Survey, based on a 1 (Strongly Disagree) to 5 (Strongly Agree) Likert scale. Survey Question Rating Average Upon completion of this rotation, you are able to explain the structure of the UMCNO EQuIP Rotation. 4.46 At the end of this rotation, you are conversant in the principles of basic methodologies and processes 4.38 used in QI/PS. (For example, RCA, PDCA, PDSA, etc.) At the end of this rotation, you can explain the UMCNO quality and safety management/improvement 4.00 structure, policies and processes including RCA and PI Team initiatives. At the end of this rotation, you feel comfortable discussing regulatory standards for quality and safety, 4.31 including The Joint Commission National Patient Safety Goals. At the end of this rotation, you are able to identify UMCNO's central priorities for quality and safety. 4.38 During this rotation, you experienced meaningful participation in one or more of the following: 4.54 UMCNO committee meetings, RCA's, Process Improvement Teams, CLER tracers and/or event investigations occurring in the clinical setting. At the end of this rotation, you can explain how this rotation fits into the ACGME competencies and 4.54 milestones - and the rationale behind these connections. At the end of this rotation, you have thoughtfully considered the intent and impact of the CLER 4.15 program. At the end of this rotation, you understand the EQuIP program - goals, resources, requirements and 4.54 place in the GME structure. At the end of this rotation, you understand the proper processes and methodologies to formulate an 4.46 EQuIP project. At the end of this rotation, you are conversant in your specialty-specific quality improvement and 4.15 patient safety focus areas, indicators and benchmarks. Upon completion of this rotation, you understand the importance of measurement in the outcome of 4.62 patient care. Upon completion of this rotation, you are able to describe epidemiological and system-based risk 4.08 factors and prevention strategies associated with medical erro Upon completion of this rotation, you are able to communicate effectively with multidisciplinary 4.31 teams regarding PS and QI issues and topics. Resident Ratings on Post-Rotation Effectiveness Survey, based on a 1 (Strongly Disagree) to 5 (Strongly Agree) Likert scale.
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|Author:||Rodriguez, Fred, Jr.; Lincoln, Treva; Peters, C. Leigh; Blady, D.; Pruitt, E. Roslyn; McGoey, Robin;|
|Publication:||The Journal of the Louisiana State Medical Society|
|Date:||May 1, 2018|
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