Purpose: Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum—including real QI work—into the routine work of inpatient internal medicine teams.
Method: A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts.
Results: Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge.
Conclusions: Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.
Dr. Ogrinc is senior scholar, White River Junction VA Medical Center, and associate professor of community and family medicine and of medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Ms. Ercolano is senior value measurement analyst, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Dr. Cohen is associate program director and assistant professor of medicine, White River Junction VA Medical Center and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Ms. Harwood is research associate, White River Junction VA Medical Center and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Dr. Baum is associate chair of clinical quality and professor of medicine, University of Minnesota Medical School, Minneapolis, Minnesota.
Mr. van Aalst is industrial engineer, White River Junction VA Medical Center, White River Junction, Vermont.
Dr. Jones is VA Quality Scholar, White River Junction VA Medical Center, and instructor of community and family medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
Dr. Davies is assistant professor of surgery, Department of Surgery–Otolaryngology, Geisel School of Medicine at Dartmouth, VA Outcomes Group, White River Junction VA Medical Center, Hanover, New Hampshire.
Funding/Support: This material is based on work supported by the Department of Veterans Affairs Office of Health Services Research and Development grant EDU08-426 and by the use of facilities and material at the White River Junction VA in White River Junction, Vermont.
Other disclosures: None reported.
Ethical approval: This study was approved by the White River Junction Veterans Affairs Medical Center research and development committee and the Dartmouth College committee for the protection of human subjects.
Disclaimer: This work is that of the authors and not official policy of the Department of Veterans Affairs or the U.S. Government.
Previous presentations: Academy for Healthcare Improvement Scientific Symposium, Orlando, Florida, December 10, 2012.
Correspondence should be addressed to Dr. Ogrinc, 215 N. Main St. (111), White River Junction, VT 05009; telephone: (802) 295-9363; e-mail: Greg.Ogrinc@va.gov.