Jenson, Hal B. MD; Dorner, Douglas MD; Hinchey, Kevin MD; Ankel, Felix MD; Goldman, Stuart MD; Patow, Carl MD
Active engagement of both the designated institutional official (DIO) and the program director (PD) is essential to implement any change in graduate medical education (GME). Strategies that are established by the Accreditation Council for Graduate Medical Education (ACGME) or other entities are, in the end, effective only as implemented at the individual program level. The interpretation of national standards or guidelines, and the specific adaptation to the vagaries of individual institutions and programs, can lead to significant variability in implementation and potentially in outcomes. Variability occurs between programs within the same institution and between some specialty programs at different institutions.
Among the most important goals for GME are to foster improvements in health care quality, patient safety, and cost-effectiveness of care. There have been a number of efforts to achieve these goals, including the work of the National Initiative, sponsored by the Alliance of Independent Academic Medical Centers (AIAMC). The National Initiative was launched in 2007 to improve quality of care, patient safety, and GME among participating organizations through leadership and integration of GME in quality improvement and patient safety initiatives. In this report, we address (1) the key roles of both the DIO and the PD in achieving the goals of the National Initiative, (2) the challenges these goals presented to each role, and (3) some of the tactics drawn from the experiences of the National Initiative in overcoming those challenges.
The AIAMC is a national membership organization whose members are major academic medical centers (i.e., teaching hospitals) and health systems committed to quality patient care, medical education, and research (see www.aiamc.org). The mission of the AIAMC is to assist members in achieving the highest standards of patient care through the integration of medical education and research into the clinical mission.
The goal of the National Initiative, sponsored by the AIAMC, was to recognize and demonstrate the role of GME in improving patient care and safety. In late 2006, the AIAMC Board of Directors and the National Initiative Steering Committee invited all of the approximately 60 AIAMC institutional members to apply for participation in the National Initiative. In 2007, 34 participants from 21 AIAMC-member academic medical centers were selected to participate on the basis of their demonstrated leadership in using GME as a key driver to improve health care quality, patient safety, and the cost-effectiveness of care.
Patient care and medical knowledge have defined the traditional core of GME, but these two critical elements of medical education are now just two of six general competencies adopted by the ACGME in 1999.1 Beginning in July 2002, compliance for all six competencies was required by the ACGME, and residents must be rated by their PD as competent in each of them. Educational leaders in academic medical centers have sometimes struggled initially to understand, interpret, and implement all of these new competencies.2,4 One competency, Practice-based Learning and Improvement (PBLI),4 is conceptually linked to quality improvement (QI), defined as the methods of improving processes of clinical care (List 1). Much has been written recently about PBLI, and there remains variable and inconsistent implementation across institutions and across training programs.2–8
In a parallel and largely separate process, the past two decades have also seen a heightened national health focus on patient quality and safety, which is variably integrated with GME at academic medical centers. Embedding safety and quality issues into GME is a key challenge.8 To facilitate the integration of GME and QI, and to create an educational resource for academic leaders, the AIAMC, as mentioned earlier, sponsored a National Initiative that began in 2007. The initiative linked residency programs in 21 academic medical centers across the United States in efforts to integrate academics and quality through performance improvement projects coordinated at a national level. This was not “quality of education” but “education about quality.”
The DIO, serving the institution on behalf of all GME programs at the sponsoring institution, and the PD for each GME program, are in key leadership positions to facilitate integrating active health care quality initiatives within GME, and to embed process improvement principles as part of residents' education. Active program monitoring and continual review and renewal through self-assessment for program improvement are requirements for a successful DIO and PD.
The environment within the institution and the department modulates both the initiation and the success of program change. Since 1998, the ACGME has required that each institutional sponsor of GME designate a DIO. The ACGME requirements stipulate that the sponsoring institution must have “an organized administrative system, led by a DIO in collaboration with a Graduate Medical Education Committee” with the “authority and responsibility for the oversight and administration” of all ACGME-accredited programs and “assuring compliance” with all ACGME program and institutional requirements.9 From these ACGME requirements, the DIO has the duty and obligation for oversight of all ACGME-accredited programs to develop and implement patient safety and quality-of-care education and initiatives within the GME framework. For an illustration of the DIO's role, see Chart 1, “Case Study of the Role of the DIO in Quality Improvement” in this article.
DIO Responsibilities: Insights From the National Initiative
A survey conducted during 2004 of 243 DIOs revealed wide variability in DIO characteristics, roles, and responsibilities.10 In 2008, the Group on Resident Affairs of the Association of American Medical Colleges (AAMC) established “Core Competencies for Institutional GME Leaders/Designated Institutional Officials.”11 Each of the 11 competencies has several elements that define three levels: competent, proficient, and expert (see List 2).4 At least six of the DIO competencies (1, 2, 3, 4, 10, and 11 in List 2) were served through participation in the National Initiative, including at least three (1, 2, and 3 in List 2) at the expert level. In the following paragraphs, we discuss these six DIO competencies.
Maintaining the institution's ACGME accreditation
An element of the AAMC DIO competency category “Maintaining the Institution's ACGME Accreditation” (see List 2) that is ranked at the expert level is “builds upon accreditation requirements to improve the quality of the institution's overall GME enterprise.”11 This expertise is supported through the DIO's ability to link both PBLI and also the ACGME general competency, Systems-based Practice (SBP), with improving patient care (see List 1).4 Outstanding patient care reinforces another ACGME general competency, “Patient Care,” which requires that “residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.”
Another element of this DIO competency at the expert level states that the DIO “advocates for GME in the institution, strengthens the institutional commitment, and negotiates successfully for resources.”11 An early requirement of National Initiative participants was to arrange a meeting with the hospital chief executive officer and the hospital director of quality. The aims of the meeting were to develop a common understanding of the QI priorities for the institution and to align the resident projects with the goals of the hospital for improving patient care. This is a critical first step.12 The experience of the participants in the National Initiative demonstrated that collaboration with outreach to hospital leadership and administration, including the institutional quality officer and the chief executive officer, significantly strengthens institutional commitment to GME. As residents are recognized as being engaged in solving the quality challenges of the hospital, the hospital administration and board of directors develop even greater mutual interest in supporting the GME program.
Participating in the National Initiative satisfied a third element of this DIO competency at the expert level, in that the DIO “serves on a national level as an education resource to other GME leaders in maintaining Institutional accreditation.”11 Through five national face-to-face meetings, monthly phone calls, reports, and publications, the participants in the National Initiative created a vibrant network for social support for sharing ideas and solving specific problems related to QI, residency education, and advancement of GME. Resources developed by the National Initiative, including literature reviews, are freely available as educational resources (see www.aiamc.org).
Maintaining the institution's residency programs' ACGME accreditation
One of the responsibilities of the DIO in maintaining accreditation is to monitor compliance with the six general ACGME competencies.11 The National Initiative provided a framework for initiation and completion of QI projects that directly addressed PBLI and SBP, two of the six general ACGME competencies.
Improving the institution's education program
DIO participants in the National Initiative demonstrated at least seven skills of the AAMC DIO competency to improve the institution's education program.11 The first two, listed below, are at the proficient level, and the other five are at the expert level.
* Develops processes to monitor each program's progress implementing competency-based structure, tailored educational offerings, and outcome-based assessments within the ACGME's six competency domains
* Promotes and monitors scholarly activities of residents and teaching faculty
* Creates educational opportunities for PDs and residents that move local culture forward
* Educates and empowers PDs and residents to contribute in their program's evolution towards competency-based education
* Plans strategically how incremental steps will move the institution's educational culture forward
* Creates collaborative educational initiatives across multiple specialty programs
* Collaborates with other institutional leaders and aligns educational outcomes with patient care outcomes to promote educational and clinical excellence
One of the expert elements, above, for this competency, focusing on collaboration with other institutional leaders and aligning educational outcomes with patient care outcomes, is at the heart of the National Initiative. Not only did DIOs collaborate with chief executive officers, board members, chief quality officers, and chief financial officers at their own institutions, but they interacted with these leaders from other organizations as well. The intent of the National Initiative was improvement of the quality of patient care outcomes, which was aligned across institutions through three themes: handoffs and transitions of care, reducing hospital-acquired infections, and medication safety.
Developing and supporting residency PDs
It is an obligation for the proficient DIO to serve as a readily available expert resource and mentor for PDs. Through participating in the National Initiative, PDs had guidance and support in developing and sustaining QI projects, as well as strengthening interinstitutional networking with PDs in other independent academic medical centers. The work of the National Initiative certainly “encourages program director participation in national professional development opportunities (AAMC, ACGME, program director associations),” an element at the proficient level of this DIO competency.11
Working in the health policy context
From the beginning, the National Initiative was conceptually linked to the Institute for Healthcare Improvement (IHI) and the Institute of Medicine agendas to improve the quality and safety of patient care. Linking the National Initiative with the IHI's “5 million lives campaign” significantly strengthened the alignment of the participating residency programs with the clinical quality goals of the hospitals and hospital boards. This observation was important in the success of the National Initiative collectively, as resident QI projects were perceived by hospital leadership as supporting, rather than competing with, hospital quality initiatives.
Developing further as a GME leader
This AAMC DIO competency includes both personal and institutional components.11 At the expert level, the competency, “Contributes to the creation and implementation of leadership development courses provided by professional organizations,” embodies the formative work of the participants in the National Initiative as they developed the program and tools for the interinstitutional initiative. Participants in the National Initiative became leaders of QI initiatives in their individual hospitals, in some cases serving as the designated academic leader or DIO as well.
PD Responsibilities: Insights From the National Initiative
Unlike the DIO competencies, which have been formally delineated,11 PD competencies have not been explicitly defined. A competency-based PD job description has been published.13
PDs have traditionally focused their curricular efforts on knowledge transfer and procedural competency. It is just as critical that PDs ensure adequate time in the curriculum for experiential QI involvement for residents.14 To integrate residents in hospital program improvement initiatives, each PD must be personally familiar with current and planned hospital QI initiatives in order to allot resident time that facilitates residents' participation. Each specialty and residency program should identify those initiatives and outcomes that are of particular relevance to the specialty and institution. Residents' participation should include both projects that are aligned with hospital QI initiatives and also service on standing hospital and department QI committees. The PD should aid in developing a culture of collaboration with nursing, pharmacy, and other health care providers to facilitate residents' integration in multidisciplinary teams, which is essential to success.8 The PD must ensure that residents have the opportunities, are empowered, and are actively engaged in relevant QI projects.
The PD should be an advocate for residents' participation in projects that provide meaningful opportunities for residents as well as for the faculty who serve as mentors for the residents. Project selection was important in the National Initiative to address issues relevant within the program. The PD must ensure sufficient expertise, time, and needed resources for the residents' QI projects to optimize these as meaningful learning experiences for the residents. The greatest success is derived from residents' involvement in projects that are innovative, longitudinal, and experiential.
The PD may also serve as a mentor for other faculty to develop expertise as they become the champions for QI projects in the residency program. This is an opportunity to recognize such a champion as an associate PD. The National Initiative is a model of how a PD can coordinate training of faculty and residents to successfully participate in QI projects.
For the DIO and PD, integration of QI into the residency program has the advantage that collaborative resources are readily available from institutional sources, including the institutional chief quality officer, as well as from national resources such as the Open School of the IHI (http://www.ihi.org/IHI/Programs/IHIOpenSchool), publications from the National Quality Forum (www.qualityforum.org/publications/reports), the American Board of Internal Medicine's Clinical Preventative Services Practice Improvement Module, and other specialty-specific resources.
Despite what should be a natural collaboration, in many institutions QI initiatives and GME have developed in separate silos. Typically, QI opportunities are identified and projects are developed that focus on the interests and needs of attending physicians, nurses, and allied health care providers. Residents and fellows are sometimes excluded, using rationales that they are too busy already providing care to patients, or that they are not “permanent” employees and are only at the hospital a short time.
Given the central role of residents in patient care, such rationales are short-sighted. Residents and fellows have tremendous working knowledge and unique insights about the functioning of a hospital and how patient care is actually delivered. They experience directly the processes of care and the breakdowns in those processes. They are bright, creative, dedicated to improving patient care, and adept in developing workarounds that usually improve patient care even in suboptimal systems. The hospital system often inhibits residents' involvement because of patient care priorities, inertia, and the perception by hospital leadership of residents' relative lack of experience in fixing these processes and addressing their complexities. If given time and responsibility, however, residents could contribute substantially to correcting these breakdowns and developing new systems to fix these bundles of related clinical processes.
One approach is to integrate QI projects from individual residents, resident teams, and residencies in a “bottom-up” approach to institutional QI processes to complement “top-down” efforts. Other organizational resources or players are then engaged, depending on the degree of integration or need for resources or mentorship.15 If residents are not recruited as part of the systems solutions, their workarounds to “fix the problem” may actually hide the real problem and delay the appropriate improvement. The wrong “fix” may actually make the appropriate solution more difficult to implement. This is “working harder,” not “working smarter,” and it is the antithesis of QI. Residents' knowledge and insights about process complexities and realities need to be incorporated into hospital QI efforts. Residents as learners are less encumbered by traditional processes and are usually early adopters, both of new technology and of focused initiatives. Their unique position provides an important opportunity to effect change more rapidly. Academic hospitals should aggressively capitalize on this opportunity to drive faster adoption of desired behaviors across the institution (see the boxed text, “Case Study of the Role of the DIO in Quality Improvement” in this article). One obstacle is that some faculty who are expected to mentor residents may not uniformly have the training and skills to effect desired changes.16
The ACGME recognized the critical need for all physicians to have competency in continuous QI with the competency in PBLI (see List 1). This competency, as initially approved by the ACGME, “involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.” Residents are at a particularly formative stage in their career development, where introduction of QI principles is most valuable. They are at a transition of thinking of one patient at a time to thinking across a system and a population of patients. A pilot study showed that a workbook-based, project-focused curriculum improved self-efficacy in identifying appropriate measures, benchmarking comparisons and best practices, and implementing structured change using Plan-Do-Study-Act methodology.17 Participating in QI projects directly supports developing PBLI and SBP competencies and also provides the framework for developing competencies in teamwork, communication, and interpersonal skills.
There have been seismic changes in GME and health care in the past decade. The ACGME has established the six general competencies that all graduating residents must demonstrate. These competencies are being adopted at other levels of education, becoming part of the undergraduate medical education curriculum as well as continuing medical education objectives. They are also used by state licensing and specialty certification boards and The Joint Commission as the core for documenting continued competency in practice. For example, the American Board of Family Medicine requires a practice improvement module as part of its maintenance of certification process. The American Academy of Family Physicians developed the METRIC (Measuring, Evaluating, and Translating Research Into Care) program to facilitate specific practice improvement methods in evaluating one's clinical practice. In the future, specialty certification boards may require and facilitate ongoing physician involvement in QI.18 These developments reflect the realization that it is necessary to develop learners and practitioners with lifelong learning skills. This, in turn, is mandated by the continuing growth of medical knowledge and the reality that a practitioner cannot be equipped to be competent without instilling the desire and skills for continued learning.
Regarding QI, the challenge is not just to increase awareness and learning about QI but to use this as a method to achieve improved clinical outcomes. It has been stated that “high-quality learning is impossible in the absence of high-quality patient care; likewise, high-quality patient care is impossible without high-quality learning.”19 The National Initiative was proof-of-concept of the synergy of GME with improving patient care, which has been validated also by others.6,12,20 The National Initiative also provided a fertile testing ground that led to several findings of special interest to DIOs and PDs that can be extrapolated across other GME programs.
One unmet need is a defined, standardized resident curriculum for QI to provide residents with the necessary tools and skills to become competent. The Open School of the IHI, the American Board of Internal Medicine's Clinical Preventative Services Practice Improvement Module, and other print and Web-based materials are potential resources that might be used as part of a solution.5,16,20–22 Developing the appropriate QI curriculum requires collaboration of DIO and PD physician educators, nonphysician educators, QI experts, and residents themselves. An effective QI curriculum should begin early in medical school, continue with advanced training during residency and fellowship, and be continued as lifelong cycles of analyses and improvements. Part of the training for every resident must include hands-on, direct participation in QI projects that also provide opportunities for team building and leadership development. The DIO and PD can establish these requirements at the institution or in the training program as a component of implementing the ACGME PBLI competency (see List 1).
Prospective DIOs and PDs should be mentored and proactively developed to attain the skills necessary to succeed when they assume these responsibilities. A survey of DIOs conducted during 2004 found that having served on quality assurance/performance improvement committees at their institution was beneficial in fulfilling their DIO responsibilities.23 PDs who do not have experience in hospital QI initiatives should be encouraged to pursue further training and gain additional experience in quality and patient safety. Faculty who show potential as medical educators and leaders should gain personal, rigorous experience in QI initiatives as part of their own preparation for these roles.
One beneficial aspect of the National Initiative is that it provided a recognized, scientific and social forum for sharing best practices across participating institutions. This multiorganizational collaborative facilitated cross-institutional information sharing, collaboration, and social support that contributed to faster and greater team success. Multiorganizational collaborative QI teams have been shown in other settings to contribute to individual and collaborative success24 but do not alone guarantee accelerated improvement.25 Just as the National Initiative achieved success at the institutional level for integrating GME with quality initiatives, a broader effort is necessary to recognize and incorporate QI as a mainstay of all professional meetings rather than isolate this field in separate “QI” meetings.
The critical contribution of residents in QI at academic medical centers is innately evident but relatively slowly nurtured. There is now a breadth of experience and success formally involving residents to varying degrees in QI.2–8,16,20,22 Residents are important members of the health care team and can contribute greatly to improving the quality of care and the patient experience. Sharing information and empowering residents as part of the process are critical to sustained improvements.26 Constraining residents within strict parameters, permitting participation at arm's length, and not allowing residents to challenge prevailing ideas impede our institutional progress and also preclude effective development of tomorrow's physician leaders and patient advocates.
The National Initiative modeled experiential learning that combined case-based, hands-on practical experience with written objectives.27 There were linkages between cognitive skills, mentoring, practical experiences, and repeated self-reflective evaluations. Active participation of residents in QI projects incorporating team-based experiential learning may be essential for developing residents' competence in PBLI.2,21 However, hands-on, practical experience is an important adjunct and not a replacement for knowledge and clinical judgment.28
Team building and leadership development were tangible outcomes of integrating GME with patient care and safety initiatives as part of the National Initiative. The hierarchical system of residency education can be described as a team network. The DIO collaborates with the PD, the PD collaborates with the residents, and the residents assume leadership responsibilities as they are mentored in QI projects. Collaborations should be promoted and nurtured at all levels—between residents in different programs at the same institution, PDs within the same institution, and PDs and DIOs across different institutions. The leadership skills developed by residents are perhaps the most consequential outcome of the National Initiative. Residency training has historically afforded insufficient attention to leadership competencies.29 Mentoring residents by fostering greater interest, facilitating acquisition of knowledge, nurturing expertise, and helping develop greater self-awareness for self-reflection all serve to establish habits during residency training that are the foundation of being a lifelong learner. Problem-solving skills and a commitment to lifelong learning have been identified as key competencies for developing physician leaders.30 The role of the DIO and PD in creating opportunities to develop problem-solving skills and team and leadership skills is critical. Success during residency portends developing lifelong competency in PBLI, which the ACGME expects and modern health care delivery requires.
Residency training provides a unique opportunity to meet a critical need to improve patient safety and the quality of health care. The DIO and PD individually, and the DIO–PD and also PD–PD partnerships, are critical to meet this need. The DIO has both the mandate and obligation to integrate QI initiatives into residency education to drive improved patient care and patient safety. DIO leadership, along with chief quality officer leadership, is critical to establish experiential learning as the mode of institutional QI within residency programs. DIO leadership is also critical to establish the manner of QI as being focused on building teams that permit residents to both follow and lead. PD leadership is critical to establish the mechanisms to support identifying needs and implementing specific projects. The PD ultimately must tailor and refine the integration to the needs and opportunities of the specialty, the residency program, the individual residents and mentors, and the specific QI project. Integration across these components, coupled with solving meaningful clinical problems, creates a strong impetus for residents to individually and collectively embrace QI and inculcate these skills into their own learning portfolios.
The significance of achieving success in this endeavor cannot be overstated. It should be considered only a partial success to change a residency program or even an institution. More importantly, shaping and embedding lifelong learning and competency skills for PBLI during residency training can have an impact on patient care for decades. As each generation of learners builds on previous successes, even greater successes can be imagined and achieved.
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