Patow, Carl A. MD, MPH, FACS; Karpovich, Kelly; Riesenberg, Lee Ann PhD, RN; Jaeger, Joseph MPH; Rosenfeld, Joel C. MD, MEd; Wittenbreer, Mary MLIS, MALS; Padmore, Jamie S.
The quality improvement (QI) movement, with its roots in improving manufacturing processes, emerged in health care as a new model for improving quality in the late 1980s and early 1990s.1 Continuous QI, a popular QI method, introduced statistical control methodologies for process improvement and team dynamics into health care settings to improve care.2 Hospitals frequently added QI departments to create QI teams and projects, but they rarely involved medical students or residents. As early as 1993, it was noted that residents were “invisible” as participants in the QI movement in U.S. medicine.3 But awareness of the importance of residents to quality of patient care in academic hospitals and clinics is rapidly changing. Accreditation organizations, national patient safety advocacy organizations, and hospital leaders are increasingly interested in having residents engage in QI projects to improve patient care.
Residency programs remained largely separate from QI activities until the Accreditation Council for Graduate Medical Education's (ACGME's) adoption of the six general competencies in 1999. With the requirement that all residency programs begin integration of the general competencies in 2006, QI techniques were introduced by residency programs as one means of incorporating the competencies of “practice-based learning and improvement” and “systems-based practice” into curricula.4 These competencies, while not prescribing any specific QI methodology, require residents to reflect on the outcomes of clinical practice and to understand the principles of improving the processes of care.
To better understand the effect of resident QI initiatives on patient care, we carried out a literature review to identify examples of QI initiatives in which residents were actively engaged as leaders or active participants and to determine the extent to which those initiatives demonstrated significant improvement in process and care outcomes. We conducted that review in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient Care Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.
A work group of the National Initiative (described above) was established in April 2007; we, the authors of that report, were the members of that group. Our role was to develop resources and write systematic reviews of the literature relevant to the National Initiative's goals. This study was performed as one of a series of literature reviews initiated by that group. To reach consensus about each manuscript, we engaged in regular, substantive discussions about the manuscript's concept and design, such as key questions, inclusion and exclusion criteria, search strategies, and content of the review. The specific topic, appropriate technique, and final presentation of this review are the product of a progressive, iterative, and qualitative process of refinement of the writing and editorial process by all of us.
We explored the literature on resident-led QI projects through electronic literature databases, including MEDLINE, ExcerptaMedica (EMBASE), the cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Education Resource Information Center (see Figure 1).
The initial search was limited to U.S. and Canadian publications in the English language between 1997 and September 20, 2008. The following medical subject headings (MeSH) were used to search the four electronic literature databases mentioned above: hospital teaching, medical graduate education, internship and residency combined with quality of health care with the following exclusions: work hours, duty hours, fatigue, patient safety, nursing, breastfeeding, curriculum, dental clinics, and medical students. All MeSH terms were exploded with the exception of hospital, teaching.
MeSH terms of the articles that fit the criteria were listed, and new searches were performed using the above MeSH terms combined with additional MeSH terms: program evaluation, cost control/methods, sentinel surveillance, risk patient guidelines, risk management, competency-based education, patient care team, continuity of patient care, efficacy, and organization and management of quality circles. All terms were exploded, including hospital, teaching. These additional searches were limited to U.S. and Canadian English-language publications published between 1987 and July 30, 2007.
A final comprehensive search was conducted using the terms housestaff or house officer. Housestaff was mapped to the MeSH terms internship and residency. House officer did not map to a MeSH term. Both terms were put in quotes and were searched using the original MeSH string hospital teaching, medical graduate education, internship and residency combined with quality of health care with the following exclusions: work hours, duty hours, fatigue, patient safety, nursing, breastfeeding, curriculum, dental clinics, and medical students. The search was limited to January, 1987 to September 20, 2008.
To ensure completeness of the search, additional relevant articles were identified by hand-searching the references of included articles. Identified titles were reviewed for inclusion in the study. Articles were archived using EndNote X1 (Thomson Corporation). We analyzed the MeSH terms of the articles that were identified by hand-search, and no pattern of common MeSH terms was detected.
Criteria were chosen to identify QI initiatives in the U.S. and Canadian care systems that incorporate active resident participation; that is, articles were included if they described both a QI intervention in a residency teaching program and integration of housestaff in the QI process or team. Articles were excluded if they did not (1) occur in the United States and/or Canada, (2) discuss a QI project intervention, (3) identify active resident leadership or participation in the QI project, or (4) have a full article available for review. Articles that were published before 1987 or not written in English were also excluded. “Active resident leadership or participation” was defined for the purposes of the study as meaningful inclusion of residents in the leadership, participation, planning, or development of the QI teams or initiatives.
Neither the clinical setting nor the objective of the QI initiative was used as a factor in making the decision about whether to include an article. Articles could include more than one initiative. There was no requirement that there be process or outcomes measures included in the article, although a principle reason for engaging in the literature review was to gain insight into the clinical effectiveness of residents' participation in QI initiatives.
Title and abstract review
All citations, produced from the above MeSH and reference searches, were independently reviewed (C.P. and K.K.). In the first of three phases, the titles of these citations were reviewed for eligibility and categorized as either not applicable or applicable. If disagreement occurred regarding a citation, the abstract was reviewed for further discussion.
The abstracts of all selected citations were independently reviewed (C.P. and K.K.) for eligibility. The reviewers established four groupings to categorize the citations: eligible, not eligible, background article, and possible. Full-text articles were obtained for all articles rated “possible” to assess their proper inclusion status and, in the third phase of the review, were independently reviewed. The possible articles were placed into three groupings: eligible, not eligible, and background article. The full-text articles were retrieved and abstracted for all citations categorized in the final groupings: included, background, and not included articles.
Twenty-eight included articles were abstracted independently (C.P. and K.K.) using a standardized form. All of us reviewed and discussed variations in abstracted data until a consensus was reached. Abstraction disagreements were minor, and all disagreements were resolved through discussion until a consensus was reached. Extracted information included the date of the project, setting, level of resident participation, leadership of the project, whether there were single or multiple projects discussed, and the QI approach that was employed. Each study was categorized as a clinical QI project, a randomized controlled trial, and/or an educational intervention. Additional abstracted data included whether the ACGME or the Institute for Healthcare Improvement was mentioned in the text, the specific topics of the projects, methods used to obtain the data, measurement of the data, outcomes, barriers encountered, participant responses and lessons learned, and evidence of improvement in patients' health.
Characteristics of eligible studies
Twenty-eight articles met inclusion criteria—see Table 1. Among articles that were not included were articles that described QI initiatives that included residents but failed to document their active participation in the QI process or QI teams.5 The range of residents' involvement was variable, from residents engaged in multidisciplinary teams6 and residents' participation in surveys7 to residents' leadership in clinical QI projects.8,9
The included studies were published from 1990 to 2008, with a bimodal distribution of publications peaking between 1996 to 1998, and 2003 to 2008. The three years with the largest number of publications were 1998, 2004, and 2006, each with 5 articles. There was a variable lag between initiation of the QI initiatives and publication of 1 to 7 years, approximately 2.5 years on average.
The QI efforts were primarily performed in urban academic settings. Sites of the QI initiatives included university hospitals (seven), independent academic medical centers (nine), children's hospitals (three), and Veterans Affairs hospitals (two). Four of the initiatives occurred in internal medicine residency programs and five in family medicine residency programs.
Thirteen articles described multiple QI projects, 14 described single projects, and 1 described residents' involvement without specifically describing the nature of the QI initiatives.
Features of initiatives
The included studies described three broad types of QI initiatives: improvements in residents' clinical performance, interdisciplinary QI teams, and curriculum innovations in quality management through resident-directed projects. Thirteen articles described QI initiatives with multiple projects or topics for improvement. Single-topic QI projects included improvement of clinical test-ordering procedures,10 sign-outs,11,12 deep vein thrombosis prophylaxis,13 asthma-inhaler patient teaching and tuberculosis policies,7 diabetes management,6 adverse drug reactions,8 medication reconciliation,14 and pediatric consultations.15
The nature of the participation by residents in the QI initiatives was highly variable. Multidisciplinary teams were reported in nine articles, although the makeup of the team membership was not always clear. The degree of influence, control, or action by residents frequently was not fully described. In one example, residents were deeply engaged in the QI culture of the institution, including the residency program itself. The residency program was entirely restructured on the basis of a values statement generated by residents, a training program for residents in the principles of QI, participation in team-based QI initiatives, and creation of a governance structure that included a significant percentage of residents.16
Leadership of the QI initiatives in the 28 included articles was also highly variable. Of the 25 articles that specifically described the persons or team responsible for leading the initiatives, 11 were led by residents. Six initiatives were led by faculty members or program directors, and eight were led by hospital or health system administrators, including a medical director, a service chief, a vice president for health care quality, a director of inpatient services, a research team, multidisciplinary committees, and a QI officer.
The QI approach is most frequently described as continuous QI (CQI), seven articles; or as QI, seven articles. Other terms for QI approaches include rapid cycle improvement, quality assurance, utilization review, and total quality management. Five articles describe efforts to educate physicians or teams about a clinical quality issue without using a specific term for the method of QI employed.
Nine articles describe formal QI curricula provided to residents and fellows, followed by engagement in QI activities. The formats for the learning experience included a fellowship in quality assurance and utilization review,17 monthlong QI electives,14,18–20 a yearlong experience,21 and residents' participation in seminars, followed by team-based QI projects.22–24
The included articles were highly variable in their experimental design and scientific rigor. All 28 articles described improvement initiatives related to the quality or safety of patient care, except the article by Horak and colleagues,25 who described improvements in multidisciplinary teamwork using a QI methodology. Sixteen of the 28 (57%) articles included a reference to a specific improvement in process outcomes, and 5 (18%) described a change in patients' health outcomes. Of the 11 articles that described a single QI initiative, only 1 (5%) described a randomized controlled trial.26 Ten citations described cohort studies with “before and after” data collection.
Results of projects
Table 1 summarizes the setting, QI topic, measurements, and outcomes for the included articles. Eleven of the articles, 10 of which involved multiple projects, did not specify the measurements used to evaluate improvements in care process or clinical quality. Of those articles that identified QI measures, all provided data on the extent of improvement in outcomes, except for two of three projects described by Weingart and colleagues.22
Measurements of QI for the 16 studies reporting outcomes measures relied on chart reviews (9 of 16; 56%). Other means of obtaining data included development of summary sheets,27 a diabetes registry,6 pre- and posttests of residents,28 and morning report.29
One objective of this investigation was to determine whether residents' participation in QI initiatives could improve patient health outcomes. Five of the 16 studies that provided outcomes measures documented improvements in patients' health that were due to the residents' QI initiatives. Two studies improved diabetes management6,30 through hemoglobin A1c control. Other measures of patients' health included a decrease in the number of perioperative cardiac events after prescription of beta-blockers,8 adverse patient events after hospital transfers,12 and adverse drug reactions.29
Eleven articles included process measures or surrogate measures for improved health, such as immunization rates or clinical guideline use. There was wide variation in the effectiveness of residents' projects. Annamalai and Deckard9 described a deep venous thrombosis risk-assessment tool used by all admitting physicians after a communication campaign led by residents. The increase in use of the tool by residents was markedly higher, from 50% to 66%, than that recorded for all admissions, 39.6% to 41.7%. Coleman et al27 described improvements in use of medication lists (10% to 40%, P < .001), data summary sheets (14% to 40%, P = .017), and screening for microalbumin in diabetics (5% to 29%, P = .001) in a family practice residency program. Mohr et al,31 in a university pediatric residency continuity clinic, were able to increase immunization rates from 60% to 86% (P = .04).
The ACGME general competencies, as found on the ACGME Outcomes Project Web site,32 were mentioned as an educational rationale in 17 of 28 (61%) articles. Two of the competencies, systems-based practice and practice-based learning and improvement, were specifically mentioned in 10 articles (36%).
Six of the included articles incorporated an assessment of the educational value of the QI initiative for the residents. In three articles, a pre- and postintervention survey was given to participating residents. Djuricich et al24 surveyed residents who participated in a QI curriculum and project. Statistically significant improvements were demonstrated in knowledge, perceived knowledge, and self-efficacy. A questionnaire, the Quality Improvement Knowledge Application Tool, was used in two articles14,18 to measure pre- and postproject knowledge and confidence. Three articles used post-QI-project surveys. Weingart et al22 surveyed 19 residents participating in a three-week QI elective. Sixty-three percent reported an improved understanding of quality in health care, 88% better understood QI in their own institution, and 56% reported that they changed their behavior as a physician. Frey et al21 used a self-reported survey of residents just before graduation to demonstrate lasting perceptions of confidence in evidence-based guideline development among participating residents. Participants in an independent study project indicated the experience was “extremely helpful,” although detailed survey response data were not provided.23
Most frequently, the effect on education was mentioned in relation to residents' barriers to participation, accommodations made to facilitate residents' participation, and lessons learned from the initiatives.
Impediments to residents' participation in QI projects were mentioned in 14 articles (50%—see List 1). Residency program leaders also describe methods to increase residents' participation in QI, including altering schedules to facilitate attendance, mandatory presentations, the leadership making participation a priority, faculty member incentives,27 holding team meetings during regularly scheduled residents' functions,33 providing refreshments and including a specialist in CQI as a facilitator,13 recognition, including gift certificates for best projects, requiring completion of a project for graduation, and possible disciplinary action if the project is not complete,8 internal grants,22 providing information to residents about the institutional review board process,23 timely communication of working group agendas, shared team roles in which residents can substitute for one another, projects structured to take advantage of fresh input from changing personnel,28 and explicit ownership of the project by residents.14
Recommendations were made to facilitate the development and operations of residents' QI projects and teams. These include
* Capitalizing on residents' enthusiasm for QI. Residents themselves were motivated to participate in QI12 and were able to make suggestions to improve the team function.34
* Recognizing that residents can be empowered to improve care and can be trusted to act responsibly.16
* Focusing on active, experiential learning.28
* Avoiding QI jargon.16
* Limiting team size to two to five resident members, to avoid scheduling conflicts.
* Obtaining input from all team members early, including nurses.
* Carefully considering the project charge, to avoid too large a scope for the project.
* Monitoring data collection so that only the minimal necessary data are collected.
* Regularly scheduling meetings with faculty to sustain projects.8
* Recognizing that residents may not be able to change clinical culture and patient outcomes alone.
* Including hospital and nursing leadership.9
Few published reports of residents' QI activities
Nearly three decades after its introduction in health care, institutional QI activities in hospitals and clinics remain largely isolated from residents' education. QI projects that actively include residents are barely visible in the published literature. In this study, thorough searches of medical literature databases and referenced publications identified only 28 articles in which residents were active in leadership, participation, planning, or development of QI projects.
The paucity of articles identified by this comprehensive literature search suggests that there is a need for high-quality, rigorous studies to document the effectiveness of residents in improving patient care. Studies that link patient health outcomes with residents' QI initiatives are of particular interest, yet only five articles were identified. Nationally, QI is shifting from process measures and surrogate measures of health to measures of patients' health and well-being. Projects that demonstrate improvements in patients' health related to residents' QI activities would serve to focus hospital and clinic leadership on the value of residents in improving patient care and would provide a fertile field for the next generation of quality-conscious physician leaders.
Barriers to residents' QI efforts
Barriers to incorporation of residents into QI efforts are becoming better understood.35,36 Three central cultural values found in academic medical centers that undermine QI engagement are the placement of a higher value on individual autonomy than on commitment to the well-being and goals of the enterprise, resistance to process standardization, and low regard for systems thinking.37 Academic centers also do not value QI as an academic discipline to the same extent that laboratory or clinical research is valued in career development and academic recognition. Though these cultural values are not confined to academic centers, their presence there makes it difficult for emerging resident leaders to commit to QI initiatives.
An additional impediment to publication is confusion regarding institutional review board requirements regarding research initiatives and publication of reports of QI projects. Research is a systematic investigation, including research development, testing, and evaluation, designed to contribute to generalizable knowledge, whereas QI's purpose is limited to implementing a practice to improve the quality of care and collecting patient or provider data regarding the implementation of the practice for clinical, practical, or administrative purposes.38 Lack of clarity about the collection of confidential patient data and requirements for use of clinical data in research, especially surrounding publication of findings, can discourage residents from seeking publication of QI projects. The Standards for QUality Improvement Reporting Excellence guidelines39 have the potential to open opportunities for publication through a better understanding of publication requirements and a detailed approach to reporting methods and findings.
Our literature search has limitations, and it may not represent the entire universe of published articles on active involvement of residents in QI teams and projects. It is possible that appropriate articles were not identified because of a number of factors, including
* The databases used in this study may not have identified residents as participants in the QI activities in the title or abstract.
* The search strategies may not have included all relevant terms. An effort to control for this possibility was made by examining by hand the search terms assigned to articles identified by the review team. No consistent pattern of missed terms was identified.
* The word choice used by the author in the title and summary may not have identified the project as a residents' initiative.
* Residents' projects are not being submitted for publication. Many resident projects are conducted in short time periods, with limited data. Clinical time demands may interfere with opportunities for residents to write about their QI projects.
* Residents' projects are not being accepted for publication. Acceptance of QI projects as scholarly activity in peer-reviewed journals has been the subject of controversy.40 Many QI projects are not published, or they are published in newsletters and QI bulletins. Confusion about the role of institutional review boards in preauthorizing and approving QI studies may contribute to the reluctance of residents to publish their projects' findings. Recent publication of guidelines for reporting of QI initiatives may decrease barriers to dissemination of project results.41
Program directors, designated institutional officials, and institutional leaders are, and will continue to be, challenged to introduce team-based learning, faculty training, resident didactics in QI, and time to complete projects into the resident experience. Progress has been made in formalizing assessment of QI project proposals42 and identifying patient care quality measures to assess educational outcomes.40 Academic medical centers are well positioned to integrate resident education and QI from their role in teaching and research.40 As efforts to integrate residents and QI expand, there is an opportunity to build a robust body of evidence to demonstrate whether QI initiatives enhance the quality of patient care, the quality of the learning environment, and the practice of medicine.
Many thanks to Ingrid Philibert, PhD, MBA, senior vice president, field activities, ACGME, for assistance in identifying articles, and to Nylla Hanson and Maria Berens, HealthPartners Institute for Medical Education, for preparation of this manuscript.
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