In 1999, the Institute of Medicine's seminal report, To Err Is Human: Building a Safer Health System,1 illustrated the need to examine patient safety practices and create processes and systems that addressed improvements. Since that time, the Accreditation Council for Graduate Medical Education (ACGME) has required teaching institutions to promote systems-based practice as a core competency.2 At the heart of these mandates is the need to improve safety in patient care and involve all members of the health care team in accomplishing this goal, especially young physicians working in high-reliability organizations.3,4 This essay was written (1) to urge leaders of teaching hospitals to engage housestaff in their quality and patient safety (QPS) processes and (2) to describe a way to foster such engagement and present how it has succeeded at our institution.
Teaching hospitals are challenged to provide formal training to postgraduate trainees in the area of QPS. Typically, QPS is not a dominant theme in medical school curricula; if physicians are to become QPS leaders in the future, it is incumbent on their postgraduate mentors and supervisors to provide education and guidance on this topic.5,6
There is a related need in teaching hospitals, because quality initiatives seldom include residents.7 A systematic review of the literature from 1990 to 2008 found evidence of only 28 articles describing residents' engagement in quality improvement (QI).7 That review categorized residents' involvement in various QI initiatives, including improvements in residents' clinical performance, interdisciplinary QI teams, and curricula innovations in quality management.7 Some of the barriers to residents' participation in QI initiatives described by Patow et al7 include lack of time, low attendance, crowded curriculum, away rotations, limited data collection capabilities, presumption that residents have little interest in QI, skepticism, and program expense. Although all residency programs need to attest to the fact that their graduates are sufficiently trained in systems-based practice and practice-based learning, resident QI projects are rarely aligned with organizational strategic goals. Because housestaff are the frontline providers of care to patients, and medical errors frequently occur based on their actions, it is essential for health care organizations to engage residents in QPS initiatives. In addition, identifying resident leaders to facilitate communication with other housestaff is a crucial component of improving QPS.
Moreover, given the importance of engaging physicians in QPS in the current national health care discussion, new paradigms of policy and decision-making infrastructure are warranted to educate the next generation of physicians.
The Resident QPS Officer Position and Its Importance
In early 2008, the Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes, to promote greater housestaff participation in QPS initiatives, and to improve communications among housestaff, hospital leadership and governance, and key clinical departments.8
The HQC, led by a resident QPS officer, has identified and addressed various systems-based QPS issues. The council's approach to problem solving includes (1) identifying QPS issues, (2) collecting data, (3) analyzing data, (4) implementing process/system changes, and (5) monitoring the effectiveness of the changes. The council consists of approximately 35 residents from each clinical department in the hospital. In addition to the resident representatives, the HQC, which meets every month, consists of representatives from the pharmacy, nurses, physician assistants, information technology staff, QPS officers, and the hospital administration. The chief QPS officer and faculty advisor serve in an advisory capacity to the HQC.
The council is led by a chair and vice chair, who are both current residents. In addition, the council chair is designated as the resident QPS officer for the institution for a period of one year. HQC elections are held annually to select a vice chair, who succeeds the chair at the beginning of the academic year. Vice chair candidates are approved by their respective residency program directors to place their names in nomination before the elections. The creation of this council fulfills one of the commitments to safe and high-quality care by providing the infrastructure needed for effective communication among key stakeholders, namely, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and the housestaff.9
In his or her capacity as resident QPS officer, the council chair communicates the hospital-wide QPS goals and leads the HQC in its quality and performance improvement initiatives. The council's activities have included initiatives such as improving medication reconciliation, developing an institution-wide multimodal communications matrix for dissemination of standard and emergent information to residents, and recommending medication dosing modifications in the computerized provider order entry system.8,10–12 The HQC's role also provides an effective conduit for housestaff to discuss adverse events, participate in root cause analyses, and propose practical solutions to problems.
For the HQC to achieve its goals, it was essential to not only have institutional support but to be part of the established infrastructure of the Division of Quality and Patient Safety; aligning with that division facilitated engagement of the HQC and the housestaff in the policy and decision-making processes of the hospital. One of the main reasons that the resident QPS officer position was created was to strengthen the relationship between the hospital's strategic QPS goals and the HQC.
The resident QPS officer serves as the institutional lead to engage housestaff in QPS activities. He or she represents housestaff on hospital QPS projects throughout the institution and meets on a weekly basis with the chief QPS officer for the institution, as well as other institutional QPS officers. This serves to ensure that residents are truly part of the health care quality and safety team for the organization. The resident QPS officer can serve as a resource in the development of QPS educational programs but is not charged with education of housestaff in QPS matters. An HQC is an ideal way to support a resident QPS officer, but even in an institution without an HQC, such a position can still be created. To support a resident QPS officer without an HQC, the institution must have some venue to engage housestaff in the policy and decision-making processes, such as a housestaff GME council or a chief residents council. These types of councils can provide a forum where housestaff can convene to discuss pertinent QPS initiatives.
The resident QPS officer is fully integrated into the organizational quality and safety program. He or she is an integral member of the institution's annual QPS goal-setting process and participates in quarterly assessments on progress. Serious adverse events are discussed with the resident QPS officer, who transmits “lessons learned” to the housestaff through the HQC and related communication vehicles such as newsletters, e-mails, and discussions at monthly meetings. The resident QPS officer also presents biannual reports to the quality committee of the medical board and the board of trustees. Whereas the particular committees and forums in which the resident QPS officer participates are specific to each institution, the concept can be broadly generalized to any teaching hospital.
Given the benefits of having a resident QPS officer, institutions must ask themselves: Who is the ideal candidate to serve in such a significant administrative role? What incentives can we offer, given the already demanding schedule of a clinical residency? In our experience, the ideal candidate for this position is someone with prior exposure to QPS issues, an interest in QPS, and leadership ability. Also, the incentives for assuming such responsibility are numerous. This position can dramatically further a resident's education in QPS by providing firsthand knowledge of the complexity of health care organizations, health care systems, and the medical college, significantly adding to a resident's professional experience. In addition, being the resident QPS officer can serve as a valuable stepping stone for the creation of a future leader in patient safety and for someone looking to gain increased experience in health care administration. Finally, the former resident QPS officers have realized that having this position and leading the HQC have made a significant contribution to improving the quality of care at the institution.
Once the HQC was established, there were no barriers to creating the position of resident QPS officer, particularly because it aligned so successfully with the existing administrative structure of the Division of Quality and Patient Safety. The resident QPS officers have experienced some difficulty in maintaining the time commitment necessary to participate in the administrative aspects of QPS initiatives. It is important to separate the HQC administrative responsibilities and assign them to support staff so that the resident QPS officer can direct his or her time appropriately. Often, this requires 5 to 10 hours of additional time per week beyond the hours of the clinical residency, and these are included in work hours calculations.
To date, the housestaff perceive the resident QPS officer's position as beneficial to achieving the HQC goals because it links the residents with the hospital administration and helps the housestaff have a voice in institutional change.
What the Institution Must Do
Because the role of the resident QPS officer is critical to facilitating communications with the HQC and housestaff at large, he or she can succeed only if the organization understands, recognizes, and respects his or her roles and responsibilities as resident QPS officer. Building the appropriate infrastructure and an annual stipend from the hospital are ways to support the resident QPS officer.
In addition, to successfully implement the resident QPS officer position, an institution must also be focused on QPS and provide a milieu to nurture the development of the resident QPS officer in his or her role. Giving adequate administrative support to the HQC initiatives and activities and the resident QPS officer is also crucial to the success of the council and the individual leading it. At our institution, the HQC activities are supported by a QPS liaison, who also serves as the QPS administrator in a clinical department and assists the HQC chair and vice chair with the administration of the council. In addition to administrative support, there must be a strong commitment from an individual's clinical department chair and program director to assist the resident QPS officer in attending weekly meetings with the institution's QPS team.
Once the barriers and obstacles are addressed, the bidirectional communication between the resident QPS officer representing the HQC and the QPS division and senior hospital leadership becomes more successful and effective, facilitating the work of the council in its performance improvement activities.
With the imperative for teaching hospitals to function as high-reliability organizations, it is essential to engage housestaff as frontline providers in the institution's QPS processes. A resident QPS officer can serve as an important catalyst in this process. As a result, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.
The authors wish to thank Laura Forese, MD, MPH, Richard Liebowitz, MD, and New York-Presbyterian Hospital for their support.
Funding is provided by New York-Presbyterian Hospital in the form of an annual stipend for the resident QPS officer.
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