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Making Residents Visible in Quality Improvement

Patow, Carl MD, MPH, FACS

doi: 10.1097/01.ACM.0000365340.76551.f2
From the Editor: Quality and Safety in Medicine

Dr. Patow is executive director of HealthPartners Institute for Medical Education, associate dean for faculty affairs at Regions Hospital, University of Minnesota Medical School, Minneapolis, Minnesota, and president, the Alliance of Independent Academic Medical Centers, Chicago, Illinois.

Editor's Note: Ten years ago, the Institute of Medicine released its seminal report on medical errors, To Err is Human. To commemorate that landmark publication, this month's journal is entirely devoted to articles on quality and safety in medicine. Dr. David Nash and Mr. Neil Goldfarb, who wrote the first essay below, served as guest editors for the articles that were responses to the journal's call for papers on the topics of quality and safety. Dr. Carl Patow served as the guest editor for additional articles that discuss aspects of a national initiative sponsored by the Alliance of Independent Academic Medical Centers, which he describes in the second essay below. I thank all the guest editors for their extensive efforts in assembling this month's articles and for working with Anne Farmakidis and Al Bradford and other members of the journal's professional staff to prepare them for publication.

–Steven L. Kanter, MD

Residents are often “invisible doctors” in quality improvement. In 1993, Ashton observed this when she stated that residents were largely not included in quality improvement initiatives in hospitals and clinics, and that they were “invisible” in improving patient care.1 In the years since then, the silos of residency education and of quality improvement in health care organizations have, by and large, continued to develop independently and in isolation. Hospital quality initiatives rarely include residents, and resident quality improvement projects often are not aligned with organizational priorities.

In 2007, the Alliance of Independent Academic Medical Centers (AIAMC)* recognized that the schism of quality improvement and resident education was artificial and unnecessary, and that there were significant advantages to uniting the silos. To do so, 19 AIAMC member organizations participated in an 18-month program–the National Initiative: Improving Patient Care through Graduate Medical Education–representing major teaching hospitals from Seattle to Maine. The initiative organized quality improvement teams that carried out individual quality improvement projects strategically aligned with each hospital's specific improvement goals. For details about this effort, go to our Web site at

An important feature of the initiative was its early link with the Institute for Healthcare Improvement's 5 Million Lives campaign.2 The two initiatives had nearly synchronous starts, and each helped to reinforce the value of the other. The link raised the importance of the residents' National Initiative quality improvement projects within their hospitals, as those projects were often aligned with the hospital's clinical quality-improvement priorities. Having residents as “part of the solution” made residents' contributions more valuable and visible.

For some hospitals, this was the first time that the leadership had considered residents to be an integral part of patient safety and clinical quality. In addition, while the original focus of the initiative had been improving patient care, it soon became clear that the initiative was also improving the quality of the residents' educational experiences. Ashton predicted this would be the case in 1993.

In this issue of Academic Medicine, there are five articles with content related to the AIAMC's National Initiative. The articles by Padmore et al. Patow et al. and Riesenberg et al. are systematic reviews of the literature, undertaken to support the informational needs of the National Initiative's participants. A fourth article, by Jenson et al. reflects on the emerging roles of the designated institutional official and program directors in improving quality of care. Finally, an article by Daniel et al. describes the participation of multiple residency programs in quality improvement initiatives at an AIAMC member institution during the time period of the National Initiative.

The progress made by participants in the initiative makes clear that residents can and should be a driving force behind quality improvement efforts at academic medical centers. In our experience, quality improvement efforts shared across multiple programs and systems can improve care much more quickly and effectively than can isolated hospital efforts alone. To be effective, there must be adequate infrastructure and team resources to mount a multiinstitutional quality improvement effort. Additionally, individual quality improvement projects should be aligned with each institution's strategic patient safety goals. Finally, engagement of key internal and external stakeholders is vitally important to a successful national initiative.

The benefits of linking residents and quality improvement are many: to hospitals in meeting their quality and safety priorities, to residency programs, to patients' health, and to residents, who become visible advocates for improving patient care.

I wish to thank Dr. Kanter for asking me to be a guest editor to assemble articles related to the National Initiative for this theme issue on quality and safety issues. I also thank the staff of Academic Medicine for their excellent editing and coordination efforts.

Carl Patow, MD, MPH, FACS

Dr. Patow is executive director of HealthPartners Institute for Medical Education, associate dean for faculty affairs at Regions Hospital, University of Minnesota Medical School, Minneapolis, Minnesota, and president, the Alliance of Independent Academic Medical Centers, Chicago, Illinois.

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1Ashton CM. “Invisible” doctors: making a case for involving medical residents in hospital quality improvement programs. Acad Med. 1993;68:823.
2Overview of the IHI 5 Million Lives campaign. Available at: Accessed September 30, 2009.

*The Alliance of Independent Academic Medical Centers (AIAMC) is a national membership organization whose 70 members are major academic medical centers (i.e., teaching hospitals) and health systems committed to quality patient care, medical education, and research. 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 their clinical missions.
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