A series of Institute of Medicine (IOM) publications between 2000 and 2014 have called for significant changes to the graduate medical education (GME) system to train a health care workforce capable of responding to the changing landscape of medicine in the United States.1–3 Trainees are uniquely positioned on the front lines of clinical care to rapidly identify quality and safety gaps and suggest innovative solutions. However, they are often held responsible for gaps in care, and thus seen as part of the problem to be fixed.4,5 Instead, as frontline providers, trainees are key stakeholders who should be leveraged and engaged to be part of the solution.1,6,7
To address the lack of trainee engagement in quality improvement (QI) and patient safety (PS) efforts at academic medical centers, the Accreditation Council for Graduate Medical Education (ACGME) developed the Clinical Environment Learning Review (CLER) program, part of the Next Accreditation System.6,8,9 From observations during the first round of site visits by the CLER Committee, it has become widely recognized that there is a large gap between the ideal training environment and what currently exists around the country.9,10
There are many barriers to designing the ideal training environments that fully engage trainees in QI/PS efforts.11,12 Trainees work in high-volume, high-stress environments. Accustomed to rotating for a finite period of time into and out of well-established clinical units, trainees may not realize their important role in identifying ways that the current system could be improved. Additionally, they may lack role models with QI/PS knowledge and skills who consistently demonstrate how to make routine clinical care more safe, effective, patient centered, timely, efficient, and equitable.13 Faculty mentors then face the challenge of finding protected time to apply these principles with trainees.13 Further, structural barriers exist, such as the lack of real-time data support, and uncertainty around institutional review board (IRB) procedures for QI/PS work. Finally, trainees may view QI/PS as a separate, supplemental skill set, secondary to honing their clinical skills or surgical technique. Despite these challenges, trainees, as frontline providers, remain acutely aware of PS issues and QI opportunities and may be key partners in achieving institutional quality and safety goals.
No single best approach or evidence-based model yet exists for training institutions to meaningfully integrate trainees into QI/PS initiatives at the point of care. However, most experts agree that experiential learning, combined with didactic instruction, leads to the deepest understanding of quality and safety concepts.11,13–16 Headrick and colleagues14 proposed an “exemplary care and learning sites” model, which “links the continuous improvement of learning and the continuous improvement of care in meaningful, experiential ways.” Elaborating on that model, we developed an organizing framework with three suggested models of varying time horizons to allow for flexibility in involving trainees in the QI/PS work that should be occurring on a daily basis. In this article, we describe the development of the framework and its models and propose steps to implement these models and involve trainees in daily QI/PS activities that are integrated into clinical care. We also provide examples of these models’ implementations in a real-world setting, to illustrate to attending physicians, program directors, and leadership at training institutions what is possible within a variety of local contexts.
Development of the Three Models
To rigorously examine the concept of “experiential learning at the point of care,”14 we began with a review of the existing literature on quality and safety training within GME and the barriers to trainee engagement. An initial literature search in PubMed and Google Scholar using the search terms “quality improvement” or “patient safety” paired with “faculty,” “residents,” and “graduate medical education” resulted in over 500 citations; after reviewing all of the abstracts, we reviewed 152 citations in full. We supplemented our search of the peer-reviewed literature with the gray literature, which added another 20 articles to our review. We also conducted over 30 expert interviews with key stakeholders, including leaders from the ACGME, the Association of American Medical Colleges, the University HealthSystem Consortium, and several academic medical centers with GME programs. This initial work led to the preliminary articulation of three suggested models with three different time horizons—short-, medium-, and long-term—for trainee involvement in quality and safety work at the front lines of clinical care.
Within each time horizon, we proposed initial design elements of the three models, which we tested with the key stakeholders above and in our own training environments. On the basis of feedback from the key stakeholders and our own experience, we refined the three models to reflect an emphasis on scope of work in addition to time horizon, and three revised models emerged: short-term and team-based, medium-term and unit-based, and long-term and system-based QI/PS work. We then put all three models on a Web-based learning platform, the Institute for Healthcare Improvement’s Open School,17 to solicit input from a geographically varied sample of training institutions. Sixteen individuals representing 12 geographically dispersed institutions with expertise in GME, QI/PS, or both reviewed the three models as a group. These individuals were from a range of medical specialties including internal medicine, family medicine, and anesthesiology and held various titles including director of inpatient quality, residency program directors and associate program directors, and dean of GME. In general, these experts strongly agreed with the face validity of the models, suggested emphasizing the importance of interprofessional collaboration, and urged us to fully describe how these models could be adapted to a variety of different training environments. On the basis of this final round of feedback, we made refinements to the models that are now presented here. For a summary of these steps, see Figure 1.
Description of the Three Models
Trainees may desire different levels of engagement in QI/PS, from a broad but basic exposure, to “specializing” in quality and safety skills for their future careers. Therefore, we developed flexible models that are adaptable to the needs and constraints of the local context of the clinical setting and institution and match the interests and career goals of the trainees themselves.18Table 1 provides a definition and overview of each model. We discuss the clinical scenario, the educational and improvement objectives for the QI/PS effort, the scope, duration, and role of faculty leaders and interprofessional collaboration.
Model 1: Short-term, team-based, rapid-cycle initiatives
In the current model of residency education, trainees commonly spend anywhere from two to four (sometimes more) weeks on a particular rotation. Attending physicians are similarly on service for limited periods of time, often one or two weeks at a time. This constant flux of care teams presents challenges for engaging in quality and safety work while simultaneously caring for patients, but the opportunity exists for the team to use their time together to solve a proximal workflow issue or gap in care that the team identifies in one or more of the units in which they work. In addition, to avoid “improvement fatigue” among other staff members, as well as discarding previous projects that are on their way to success, a new team could build and improve upon a prior team’s work rather than starting a brand new QI/PS effort. The importance of interprofessional collaboration to ensure success of QI/PS initiatives is increasingly recognized. Optimally, this team-based approach would be an interprofessional experience that incorporates the valuable input of all members of the care team. However, the degree of interprofessional collaboration and interaction will depend on the composition of the care team.
Model 2: Medium-term, unit-based initiatives
The time frame for the second model differs from the first in that the team is not necessarily identifying a focus for their brief time together. Rather, the staff of a particular clinical unit, such as the nurse managers, attending physicians, nurse practitioners, and others, identify a priority for that unit, and the trainees integrate that quality or safety effort into their daily workflow. These trainees will then likely hand off the initiative to the next team coming onto service in that clinical unit at the end of the month.
Model 3: Long-term, health-system-wide initiatives
To a greater extent than the other models, the third model for integrating trainees into QI/PS activities on the front lines of clinical care emphasizes alignment with the institution’s quality and safety objectives. A key feature of this model is that the institution’s QI/PS goals are adapted and applied within particular clinical microsystems. A common scenario for a longitudinal, larger-scale improvement initiative is that a group of perhaps six to eight trainees, mentored by an advisor, rotates at various times through a particular unit or ambulatory setting. They collaborate to move the improvement project forward when they are on that rotation. A longitudinal project could last six months, a year, or even longer, and a key objective, unlike the other two models, is to make health-system-level changes across the institution that help achieve institutional objectives around quality and safety. Buy-in from unit leadership, as well as leadership from the training program and the institution as a whole, are critical to ensure that the trainees are involved in improvement initiatives that are tied to an institution-wide objective.
Table 2 provides concrete guidance on how faculty, program leadership, and institutional leaders can implement each of the models: define the problem to be addressed, encourage buy-in from colleagues, design metrics to measure progress, collect baseline data, conduct small tests of change with “Plan-Do-Study-Act” cycles based on the Model for Improvement,19 and track change over time.
Selecting a model
Several factors determine which of these three models is the most appropriate and applicable for faculty to engage with trainees and support their experiential learning about quality and safety:
- Their particular role in trainee education at a GME level;
- Their location within the quality and safety infrastructure of the institution; and
- Their comfort with the principles and practice of QI (i.e., is one a competent, proficient, or an expert educator?).
A frontline clinician–educator who is building his own knowledge of quality and safety is well positioned to use the first model to lead a short-term, team-based effort with trainees. A quality leader for a unit who has likely participated in prior QI efforts will likely facilitate the second model of experiential learning about quality and safety for trainees. A QI leader for a department with the ability to effect broader change across a department or a system will likely apply the third model to her work with trainees. As Armstrong and colleagues13 described, becoming sufficiently competent in QI/PS principles to be able to educate others is a developmental process that must be supported at the institutional level.
Table 3 summarizes the specific pros and cons of each model. Importantly, these three proposed models are flexible and somewhat overlapping, and there is opportunity for ideas to flow between models. To illustrate the fluid nature of the three models, consider this example, in which QI principles are applied to a PS issue. A team working to improve their own documentation of venous thromboembolism (VTE) prophylaxis for eligible patients might develop checklists, huddles, and other methods to improve this process (the first model). Then, a unit might build on this model to create a unit-based plan for improving appropriate VTE prophylaxis through collaborations with nurses, pharmacists, and other stakeholders (the second model). If the hospital identifies VTE prophylaxis as an institutional priority based on benchmarks that were not reached the year before, and interprofessional teams in every unit in the institution would address this gap in care through hospital-wide process improvements (such as modifying admission order sets and implementing checklists), then VTE prophylaxis is now addressed at the system level (the third model). This example illustrates how these models can not only address gaps in quality but can also address PS priorities. For other examples of real-world implementation for each model for both hospital-based and ambulatory settings, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A311.
The unifying theme among these three models is that trainees need opportunities to apply what they have learned about quality and safety. In short, they need experiential learning on the front lines of care.13 Ideally, nearly all trainees will actively participate in experiential learning about QI/PS through Models 1 and 2, simply by working on teams and in clinical care units where QI/PS at the point of care is part of the institutional culture. Those who desire additional training in this area may select to participate in initiatives at the Model 3 level, both in their design (providing trainee input into institutional priorities) as well as their execution. In summary, both patient care and trainee education can benefit when trainees are aligned with, and contributing to, the quality and safety priorities of their training institutions.
In proposing three models of engaging trainees in QI/PS work, this article outlines multiple approaches that provide options for trainees, faculty educators, and quality leaders. We acknowledge that the development of the three models was not the result of rigorous methodology or empirical testing. However, through expert consensus, we developed and implemented in our respective institutions three models with high face validity, which incorporated established best practices for teaching QI/PS through a combination of didactic and experiential learning, coupled with strong role modeling.13,16,20
The steps for implementing these models that we articulate in Table 2 may appear logical and seamless, but in reality, the barriers discussed earlier present real challenges to integrating residents into institutional QI/PS efforts. Faculty development for frontline clinician–educators in accordance with their interests, roles, and prior experiences with QI is critical to encourage them to model QI principles in daily work. The team-based and unit-based models most directly address the inherent challenges of turnover in the rotation-based GME system, and Table 2 provides important considerations in preventing “improvement fatigue” among other interprofessional collaborators who do not rotate among units. The structural challenges certainly affect the implementation of these three models and can be partially addressed by a “bottom-up” approach: As more QI/PS work is being done, it will become increasingly apparent that support for tasks such as baseline data collection and data management is needed, and IRB familiarity with QI/PS work will grow over time. Model 3, with its institution-wide, longitudinal focus, will be the most likely to produce initiatives that highlight the need for structural support, apply bottom-up pressure to obtain it, and benefit from such support.
As experts in quality and safety education have observed that QI/PS can no longer be thought of as “additional” or “extra” or an “outside interest” for trainees,12,14 one of the most promising strategies for overcoming these various barriers will be to strive to integrate QI/PS principles into routine clinical care. This integration complements other educational efforts tied to QI/PS outside the context of direct clinical care, such as trainee participation in root-cause analyses and safety event reviews, as well as quality and safety committees at their institutions.
Implementing these models will require a culture shift, such that quality and safety become viewed as fundamental to the day-to-day, minute-to-minute clinical care of patients in the clinic, wards, intensive care units, and operating rooms. Batalden and Davidoff21 advocate for this culture shift, stating, “Making improvement happen … requires … [an] unshakeable belief in the idea that everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it.” Indeed, as evidenced by the ACGME’s Next Accreditation System, future generations of physicians will be expected to understand and apply concepts of quality and safety in a climate that increasingly holds health care systems accountable for maximizing their quality and value.6
This article describes the derivation and development of three models for integrating trainees into QI/PS work, as well as concrete suggestions for implementation in local contexts. Trainees are in a unique position at the front lines of clinical care, able to pragmatically propose real-time solutions that are superior to temporary workarounds and also creatively envision large-scale improvements. They can be powerful, activated partners in institutional quality and safety efforts, given the right conditions and the right substrates.
Acknowledgments: The authors wish to thank members of the Open School team at the Institute for Healthcare Improvement (IHI): Michael Briddon, Laura Fink, and Carly Strang, as well as Jesse McCall, Donald Goldmann, Jane Roessner, and Val Weber, also from IHI, for helpful critiques, suggestions, and editing during the preparation of this manuscript.
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