Clinical environment regulations, patient and consumer demand, and changes in Accreditation Council for Graduate Medical Education (ACGME) standards have accelerated the need for systemized quality improvement efforts. Scientific discovery, technology advancements, and application of evidence-based medicine have already resulted in changes in clinical care. The 1999 Institute of Medicine (IOM) report To Err Is Human prompted health care practitioners and organizations to examine existing systems of practice as well as practices employed by individual health care practitioners as an imperative for patient safety and quality improvement.1
ACGME requirements for graduate medical education (GME) programs now include quality improvement and patient safety competencies. Practice-based learning and systems-based practice are receiving greater emphasis in preparation for the Next Accreditation System and the Clinical Learning Environment Review.2 Undergraduate medical education (UME) programs recognize and appreciate the need to incorporate patient safety, quality improvement, implementation science, and other elements as competencies required for future health care providers.3,4
Although still in the early stages of development, the Association of American Medical Colleges’ (AAMC’s) initiative for Core Entrustable Professional Activities for Entering Residency includes as Entrustable Professional Activity 13 “Identify system failures and contribute to a culture of safety and improvement.”5 In addition, the AAMC Aligning and Educating for Quality initiative has the aspiration of “aligning and educating for quality to assist medical schools in development of curriculum, faculty and programs in systematic incorporation of these skills starting in the earliest stages of medical careers.”6
Quality improvement efforts are in progress on multiple fronts; however, implementing these requirements, engaging learners (medical students and residents), and supporting this work remains challenging. As novices in clinical care, medical students struggle to understand how best to provide health care in ever-changing clinical environments. Likewise, resident physicians must consider the balance of multiple learning demands, duty hours restrictions, and work–life integration as they become the health care providers of the future. Faculty members continue to struggle to do more work with fewer resources including the valuable resource of time. For many faculty members, quality improvement is a new skill set they must learn in the face of demands to master many other new skills.7–9
The necessity of developing interprofessional teamwork competencies, engaging allied health providers, and aligning quality improvement priorities with regulatory and business priorities has led to an unwieldy and overwhelming workplace and learning environment. As our health care systems are tasked with participating in quality improvement to meet standards from multiple accrediting and quality-monitoring agencies, the challenges of defining success, engaging learners, and prioritizing projects will be amplified.10–12 There is growing recognition of the importance of aligning initiatives and improvement efforts across health care systems to address these challenges. In this Perspective, we explore both the concept of bidirectional alignment as well as the importance this concept will need to hold within institutional priorities in order for health care to achieve the next stages of quality improvement and patient safety.13
Challenges to Quality Improvement Efforts
To engage the current health care workforce in patient safety and quality improvement initiatives, the historical, economic, and workforce-related challenges of the current climate have been examined in detail. Attempts to remove barriers in order to create better clinical environments for the provision of safer health care have resulted in changes: Greater acceptance of a team approach, improved clinical decision support, and the incorporation of checklists are part of this enhanced clinical milieu. Yet, many barriers remain.8
From the perspective of learners, the priorities for health care improvement at the institutional level often appear to focus on regulatory imperatives. Less emphasis is placed on understanding the challenges faced daily by frontline staff as they provide safe and timely care in the clinical milieu. Engaging learners as participants in systems is an integral part of their clinical educational experience.3,9 However, engaging learners in quality improvement efforts has not been consistently viewed as an institutional priority.
Approaches to Quality Improvement
Early efforts toward quality improvement focused on the involvement of the health care workforce in safety initiatives. In the process, a number of approaches and methods emerged.14 Whether systems use Lean, Six Sigma, rapid plan–do–study–act cycles, or other methods, best and promising practices now exist in a variety of forms.15 The importance of engaging frontline staff has gained acceptance as a vital component of quality improvement. These efforts have created momentum and renewed excitement about the possibilities of designing better health care systems that are evidence based. Determining what works for specific care environments has been a key to success.16,17 At the same time, implementation science and reliability research in health care has the potential to enhance efforts at the organizational level.17,18 The voice of the customer is a key element of implementation science, Six Sigma, and new information technology (IT) business models.15,17,19
Next Steps: High-Reliability and Learning Organizations
Health care quality improvement visionaries view high reliability and creation of learning organizations as having great potential for enacting positive change.18,20 While the steps mentioned previously are leading to improvement, some organizations are exploring examples and models used in other industries that could be adopted or adapted to create models of high reliability for health care.18,21,22 The five characteristics of high-reliability organizations are preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.23 The five features of a learning organization are systems thinking, personal mastery, mental models, shared vision, and team learning.24 Why has the integration of learning organizations into health care proved to be so difficult? Our hypothesis is that the barriers to the realization of this vision are the same barrier that our learners currently face in engaging in meaningful quality improvement efforts as part of their training. To move health care organizations to the envisioned future state, bidirectional alignment within the organizational culture will be necessary. Bidirectional alignment is a concept from the IT industry. It is defined as “moving or operating in opposing directions or capable of reacting or functioning in opposing directions.”19,25 In e-commerce business models, bidirectional alignment has been used to reshape governance structures to include the voice of the customer at the highest levels of organizational priority setting, decision making, and strategic planning. Including the voice of the customer in strategic planning is not a new concept. Other business models use a variety of approaches to incorporate information from customers in creating their strategic plans.26,27 The difference is that the bidirectional alignment model incorporates intelligence gathered from customers to set major organizational priorities. We believe that implementation of bidirectional alignment has been overlooked in our efforts to improve health care quality.
An example of the incorporation of bidirectional alignment in health care includes setting organizational priorities that originate from the vantage point of learners as well as from leaders. This creates a number of advantages. First, the fresh perspective learners bring to the workplace differs from other members of the health care workforce. Seasoned veterans are more experienced. Typically, experience is an advantage. However, experienced persons are also more likely to be entrenched in practices that may no longer be effective, efficient, or safe. Additionally, learners have fewer preconceived notions about the health care milieu making them more likely to be open to innovative approaches. Last, learners are already in a learning mind-set and can share a learning approach with the experienced frontline staff. At present, we find little evidence that bidirectional alignment is a driving priority in health care. Allowing priorities to originate from the vantage point of learners—and leaders—allows organizations to do a better job of harnessing the intelligence of all organizational members.
To our knowledge, bidirectional alignment has not been specifically described or used in present-day high-reliability or learning organizations’ definitions or models. However, many of the concepts overlap. For example, approaches to team learning are the same as or similar to approaches to creating organizational bidirectional alignment.
Innovative Approaches to Curriculum and Success as Educators
Innovative approaches to curriculum have emerged both at the GME and UME levels. Educators have started to share approaches, develop competencies, and document promising practices in quality improvement.4,28–32 Beginning in the 1990s, a growing body of literature has emerged regarding the benefits of student engagement, especially in higher education settings.33 The importance of including the learner in the design of the learning environment is important, as indicators of best and promising practices related to quality assurance and improvement in learning environments are now well documented.34 Students are better engaged in learning if they participate in both the design and evaluation of teaching materials and content. Application of this knowledge in quality improvement initiatives in clinical environments would engage learners in the design of quality improvement initiatives in real time and offer excellent learning opportunities. Recently, medical educators in clinical environments have expressed frustration as they struggle to meaningfully engage learners in the day-to-day complexity and ambiguity of health care. Organizational and institutional barriers remain in place that separate students and residents from access to systems-level quality improvement resources.3
Bidirectional Alignment as a Missing Element
There is growing recognition of the importance of aligning initiatives and improvement efforts across health care systems. Typically, this form of alignment occurs “top-down,” beginning with compliance efforts related to local, state, federal, or accreditation regulations. Inclusion of frontline staff in evaluating organizational compliance efforts is uncommon, if at all. Educators are engaging learners in increasingly innovative approaches in quality improvement initiatives. Often, these approaches are aligned with the priorities that have already been set by health systems. On the other hand, some may be entirely separated from the efforts of the health care system and focus solely on classroom learning or research endeavors.4 Newer business models, especially e-businesses and technology-enhanced traditional businesses, are increasingly recognizing the importance of the voice of the customer in their models of shared governance.19 While most businesses will look at customer information at various stages of strategic planning, bidirectional models incorporate the customer into governance. This means that priority setting and decision making include the intelligence available from this information.19,25–27 In academic medicine, learners should be actively engaged during the earliest stages of priority setting and decision making. Bidirectional alignment offers a platform for incorporating learners’ perspectives in priority setting and decision making related to quality improvement.
Meeting the Challenges of the Existing Culture
Inherent in the culture of health care is an unspoken assumption equating safer with more experienced. This assumption leads to conflict, especially when more experienced health care providers must change their workplace behavior. Creating standard, reliable work processes requires focusing on existing health care providers as they address regulatory, safety, business, and institution priorities. To date, workflow processes and environments offering potential to support learning are often neglected. This has been manifest in a number of health care systems in the design of electronic health records, incident-reporting mechanisms, and continuing education training teams. Present-day practices typically exclude learners from participation by design. An examination of the features of high-reliability and learning organizations reveals that those organizations do not fall into the trap of viewing only the senior members of the organization as experts because they possess the most experience overall. High-performing organizations embrace diversity and inclusion in the broadest sense and recognize that everyone brings native intelligence into the workplace. These organizations honor the resulting multitude of viewpoints and are more likely to use teamwork in designing systems of work. In turn, those systems of work are most likely to improve outcomes and performance.
In her 2014 book Rookie Smarts, author Liz Wiseman35 describes the advantages of gathering knowledge from “rookie” intelligence. Health care organizations fit her description of workplace environments that may benefit the most from this type of approach of learning. According to Wiseman, the “right terrain” where rookies can play an important role includes new frontiers, with short business cycles, and situations where multiple answers are needed because the problems are too big to have answers that are already known. Our complex health care organizations need to embrace more rapid change as knowledge evolves from growing sources of scientific discovery. Some high-performing organizations are incorporating learner perspectives into the work of quality improvement.36
An Envisioned Future State
Learners should be viewed as contributors in the provision of health. Viewing them solely as consumers of health system resources is naïve. Learners are significant contributors to the health of the population and should be considered an untapped source of innovation. Adopting this perspective is in the best interest of learners, teachers, and the public. According to the AAMC 2011 State Workforce Data Book there were 258.7 actively practicing physicians for 100,000 patients across the United States. There were also 35.8 medical residents and fellows and 31.4 students for the same population of 100,000 patients.37 Given the large number of learners participating in health care systems at any given time, their direct role in patient care and their unique perspective are often at the very front line of health care. It seems contradictory to the emerging understanding of quality improvement that their efforts are not considered in the broader context of this work.
Not only are learners already within the systems of health care but they often represent the front line that constitutes the various components of the systems that the patients also experience. While debates about the cost of educating medical students and residents continue, taking the time to reconsider the role of the learner and more actively addressing their needs offers an opportunity to create bidirectional alignment in health care organizations. Enacting this strategy will require a shift in thinking regarding the role that learners play in the health care workforce and the value that medical education brings to health care systems.38
Creating the Envisioned Future State
Medical educators have already started to make this shift. One example, the Exemplary Care and Learning Site (ECLS) model, combines quality improvement and learning to improve patient outcomes while meaningfully engaging learners in quality improvement work.39 By using the ECLS model, organizations move away from top-down alignment and move toward bidirectional alignment. In turn, information gathered at ECLS sites can be used to set institutional priorities and allocate resources to enhance learning and quality improvement efforts on the front line. The collaborative efforts engaged to develop the ECLS model were supported by the Institute for Healthcare Improvement and the AAMC initiatives regarding teamwork in health care.40 Published accounts of this work support the hypothesis that learning in teams not only enables individual team skills development but also enhances institutional performance.41
Johnson Faherty and her colleagues30 describe three models designed to both engage learners and improve quality at the point of care. Similarly, Tad et al31 have reimagined morbidity and mortality conference activities, and Stueven et al32 have used resident surveys to improve the climate of patient safety as well as to engage learners. As support for improving clinical and learning environments continues to gain momentum, we will need to reframe our thinking about learners and their roles. As new methods emerge, understanding and implementing bidirectional alignment will become increasingly important to best take advantage of the knowledge being generated at the front line.9,30–32,38
Some patient advocacy groups are in the early stages of identifying barriers to patient and family participation in health care quality improvement, especially those pertaining to patient safety.42,43 Quality and safety efforts must become a priority of health systems if the potential for improved safety is to be realized. Nevertheless, there is growing recognition that truly achieving the outcomes for quality improvement and safety envisioned by pioneers and visionaries in the field will require greater inclusion of those persons on the front lines. We believe that students and residents should be included in these efforts in addition to patients and families. Although health care systems vary widely, these organizations have many similarities. Best and promising practices will emerge from research that considers common features of these systems. Regulatory imperatives will create new priorities for improving health care, and new quality improvement approaches will need to be developed and implemented, especially at the local level. There are many differences in individual health care systems in terms of mission priorities, populations served, and needs of the health care providers within those systems. Implementation science and reliability research recognizes these differences as potential challenges to improving quality where it counts most—the local level.8,17,20 Health care organizations will need to learn more about their own systems of care if they are sincere in their desire to create and increase stakeholder value and improve quality and safety.
Information about systems of care is available from multiple sources—clinical outcomes, patients, families, the community, frontline staff, quality metrics—and the gathering of system data is increasingly supported by IT. The intelligence needed to analyze, prioritize, and implement changes to improve systems of care should also come from multiple sources. Priorities exist at the front line of care—medical students and residents constitute members of the teams at the front line of care. Just as IT-focused businesses have incorporated the voice of the customer in shared governance, health care organizations should aspire to do the same. IT organizations can help health care organizations learn how to do a better job of gathering information—and how that information should be used to create more agile and responsive systems of care.
Health care systems that want to stay “ahead of the curve” should engage learners who are already working in and are familiar with these systems. Learners should play an active role in the creation of systems that include bidirectional alignment. This will allow health care systems to be better oriented toward the future and, as such, proactive rather than as they are now: reactive.
Acknowledgments: This article is dedicated to the members of the University of California, Davis Medical Center Patient Care Services, Quality and Safety Department, Performance Excellence, and Information Technology, Knowledge Management Teams for the remarkable work they do to advance patient care. Likewise, it is dedicated to the Gordon and Betty Moore Foundation for its commitment to patient safety. In addition, the authors especially wish to thank Jacqueline Stocking, RN, MSN, MBA, Christine Edwards, MLIS, Jared Quinton, MHSM, CSSBB, Hershan Johl, MD, William Montalvo, RN, Kristina Dees, RN, and Hao Zhang, MS, for allowing observation of their work for this article.
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