Academic medical centers (AMCs) are undergoing dramatic reform in their care delivery and learning environments to promote a culture that fosters high-value, efficient care.1 AMCs are expensive delivery systems,2,3 and four-fifths of health care spending has been attributed to patient care decisions that physicians make.4–6 In response, recent legislation has emphasized that physicians should participate in programs aimed to reduce total costs of care and improve quality outcomes. Although medical education, in particular graduate medical education (GME), is the foundation of and a key lever in physician practice patterns, it has historically been excluded as a key opportunity for transformation to reach these goals.7–9 Traditionally, medical education and the health delivery system have existed in different silos and addressed different AMC missions, which can affect the training of the future physician workforce.10
Programs such as the Accreditation Council for Graduate Medical Education’s (ACGME’s) Clinical Learning Environment Review and others now focus on how well trainees’ activities are integrated in institution-level initiatives and how well trainees are taught to deliver quality, cost-efficient care.11–15 AMCs, however, struggle to align trainee activities with the mission of their delivery systems. For example, residency education leaders may not be aware of, or not be invited to, discussions about health system priorities and infrastructure. As a result, although most residency programs sponsor quality improvement activities, their efforts are at risk of becoming time-limited experiential activities as opposed to sustained, scalable, and high-impact institutional improvements. We believe that to achieve the vision of an integrated learning system and health system, it is vital for AMCs to create the infrastructure that promotes alignment between training goals and the delivery system. Greater alignment between these areas would be associated with enhanced infrastructure to engage and support resident initiatives, such as staff support to access health system quality data.16
One way to enhance alignment is to create infrastructure that supports leaders who can help bridge the delivery and education systems. Two recent articles have discussed the role and frameworks for these bridging leaders.10,17 For example, the medical director for quality and value improvement (R.G.) at UCLA Health works in the health system and integrates education leaders and trainees into key system design teams. Likewise, the bridging leader at the Perelman School of Medicine at the University of Pennsylvania reports both to the chief medical officer and also to the dean for GME and plays a critical role on committees to shape and translate system priorities to department educators.18 Various types of bridging leader roles continue to emerge and provide important vehicles to improve alignment between the GME and the delivery systems of AMCs.
In addition to advocating bridging leadership, in this Perspective, we outline four additional steps that AMCs could use to create an infrastructure that supports alignment of their delivery and educational systems so that residents are prepared to deliver high-value care. This infrastructure includes aligning strategic planning, supporting alignment with data, leveraging existing staff and infrastructure, and having incentives to encourage alignment. We define:
- value as the quality of care over the cost required to deliver that care19;
- quality as the degree to which health services increase the likelihood of desired health outcomes that are safe, timely, effective, efficient, equitable, and patient centered (i.e., STEEEP19) and are consistent with current professional knowledge; and
- cost as the negative financial, physical, and emotional effects on patients and the health system.
Aligning Strategic Priorities to Achieve High-Impact Outcomes
Resident initiatives can be educational and help improve the value of care that they provide if trainees are directed toward priority areas. Yet, identifying opportunities can be complex. Health systems, such as those of AMCs, focus on initiatives that improve quality but also generate a return on investment (ROI) to support future growth. Such drivers depend on payer mix, including involvement with advanced payment models, payer penetration, institutional culture, and institutional missions. What creates an ROI among patients paid through partial- or full-risk contracts (i.e., contracts that involve risk of gaining or losing money based on quality and value performance) may be the opposite for the hospital. For example, avoiding hospitalizations may improve performance for a risk-based contract (which has incentives to reduce utilization) but may reduce the overall ROI of the health system if the associated hospital-based reimbursement is larger and paid by a fee-for-service or diagnosis-related-group payment (one that encourages increased admissions). In contrast, avoiding hospitalizations for patient placement, which are generally poorly reimbursed, may both improve the contract’s performance and increase the ROI. Health systems must balance these effects when determining how beneficial they are for overall performance. Additionally, these measures are prone to frequent changes by payer groups, so the nuances of data specifications can be complex to understand and make actionable.
Educational and delivery system leaders can cocreate initiatives to support cross-communication of priorities in several ways. For example, they can prioritize initiatives that support delivery system, GME, and resident interests. At University of California, San Francisco (UCSF), a long-standing partnership between the delivery system and GME provides training programs an opportunity to select an organizationally aligned quality improvement project. In recent years, proposals require explicit connections between project choice and medical center priorities (e.g., improving patient experience, reducing harmful events, lowering total costs of care). The program selection committee comprises leaders from the delivery system and GME, further aligning leaders through the process.20 Residents themselves can be trained to understand which delivery system priorities are resourced for implementation, which may trigger their internal motivation to participate in high-value, high-impact care efforts.
At the University of Chicago Pritzker School of Medicine, to maintain resident motivations for improvement, trainees are invited to submit opportunities to reduce low-value care within the health system to a crowdsourcing challenge. They are specifically asked how their problem relates to the annual operating plan so that they can learn to frame their ideas within the delivery system’s mission. Delivery system leaders vote on the top problems, which then inform the call for projects that are resident led and institutionally supported.21
Supporting Alignment With Data
Leveraging valid, actionable trainee data that can have high impact is vital for resident engagement in value improvement. This requires choosing high-priority measures for residents, ones that are in their purview of influence, such as reducing overuse of imaging, transfusions, and labs.22,23 For example, researchers from Cincinnati Children’s Hospital Medical Center reviewed National Quality Measures Clearinghouse measures and identified 28 resident-sensitive measures for pediatric emergency medicine based on the importance of measures for quality care and representation of resident work.22 It also can be beneficial to expose residents to system-wide high-priority measures. For example, length of stay or patient experience “top-box” ratings may emulate performance metrics or incentives that residents encounter in their future careers.
For measures to be meaningful to residents, they should not only reflect the actual patients a resident cared for (i.e., correct attribution) but also reflect an accurate assessment of performance (i.e., be valid). For example, surgery residents should be able to receive performance data on the patients whom they actually took to the operating room, and psychiatry residents should see how many of their clinic patients are on generic medications. To ensure accuracy, residents should be involved in the process of validating data and measures. UCLA Health, for example, has built over 200 data dashboards with over 2,500 customized metrics, validated by quality-value officers in every division and department, that are now being leveraged to create meaningful resident measures.24 Teams can precisely define breast cancer screening by leveraging data written in the text of resident notes, and can incorporate medications filled at outside pharmacies through claims data integration.
Residents also can benefit from data provided at the patient encounter level to improve practice patterns. For example, the University of Washington School of Medicine had internal medicine residents review their primary care panel and inpatient-based readmissions cases a few times a year.25 They identified patterns for improvement both in the resident purview (e.g., reviewing discharge plans and medication management both prior to discharge and returning to clinic) and at the delivery system levels (e.g., access to primary care or specialist follow-up visits). Through this data-driven feedback, residents can review outlier cases to provide practice feedback.
Additionally, institutions can strive to integrate multiple data sources to create a holistic view of resident performance and the learning environment. Delivery system data could be integrated with GME performance data from ACGME surveys and patient experience data from surveys such as the Press Ganey survey (a questionnaire used to measure patient experience). At the University of Chicago, as part of their ACGME Pursuing Excellence project, data on teamwork are examined from both the ACGME resident survey and from staff engagement surveys. Data from both these sources are systematically studied to identify those clinical units and residency programs that could most benefit from creation of IGNITE (Improving GME Nursing Interprofessional Team Experience) teams, which consist of frontline nurses and residents who engage in performance improvement projects supported by GME and delivery system staff to improve interprofessional collaboration.26 These data also can be used to evaluate the impact of the IGNITE program on metrics such as resident perception of effective interprofessional teamwork (using an ACGME survey) and nursing perception of interprofessional collaboration (using an engagement survey).
Leveraging Existing Staff and Infrastructure to Support Alignment
Resident initiatives can create sustained impact by linking trainees to the institutional staff supporting high-value-care improvement efforts. Staff could include nurses, social workers, care coordinators, operational staff, and data analytic teams that could support the design and implementation of improvement efforts throughout their health system. By creating pathways for residents to work with these team members, they can build skills in interdisciplinary work.27 Communication, coordination, and cooperation are key factors to reach successful implementation and quality outcomes. For example, at the University of Chicago and at UCSF, lean management28 teams work to integrate residents into existing infrastructure, such as attending safety huddles or participating in kaizen events (i.e., short-duration improvement projects). The organizer (R.G.) of a program at UCLA reports that the staff from the Office of Accountable Care and the value analytics team have integrated residents representing various departments into long-term initiatives to address key drivers of spending among high-cost patient populations.
Creating Incentives to Foster Alignment
Augmented incentive systems through medical education could propel further alignment between education and delivery systems.7 Financial incentives (e.g., bundled payments, value-based purchasing, population-based payments) have been important motivators for health care communities to engage in care transformation and to change clinical practice toward value-based care. Physicians who are paid by alternative payment methods, for example, tend to recommend fewer services than do those who are paid under fee-for-service models.29 Similarly, programs such as those at UCSF and the University of Colorado School of Medicine have tied their resident quality improvement programs to financial incentives.20,30 National education leaders could also assess alignment among training health systems to increase accountability. Although value-based payment models and incentives are not a panacea, they are a powerful tool that, if carefully crafted, can synergistically engage educators and delivery system leaders.7
AMCs are under regulatory pressures to achieve high-value care, and the contributions of residents serve as a key factor to achieve this goal. Aligning missions across education and delivery system leadership can help create the infrastructure for improvement within AMCs so that residents become part of the reason for institutional success in improving performance. The four steps described above provide a strategy for AMCs to achieve alignment for high-value care delivery.
The authors wish to thank the education and health system leaders at the institutions described in the manuscript.
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