Over the past 2 decades, the recognition of quality improvement (QI) as an essential core competency for physicians has resulted in its incorporation in graduate medical education curricula in many countries. There is general consensus that QI learning should be experiential,1,2 which often translates to residents actively participating in or leading QI projects at their local institution. Much has been written about the various challenges that residents and residency programs face when carrying out QI work.3 Yet residency training is a unique period when learners begin to personally experience the patient safety and quality-of-care issues that affect health care systems and increasingly take responsibility to address them. In this Invited Commentary, we highlight the importance of residents as change agents in QI and propose ways in which health systems can engage residents in QI work. We write from the perspective of a former resident (P.W.L.) who participated in a QI residency curriculum led by a QI faculty member (B.M.W.) at the University of Toronto in Toronto, Canada.
The article by El-Dalati and Cronin in this issue, entitled “The Importance of Being Earnest,” describes the experiences of infectious diseases trainees at the University of Michigan leading a QI initiative aimed at improving the care of patients diagnosed with infective endocarditis.4 Framing their problem with local data combined with a particularly sobering patient case, El-Dalati and Cronin successfully engaged physicians from cardiology, cardiac surgery, and infectious diseases to form a multidisciplinary working group, which served as a forum to facilitate interprofessional communication. Their collective efforts resulted in a significant decrease in the in-hospital mortality rate for patients with endocarditis from 29.4% to 7.1% over a 1-year period.
The experiences described by El-Dalati and Cronin highlight some of the reasons why residents are in a unique position to lead and carry out QI work. Fixing quality problems often requires team members to “go to Gemba” (a Japanese term from Lean QI methodology meaning “the actual place”), which refers to visiting the frontlines to see the actual processes being used, understand the work, ask questions, and learn. Residents “live at Gemba” by working on the frontlines of the health care system. Their integration into the clinical workflow in clinics, wards, and operating rooms positions them perfectly to observe and characterize the underlying processes that contribute to patient safety and health care quality problems. Residents often rotate through several institutions during their training and quickly gain multiple perspectives on problems beyond how they are addressed at a single health care facility.
El-Dalati and Cronin reflected, “Sometimes it takes fresh faces to solve old problems.”4 Residents’ practices and perspectives are less entrenched than those of their faculty counterparts, which enables them to offer fresh ideas on the QI process. Their creativity and ingenuity serve as assets when coming up with new and innovative changes to test using rapid change cycles. Their constant presence on the frontlines of health care are conducive to real-time assessments, reflection, and adjustments during the crucial implementation phase of a QI project. Importantly, resident-led improvement efforts resulting in better patient care, which is visible to others in near-real time, represent early wins that serve as a powerful example for how frontline clinicians can influence systems change.
Despite these advantages, resident-led QI work is not without its challenges. Residents have competing demands on their time, lack access to necessary resources, and rotate away from the site of the improvement work. Some general challenges associated with carrying out QI work are also magnified for trainees. For instance, navigating the social dynamics that underlie stakeholder engagement can be difficult for residents, who may be viewed as junior or lacking experience. El-Dalati and Cronin described this challenge as they had to persuade staff physicians from multiple specialties to form a working group. This example underscores the important role of the QI faculty mentor: to use established connections to equalize any perceived power differentials and maximize the chances of engagement.
Therefore, having adequate mentorship by QI-trained faculty is vital to unlocking the full potential of residents as QI change agents. Residents with no prior QI experience may be particularly vulnerable to common pitfalls in this work, such as rushing to solutions without a theory of change, improper data collection methods, or failing to fully refine an intervention before evaluation. Having appropriate faculty mentorship to carefully select a project of the right scope and breadth, anticipate pitfalls, and provide guidance when barriers arise is instrumental not only in the success of a resident-led project but also in residents’ ability to achieve advanced competencies in QI.
The integration of QI practicums into medical training is becoming commonplace in many residency programs. At the University of Toronto, the Co-Learning Curriculum in QI was introduced in 2011 and has since expanded to include 21 subspecialty programs across 2 different medical departments.5 Having participated in the Co-Learning Curriculum in QI as an infectious diseases fellow 3 years ago, the experiences described by El-Dalati and Cronin resonated with one of us (P.W.L.). Their experiences matched ours working with resident colleagues on a QI project during their training. Similar to El-Dalati and Cronin, our resident team drew inspiration from their frontline experiences. Our team observed that patients receiving outpatient parenteral antibiotic therapy often underwent double-lumen peripherally inserted central catheter (PICC) insertions unnecessarily, resulting in higher complication rates. With limited prior experience in QI work and a strict timeline, tasks such as stakeholder engagement, navigating ethics review requirements, and completing small sample audits felt daunting and at times overwhelming.
As El-Dalati and Cronin pointed out, maintaining resilience when obstacles occur was key, and having the support of motivated QI-trained faculty mentors helped our team maintain focus, momentum, and positivity. Through discussions with the interventional radiology department, our team ultimately focused on reducing the inappropriate use of double-lumen PICCs at our hospital. By applying the principles from the Co-Learning Curriculum in QI, a “default to single-lumen” policy was implemented where double-lumen PICCs were inserted only if prespecified criteria were met.6 This resulted in a significant increase in the use of single-lumen PICCs from 19% to 67% in noncritical care units with a corresponding reduction in PICC-related complications.6 As El-Dalati and Cronin explained, framing the problem in a manner that was relatable to all stakeholders was one of the major turning points in the project.
We believe that the success of resident-led QI projects is a product of engaged residents, a carefully chosen QI project, and support from highly dedicated QI faculty mentors. The successful engagement of residents requires a careful review of how QI is integrated into existing medical education and health systems infrastructure. This particular topic was addressed at a recent consensus conference organized by the Royal College of Physicians and Surgeons of Canada.7 Educators and health systems leaders convened to develop 4 action statements aimed at bridging the gap in QI-related medical education: (1) establishing a culture of QI and patient safety; (2) building partnerships with health systems leaders and educators to create learning environments for residents; (3) investing in learners, faculty, and frontline health care workers to support QI initiatives; and (4) recognizing and celebrating residents’ achievements in the development or implementation of QI models that improve care. Institutions in the process of developing QI curricula for residency should consider these essential components to optimize opportunities for resident engagement.
Training programs and clinical institutions typically see residents as frontline care providers whose primary role is to treat the patient in front of them. Yet, by enabling residents to “treat the system” through QI work, they can take on the role of residents as change agents, which has the potential to have long-lasting effects on patient care on a much wider scale. However, training programs must do more than simply harness residents’ enthusiasm and root them on from the sidelines. Instead, they must create an environment that is conducive to successfully implementing changes at the curricular, institutional, and health systems levels.
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2. Jones AC, Shipman SA, Ogrinc G. Key characteristics of successful quality improvement curricula in physician education: A realist review. BMJ Qual Saf. 2015;24:77–88.
3. Weiss KB, Co JPT, Bagian JP; CLER Evaluation Committee. Challenges and opportunities in the 6 focus areas: CLER National Report of Findings 2018. J Grad Med Educ. 2018;10(suppl 4):25–48.
4. El-Dalati S, Cronin D. The importance of being earnest. Acad Med. 2021;96:18–20.
5. Wong BM, Goldman J, Goguen JM, et al. Faculty-resident “co-learning”: A longitudinal exploration of an innovative model for faculty development in quality improvement. Acad Med. 2017;92:1151–1159.
6. Lam PW, Volling C, Chan T, et al. Impact of defaulting to single-lumen peripherally inserted central catheters on patient outcomes: An interrupted time series study. Clin Infect Dis. 2018;67:954–957.
7. Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: An urgent call to integrate quality improvement and patient safety education with clinical care. Acad Med. 2020;95:59–68.