Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review

Abstract

The Accreditation Council for Graduate Medical Education requires that trainees show progressive milestone attainment in the practice–based learning and systems–based practice competencies. As part of the Clinical Learning Environment Review, sponsoring hospitals must educate trainees in health care quality improvement, provide them with specialty–specific quality data, and ensure trainee participation in quality improvement activities and committees. Subspecialty–specific quality improvement curricula in nephrology training programs have not been reported, although considerable curricular and assessment material exists for specialty residencies, including tools for assessing trainee and faculty competence. Nephrology–specific didactic material exists to assist nephrology fellows and faculty mentors in designing and implementing quality improvement projects. Nephrology is notable among internal medicine subspecialties for the emphasis placed on adherence to quality thresholds—specifically for chronic RRT shown by the Centers for Medicare and Medicaid Services Quality Incentive Program. We have developed a nephrology-specific curriculum that meets Accreditation Council for Graduate Medical Education and Clinical Learning Environment Review requirements, acknowledges regulatory quality improvement requirements, integrates with ongoing divisional quality improvement activities, and has improved clinical care and the training program. In addition to didactic training in quality improvement, we track trainee compliance with Kidney Disease Improving Global Outcomes CKD and ESRD quality indicators (emphasizing Quality Improvement Program indicators), and fellows collaborate on a yearly multidisciplinary quality improvement project. Over the past 6 years, each fellowship class has, on the basis of a successful quality improvement project, shown milestone achievement in Systems-Based Practice and Practice-Based Learning. Fellow quality improvement projects have improved nephrology clinical care within the institution and introduced new educational and assessment tools to the training program. All have been opportunities for quality improvement scholarship. The curriculum prepares fellows to apply quality improvement principals in independent clinical practice—while showing milestone advancement and divisional compliance with Clinical Learning Environment Review requirements.

The Accreditation Council for Graduate Medical Education (ACGME) Internal Medicine Subspecialty Milestones specifically require that trainees show competence in practice-based learning and improvement (PBLI) and systems-based practice (SBP) (Table 1). In addition, hospitals that sponsor training programs are assessed by the ACGME during frequent site visits as part of the Clinical Learning Environment Review (CLER) Program, which was developed to ensure that sponsoring institutions facilitate and support postgraduate medical education (¹,²). One emphasis area of the CLER is heath care quality improvement (QI). Sponsoring institutions must show that trainees are included in quantitative programs to “improve systems of care, reduce disparities, and improve patient outcomes” (¹,²). Specifically, in the area of health care quality, clinical sites must, in the first four of six Pathways to Excellence, (1) provide trainees with education on QI, (2) ensure active trainee involvement in QI activities, (3) provide trainees with specialty-specific data on quality metrics, and (4) ensure trainee participation in QI committees (Figure 1) (²). The remaining two pathways focus on identifying and reducing patient health care disparities specific to the training site. The CLER requirements for QI education are, in fact, more specific than the subspecialty milestones framework.

Table 1. - The Accreditation Council for Graduate Medical Education subspecialty PBLI and SBP milestones (⁴¹)

Milestone	Description
SBP1	Works effectively within an interprofessional team
SBP2	Recognizes system error and advocates for system improvement
SBP3	Identifies forces that affect the cost of health care and advocates for and practices cost-effective care
SBP4	Transitions patients effectively within and across health delivery systems
PBLI1	Monitors practice with a goal for improvement
PBLI2	Learns and improves via performance audit
PBLI3	Learns and improves via feedback
PBLI4	Learns and improves at the point of care

SBP, systems-based practice; PBLI, practice-based learning and improvement.

Figure 1.: Clinical Learning Environment Review health care quality pathways. Component requirements of each pathway are shown. QI, quality improvement.

For specialty training programs, one method of meeting milestone and CLER requirements is to involve trainees in hospital–wide or department–level quality assurance/performance improvement (QA/PI) programs. However, as residents advance into subspecialty programs, QA/PI curricula should increasingly focus on subspecialty practice and processes. Nephrology fellowship QA/PI training should be specific to the requirements for unsupervised nephrology practice, particularly relating to dialysis, management of CKD, and care of kidney transplant donors and recipients (³).

Training should integrate with and add value to ongoing QA/PI programs of the sponsoring nephrology division, which are part of the overarching QI activities of the sponsoring hospital. Fellows should be familiar with the Centers for Medicare and Medicaid Services (CMS) 2008 “Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule,” which specifically require compliance in areas of patient safety (e.g., infection control, dialysis water and dialysate quality, reuse, and emergency preparedness) and QA/PI (tracking and reporting of quality indicators, including dialysis adequacy, nutrition, metabolic bone disease, anemia, vascular access, immunizations, and dialysis–related medical injuries and errors) (⁴). As future nephrology providers (and in some cases, dialysis facility medical directors), fellows must have practical knowledge of and experience with the QA/PI process to successfully comply with the CMS Quality Incentive Program (QIP) (⁵,⁶). The Organ Procurement and Transplantation Network requirements for assessment of transplant donor and recipients and the Kidney Disease Improving Global Outcomes (KDIGO) practice guidelines for recognition, assessment, and management of CKD (⁷,⁸) also lend themselves to demonstration of milestone attainment in PBLI and SBP and compliance with the CLER QI emphasis areas. Moreover, the ACGME requirement that training programs themselves have a QA/PI program is an opportunity to involve fellows in nephrology education–specific QI.

General Medicine Specialty QI Curricula

There are few practical guides or examples for establishing a successful QI curriculum in the internal medicine subspecialties (including nephrology). Nagy et al. (⁹) have presented a set of general, nonspecialty–specific QI and patient safety milestones for the “continuum of physician development,” which define a proficient clinical faculty member and a competent advanced specialty resident or subspecialty fellow (⁹). This schema incorporates specific examples of what a subspecialty fellow must show to be deemed competent in QI and patient safety. Nagy et al. (¹⁰) have further defined a general Common Core curriculum for Quality and Safety (the C3QS) designed to help training institutions address the CLER Pathways to Excellence in QI. After completing baseline online didactic training, points are awarded for a variety of QI activities, most of which require involvement in division–, department–, or hospital–level performance improvement (PI) projects and committees. These are tracked using the institution’s online graduate medical education assessment portfolio software. Defined point totals, depending on level of training and program length, are required for graduation. The C3QS and documentation of activity completion can help to address almost all of the CLER Pathways of Excellence in patient safety and health care quality.

Wong (¹¹) has described a detailed and practical QI curriculum for trainee physicians across disciplines developed over years at the University of British Columbia, which presumes faculty competence in QI and could be adapted for nephrology training programs.

Nephrology and Other Subspecialty QI Curricula

Maursetter briefly reported, in abstract, a structured fellowship QI curriculum, which resulted in an increase in successful nephrology fellow projects (unpublished data) (Supplemental Material). A recent “Moving Points in Nephrology” series describing practical implementation of QI projects could be used as a didactic basis for a nephrology QI curriculum (^12–16).

Although no nephrology fellowship QI curriculum has yet been reported in detail, other internal medicine subspecialty programs have developed and described curricula specific to their subspecialty. A critical care fellowship incorporated formal QI training into the program, emphasizing didactic Six Sigma training and submission of a health care QI project (¹⁷). A rheumatology program implemented a safety and PI curriculum on the basis of the CLER (¹⁸). A geriatric fellowship program described a curriculum incorporating didactic and fellow–led self–audit using the American Board of Internal Medicine “Care of the Vulnerable Elderly” PI module (¹⁹). Varkey et al. (²⁰) described a validated objective structured clinical examination (OSCE) designed to assess the efficacy of a 3-week QI elective given to endocrinology fellows, although the QI curriculum itself is not described.

QI Projects and Experiential Learning

Many subspecialty programs require that fellows be involved in QI projects; however, there must be a mechanism for evaluating whether such projects are acceptable measures of competency attainment. McClain et al. (²¹) developed a template and evaluation checklist (Table 3) defining required characteristics of QI projects that show competency, while avoiding specification of particular QI tools or proprietary methods. Required QI project characteristics are that (1) trainees be significantly involved, (2) it be educational, clinical, or research based, (3) it include baseline outcome measurement with a plan for improvement and remeasurement, (4) clinical projects include patients cared for by the fellow, and (5) at least one faculty mentor be involved.

As discussed earlier, the “Moving Points in Nephrology” series on QI for the nephrologist could serve as a template for fellow-led projects. The series uses a clinical QI project example that fellows will relate to—increasing the number of patients selecting home dialysis as their initial modality for RRT (¹²,¹³). The authors acknowledge how daunting the myriad QI analytic tools and improvement models may seem and advance the important concept that the root cause analysis tools and improvement model selected should be those with which the team, division, or institution are most familiar. Also, tools from different improvement models can be combined as necessary (¹³,¹⁴).

Fellow–Led Nephrology QI Projects

There are few reports of fellow–led nephrology QI projects, although it is likely that some are reported without making clear their status as fellow projects. Many successful QI projects are not generalizable outside of a local context and would not be reported publically. Thus, it is difficult to assess the number and effect of such projects. One program reported a fellow–led, multidisciplinary, community–based, prospective observational QI study in patients on incident peritoneal dialysis (PD). Existing PD catheter placement practice guidelines were not being consistently followed, and this was associated with frequent complications and suboptimal patient satisfaction with PD education (²²). Cohen et al. (²³) described a project to improve first year fellow communication with patients about advanced kidney disease and end of life issues, which used a full day didactic and simulation workshop. Participants reported improvement in communication skills, attitudes, and behaviors sustained for at least 3 months.

Search of American Society of Nephrology Kidney Week abstracts from 2011 to 2015 using the terms fellow, education, and quality followed by abstract review yielded nine abstracts describing fellow–led clinical QI projects (Supplemental Material). Numbers have increased over time, with four reported in 2015, two reported in 2014, two reported in 2013, one reported in 2012, and zero reported in 2011. Some may have been overlooked if the abstract did not include the key words. None seem to have been subsequently published. Projects included interventions to improve CKD practice guideline adherence, timeliness of referral for transplant evaluation and hemodialysis access placement, CKD–associated anemia management, notification of hemodialysis–dependent patients in the emergency room, short–term dietary phosphate control in patients on chronic dialysis, hyponatremia correction, PD peritonitis associated with β-cap adapters, and provider preparation to treat antibody–mediated transplant rejection.

Other subspecialty fellowship programs, notably gastroenterology (²⁴) and geriatrics (²⁵), have reported successful fellow QI projects that resulted in improvements in consultative communication and reduced polypharmacy among nursing home patients.

Because the ACGME requires that training programs themselves apply QI methods to educational processes and curriculum, some subspecialty fellows have focused their QI efforts on fellowship education. As discussed above, Cohen et al. (²³) involved nephrology fellows in a project to improve fellow interpersonal communication skills when approaching patients with advanced kidney failure. Eid et al. (²⁶) reported on hematology-oncology fellow satisfaction and in–training examination scores after implementation of the academic half–day educational format, and a group of cardiology fellows described a PI project that resulted in the development of a clinician educator curriculum (²⁷).

Faculty QI Proficiency

A nephrology–specific PI curriculum presupposes the existence of faculty proficient in QI and capable of mentoring fellows. A deficiency in such faculty is a serious barrier to implementing a QI curriculum. A recent single–center study found that, even after QI science education, residency and fellowship program directors lacked the necessary knowledge and skills to develop curricula (²⁸). A survey of pulmonary/critical care program directors indicated, although 84% felt that the QI education was important in fellowship training, only 26% had participated in a formal QI curriculum, and only 51% felt their graduating fellows were capable of independently performing QI (²⁹). Barriers included lack of time, fellow interest, and qualified faculty. There seems to be no published information regarding nephrology program director and faculty QI proficiency and comfort level in mentoring fellow QI projects, and this would be of considerable interest.

The Association of American Medical Colleges has recommended that all clinical faculty be proficient in QI and set forth a general set of competencies and milestones for proficiency, which include those in Table 1 as well as proficiency in “practicing evidence-based medicine,” “using information technology to improve practice and reduce errors,” and “knowing one’s limitations” (³⁰). However, they are nonspecific and do not provide clearly defined examples of proficiency (³¹).

Nagy (³¹) has refined this description and developed a QI milestone instrument that allows faculty to self-assess their proficiency. The instrument is freely available online. The definition of faculty proficiency includes, among others, (1) completion of institutionally required QI training, (2) use of specialty–specific performance indicators to improve personal and trainee clinical performance, (3) active involvement in division QI initiatives, (4) use of evidence-based medicine in clinical teaching and patient-centered care, and (5) effective participation in multidisciplinary patient care.

The Walter Reed National Military Medical Center Nephrology QI Curriculum

Our program’s nephrology–specific multidisciplinary QA/PI curriculum (in existence since 2009 and shown in Table 2) is designed to prepare fellows to meet nephrology-specific milestones in multiple subcompetencies, most particularly in the PBLI and SBP competencies, as well as meet the requirements of the first four CLER QI Pathways of Excellence.

Table 2. - Components of quality assurance/performance improvement training curriculum for nephrology fellows

Training Component	Multidisciplinary	Associated Nephrology Curricular Subcompetency	Associated CLER Health Care Quality Pathway to Excellence	Frequency
First and second year fellows outpatient chart audit; tracks KDIGO CKD quality indicators (recognition and management of HTN and albuminuria) (32)	Not applicable	PBLI1–4	Pathway 3	Continuous
First year fellow end of month dialysis summary audit tracks compliance with CMS QIP indicators	Not applicable	PBLI1–4	Pathway 3	Continuous
Second year fellow participation in institutional QI training seminar “Quality Rocks!” for the novice	Not applicable	Not applicable	Pathway 1	Annual
Attendance at quarterly nephrology/dialysis QA/PI meeting	Yes	Not applicable	Pathway 1	Quarterly
	Fellows, faculty, nursing staff, ancillary staff		Pathway 2
			Pathway 3
			Pathway 4
Mentored, multidisciplinary second year PI project	Yes	PBLI2	Pathway 1	Annual
		SBP1–3	Pathway 2
			Pathway 4
First and second year fellows assist in development and testing of new nephrology educational assessment tools	Yes	PBLI2	Pathway 1	As required
		SBP1	Pathway 2
			Pathway 4

CLER, Clinical Learning Environment Review; KDIGO, Kidney Disease Improving Global Outcomes; HTN, hypertension; PBLI, practice–based learning and improvement; CMS, Centers for Medicare and Medicaid Services; QIP, Quality Incentive Program; QI, quality improvement; QA/PI, quality assurance/performance improvement; PI, performance improvement; SBP, systems-based practice.

Throughout training, our previously described outpatient chart audit tool (³²) allows for tracking of quality indicators for both general and transplant outpatient clinic encounters and end of month summaries for patients on chronic dialysis. Programs can select outpatient clinic quality indicators on the basis of practice guidelines, such as those of KDIGO, which are of particular importance to their patient and practice profile. End of month dialysis summary audits track compliance with CMS QIP indicators, including anemia management, dialysis adequacy, vascular access, and bone mineral metabolism management (³³). Indicator compliance can be tracked, fellows and faculty can monitor progress, and ultimately, compliance thresholds can be used to show milestone achievement in the areas of PBLI1–4 (³⁴). Thus, the CLER Health Care Quality Pathway 3 goal of providing fellows with access to actionable, specialty–specific quality data directly related to their patients is achieved.

We concentrate most of our formal training in QA/PI in the second year of fellowship, providing didactic and experiential training to meet the CLER Health Care Quality Pathway 1 goal of providing QI education. Second year fellows attend “Quality Rocks!,” a short course designed for hospital nursing and support staff, house staff, and faculty, which provides foundation knowledge in QI to the novice learner. Course objectives are that the student (1) understands the policy foundation and critical need for improvement in health care quality and patient safety, (2) is able to use the basic tools for improvement, and (3) becomes familiar with the national-level organizations that offer resources and support. Topics covered include the six aims of health care from the Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century (³⁵), improvement tools using the Institute for Healthcare Improvement (IHI) Model for Improvement, and a brief overview of the IHI, The Joint Commission, and The Agency for Healthcare Research and Quality. Students learn through didactic instruction but also, in small group exercises, where they analyze case studies and write out their own aim statements and stakeholder lists for projects that they are developing or in which they are participating.

Fellows also attend, observe, and participate in nephrology/dialysis quarterly QA/PI meetings. This facilitates achievement of CLER Pathway 1 goals for QI education in the context of systems-based priorities for nephrology and dialysis care and also meets Pathways 2 and 4 goals for active involvement in QI activities and participation in nephrology division QI committees.

The Multidisciplinary QI Project

Didactic training is followed by performance of a multidisciplinary PI project, with fellows actively involved in the entire QI cycle. The QI project meets the CLER Pathways 1, 2, and 4 goals of ensuring progressive experiential training in nephrology–specific QI, ensuring fellow participation in QI activities and committees, and monitoring and assessment of trainee QI efforts. The project also shows milestone achievement in SBP1–3. Under the supervision of a mentor (usually the Nephrology PI Director), second year fellows work together to select a process to improve, and then, they organize, devise, and implement a strategy for improvement assisted by nursing and allied staff. All fellows work on the same project, typically two to four fellows per training year. We use the Model for Improvement framework, but the best model should be the one with which the institution or division is most familiar (¹³,¹⁷). A checklist may be used to ensure that the QI project has the necessary characteristics to show competency (Table 3). Progress is presented quarterly at a conference attended by fellows and faculty, with the first presentation within 2 months of the beginning of the second year. Results are formally presented at the conclusion of the academic year to faculty, first year fellows, and allied staff. Previous projects improved processes at the service and hospital levels. Several have been presented at hospital–wide PI summits, two have been presented at national nephrology meetings, and one was recently published (³⁶). All have met the criteria for successful trainee PI projects that show competency in PBLI and SBP as outlined by McClain et al. (²¹) (Table 3).

Table 3. - A checklist for characteristics of acceptable nephrology fellow quality improvement project

Characteristic	Specifics
All fellows involved in QI project development and implementation under faculty mentor supervision?	Participants in team
Does QI project focus on one of three areas: educational, clinical, or administrative?	Educational, clinical, administrative
Is it possible that the QI project qualifies as research? a	If yes, protocol must be submitted for determination by institution’s Department of Research Protections/Institutional Review Board
Does the QI project have all of the following elements?
Initial/baseline measurement of one outcome	Describe
Plan for improvement with defined intervention(s)	Describe
Plan for remeasurement of outcome after defined intervention to determine effect	Describe
Clinical measurements included patients cared for by fellows	Describe

Each characteristic was indicated either “Yes” or “No”. QI, quality improvement. Modified from McClain et al. (²¹), with permission.

^aSome institutions, including our own, require that the Institutional Review Board determine whether a QI project constitutes research (⁴²). Many offer checklists to assist the QI investigators in making an initial determination.

We also involve fellows in educational QI initiatives. They have assisted in development and testing of new nephrology educational assessment tools to document competency milestone attainment. This also satisfies the CLER Health Care Quality Pathway 2 goal of ensuring fellow engagement in QI activities.

Summary of QI Projects Performed by Fellows

2009–2010

Collaborating with the clinical pharmacist and nurse practitioner, fellows recognized that individual physician management of predialysis erythropoiesis–stimulating agents (ESAs) was often not meeting monitoring frequency requirements and hemoglobin targets. They developed a “CKD Anemia Clinic” protocol managed by the clinical pharmacist who adjusted ESA doses, directed iron repletion, and ordered laboratory monitoring. In a 53-patient cohort, historical performance by individual nephrologists was compared with ESA clinic management. Cohort compliance with contemporaneous Kidney Disease Outcomes Quality Initiative guidelines improved significantly (P=0.02). The clinic remains in operation, ensuring compliance with changing ESA practice guidelines.

2010–2011

Working with the nephrology dietician, clinical pharmacist, and nurse practitioner, fellows developed a multidisciplinary intervention for improving management of CKD outpatients not meeting contemporaneous guidelines for BP control. Medication compliance was assessed, and patients received dietary counseling, and home BP monitoring instruction. Significant improvement in postintervention clinic BP was documented via the chart audit tool. We continue to track BP control as a quality indicator on clinic chart audit, ensuring compliance with existing practice guidelines.

2011–2012

Perceiving substantial practice variation among faculty, fellows designed a project to standardize antibody–mediated rejection (AMR) management. Assisted by the organ transplant service data coordinator, they reviewed 5 years of cases of patients with AMR, reviewed the literature, and assessed provider preparation to treat AMR by electronic survey. Lectures were given reviewing institutional experience with AMR and the literature regarding diagnosis and management. An online “AMR Toolkit” was created for provider reference. Four months after education, faculty reported feeling well prepared to manage AMR, significantly improving from baseline (91% versus 65%; P<0.001). This project produced a local standard of care for faculty and fellows in an area with weak evidence to guide practice.

2012–2013

Working with the Department of Laboratory Services, fellows initiated institution-wide reporting of eGFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (³⁷), with a simplified reporting schema for black versus nonblack race. They showed that internal medicine and general surgery house staff were significantly more likely to assign the correct eGFR to patients on the basis of race using the CKD-EPI reporting system versus the Modification of Diet in Renal Disease eGFR.

2013–2014

Responding to administrative difficulties encountered with kidney biopsy scheduling, fellows worked with the clinical administrative and nursing staff, anatomic pathology, and interventional radiology to develop a standard procedure to streamline the provider experience arranging outpatient kidney biopsy. Pre- and postintervention provider satisfaction surveys indicated improvement in day of procedure processes (P=0.01), reduction in time to arrange renal biopsy (P=0.03), and improvement in on-time starts (P=0.03).

2014–2015

Fellows, collaborating with the CKD clinic nurse practitioner, implemented KDIGO-recommended eGFR using cystatin C and serum creatinine rather than serum creatinine alone in selected patients to confirm CKD (⁷); 88% of patients referred for evaluation of CKD stage 3, with an initial eGFR using serum creatinine alone of 45–59 ml/min per 1.73 m² without increased albuminuria, were reclassified to an eGFR using cystatin C and serum creatinine ≥60 ml/min per 1.73 m². Such patients may require fewer clinic visits and less laboratory monitoring (³⁷).

Educational QI Project 2013–2014

Second year fellows initiated a temporary dialysis catheter insertion simulation previously described and validated by Barsuk et al. (³⁸). First year fellows beta tested the simulation, and second year fellows administered satisfaction surveys before and after the event. All first year fellows reported improved procedural confidence after the simulation, which is now in routine use in our program.

Educational QI Project 2014–2015

First and second year fellows alpha tested a newly developed OSCE simulation using a validated assessment tool: the Essential Elements of Communication—Global Rating Scale 2005 (³⁹,⁴⁰). Trained actors represented patients in three “Breaking Bad News” counseling scenarios: ESRD and chronic RRT, AKI and acute RRT in the intensive care unit, and kidney biopsy. After-action feedback and satisfaction surveys were used to improve the simulation and develop a second simulation set for the 2015–2016 training year.

Summary

The nephrology–specific QA/PI curriculum and the multidisciplinary QI projects completed by our fellows have had a measurable, beneficial effect on our division’s clinical outcomes and the training program. The curriculum also ensures that graduating fellows are ready for unsupervised practice in nephrology-specific QA/PI and that those that become faculty are capable of mentoring internal medicine and nephrology trainee QI projects. Although QI curriculum focuses on enabling the trainee to show milestone attainment in PBLI and SBP and meet CLER Health Care Quality Pathway requirements, training should be value added, designed to address clinical process needs of the entire nephrology division. Fellow progress in PBLI and SBP may be shown by tracking compliance with nephrology–specific quality indicators on the basis of nationally accepted practice guidelines and CMS requirements. This prepares fellows for the realities of practice, especially in ESRD services. Fellow QI projects should not be an additional burden for the training program and fellows. Rather, projects should have clear utility and effect on institutional nephrology clinical practice. Projects that are not completed may have an adverse effect, in that fellows may feel that their work has been wasted and that QI is not particularly important. Engaged faculty mentorship is essential. QI projects should be viewed as of equal import to academic research projects and approached with the same rigor. Moreover, when fellows see that previous trainee QI projects have had a positive effect on their own practice, they invest in their own project with greater enthusiasm. They also have an opportunity for scholarship outside of traditional academic research, which may be used to show ACGME Medical Knowledge milestone advancement. The QI curriculum prepares fellows to apply the principals of QI after they advance into independent clinical practice—the overarching curricular goal beyond demonstration of milestone advancement and compliance with CLER requirements.

Disclosures

None.