The role of resident and fellow trainees in patient-centered improvement processes is critical to a health care system’s success. There is a growing impetus to incorporate patient safety and quality improvement into the educational framework of physicians in training. As part of the Next Accreditation System, practice-based learning and improvement and systems-based practice domains mandate that residents and fellows be assessed on their ability to enhance the quality of care and advocate for patient safety. Best practices for incorporating quality improvement and patient safety into the curriculum of residents and fellows remains an area of interest for educators.
Key points
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As part of their Next Accreditation System, the Accreditation Council for Graduate Medical Education set forth expectations for trainee proficiency in health care quality and patient safety.
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The Clinical Learning Environment Review was established with the primary goals of learning how to best optimize patient safety and clinical quality where trainees are providing care.
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Teaching the basic principles of patient safety and quality improvement methodology can be accomplished through didactic sessions, but incorporating quality improvement projects into the curriculum has been shown to further engage learners and help facilitate development of application skills.
Introduction
All the flowers of all the tomorrows are in the seeds of today
The US health care system is plagued by unnecessary variations in care resulting in many children receiving suboptimal health care. With the publication of To Err is Human and Crossing the Quality Chasm , the Institute of Medicine brought to light the shortcomings of our health care system in providing safe, high-quality health care for patients. The call for a national effort to address these shortcomings has resulted in a surge of support for focused initiatives aimed at eliminating disparities in health care delivery and improving safety in health care. It is now recognized that improving the overall health care system requires physicians with competence in safety and quality improvement (QI) skills.
Despite the growing popularity of this movement, there remain barriers to progress. Although recognizing specific problems and providing targeted solutions have provided some amount of measurable benefit, it has become apparent that the primary obstacle to change lies in the culture of medicine itself, a culture that, in its not-so-distant past, was deeply committed to the ideals of autonomy, authority, and self-reliance—all of which have been shown to detract from an environment focused on achieving safety.
With this in mind, there has been a push toward a grassroots effort to start promoting safety and QI early on within the course of medical education. By teaching core concepts of quality care and patient safety to young physicians, a generation of health care professionals capable of passing on these values to their colleagues and, most importantly, future trainees becomes a reality. Hence, there is a growing impetus to incorporate patient safety and QI into the educational framework of physicians in training.
Introduction
All the flowers of all the tomorrows are in the seeds of today
The US health care system is plagued by unnecessary variations in care resulting in many children receiving suboptimal health care. With the publication of To Err is Human and Crossing the Quality Chasm , the Institute of Medicine brought to light the shortcomings of our health care system in providing safe, high-quality health care for patients. The call for a national effort to address these shortcomings has resulted in a surge of support for focused initiatives aimed at eliminating disparities in health care delivery and improving safety in health care. It is now recognized that improving the overall health care system requires physicians with competence in safety and quality improvement (QI) skills.
Despite the growing popularity of this movement, there remain barriers to progress. Although recognizing specific problems and providing targeted solutions have provided some amount of measurable benefit, it has become apparent that the primary obstacle to change lies in the culture of medicine itself, a culture that, in its not-so-distant past, was deeply committed to the ideals of autonomy, authority, and self-reliance—all of which have been shown to detract from an environment focused on achieving safety.
With this in mind, there has been a push toward a grassroots effort to start promoting safety and QI early on within the course of medical education. By teaching core concepts of quality care and patient safety to young physicians, a generation of health care professionals capable of passing on these values to their colleagues and, most importantly, future trainees becomes a reality. Hence, there is a growing impetus to incorporate patient safety and QI into the educational framework of physicians in training.
Patient safety and quality improvement as part of graduate medical education
The need for engagement and integration of QI and patient safety initiatives within graduate medical education (GME) was realized early on. Residents and fellows make up a significant number of the providers involved in patient interactions within academic medical institutions. Recognizing their unique position on the front lines of care, their role in patient-centered improvement processes becomes critical to a health care system’s success. It has been suggested that a coordinated approach is required to train residents in QI and safety issues. Repeated exposure to QI and performing mentored projects and application during residency years facilitate enhanced training. However, most QI training still occurs in the form of lectures, modules that are self-guided, and electives. In a recent survey of graduating residents, QI practice was noted as the biggest deficiency of training programs, highlighting the existing holes in this aspect of training and the urgent need for improvement. Specifically, efforts to involve residents in local or institutional QI efforts seem to be poor, resulting in missed opportunities for training. This point is important to note, especially because institutional commitment to involving residents in QI is associated with a higher rate of resident participation.
As part of their Next Accreditation System (NAS), the Accreditation Council for Graduate Medical Education (ACGME) set forth expectations for trainee proficiency in health care quality and patient safety. Of the 6 core competencies outlined by the NAS, practice-based learning and improvement (PBLI) and systems-based practice (SBP) domains mandate that residents and fellows be assessed on their ability to enhance the quality of care and advocate for patient safety. Subcompetencies within these core domains further define developmental milestones relating to QI and patient safety ( Box 1 ).
| Core Competency Domain | Reporting Milestone Subcompetency | Description |
|---|---|---|
| SBP | SBP1 | Coordinate patient care within the health care system relevant to their clinical specialty. |
| SBP2 | Advocate for quality patient care and optimal patient care systems. | |
| SBP3 | Work in interprofessional teams to enhance patient safety and improve patient care quality. | |
| PBLI | PBLI3 | Systematically analyze practice using QI methods, and implement changes with the goal of practice improvement. |
“ Coordinate patient care within the health system relevant to their clinical specialty . ” This subcompetency is focused on developing trainees’ ability to assist patients and their families in navigating the complex health care system. The progression through the milestone highlights open communication and collaboration between care teams; seamless transition of care between settings, including written care plans; and recognition of possible barriers to patients and families in achieving coordinated health care. All of these aspects of care are centered on the concept of a medical home , the model of care delivery advocated by the American Academy of Pediatrics (AAP). The medical home is defined by the AAP as one that is accessible, continuous, family centered, coordinated, compassionate, and culturally effective. This patient-centered model facilitates in providing high-quality, safe patient and family experiences, and improves health care outcomes. This point is highlighted by the example of a patient with chronic medical problems, such as ventilator-dependent respiratory disease, seizures, hydrocephalus, and feeding problems requiring G tube feeds. Such a patient is best benefitted by a multidisciplinary team approach, addressing all aspects of the child’s care with the primary care team.
“Advocate for quality patient care and optimal patient care systems . ” This subcompetency is centered on the idea of the physician advocate. In progressing through their training, physicians should develop skills and knowledge that enable them to address concerns of groups, ultimately improving the quality of a system. At the highest level of achievement, trainees should be an active participant in the QI and patient safety initiatives of their health care system and demonstrate an eagerness to make an impact in the community. An example would be involvement in a project disseminating information to the community about bicycle safety and helmet use.
“Work in interprofessional teams to enhance patient safety and improve patient care quality .” This subcompetency hones in on the importance of multidisciplinary teamwork in providing optimal quality of care and a safe patient environment. Physicians in training must strive to use the full professional capabilities of all team members, practicing within the scope of their discipline. By understanding the complementary nature of an interprofessional environment, they become excellent team members, team leaders, and role models for others.
“ Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement .” Physicians in training progress through this subcompetency by developing the knowledge, skills, and attitudes needed to systematically analyze practice using the standards of medical care, change management principles, and QI methodology. It is understood that the degree to which trainees progress through this milestone depends on the clinical environment. With this in mind, advancement is achieved by thinking and acting systemically as well as demonstrating insight into how improvement opportunities can be applied on a larger scale. For example, if there is an identified variation in timing of the first dose of steroids given for children with an asthma exacerbation in the emergency department, a resident or fellow in training may be involved in a mentored quality assessment and improvement project that addresses this deficiency with the ultimate aim of improving care of children with asthma exacerbation.
The Pediatric Milestone Project does address that achieving these competencies can be particularly challenging given some of the barriers that exist within the current system. For example, the time-limited rotations/blocks that are the current model for a resident’s schedule makes is difficult to foster team relationships. Additionally, the QI and patient safety movements are relatively new areas of focus within the medical community; some academic training institutions have yet to fully develop focused initiatives and programs. Therefore, trainees’ exposure to a culture that promotes interdependent functioning is highly variable. Given the potential obstacles, the ACGME developed a complementary program along with the NAS in order to promote a learning environment that upholds the principles paramount to quality and safety.
The clinical learning environment: the foundation of quality improvement in medical education
The Clinical Learning Environment Review (CLER) program sets forth the “expectations for an optimal clinical learning environment to achieve safe and high quality patient care.” It was established with the primary goals of learning how to best optimize patient safety and clinical quality where trainees are providing care and how to best prepare trainees to meet the needs of an evolving health care system. As a key component of the NAS, CLER was designed to assess ACGME-accredited institutional efforts to incorporate quality and safety training into their curriculum engaging their trainees in the 6 important areas of health care quality and patient safety along with feedback on how they can improve the process. The CLER program provides ongoing site visits by an expert committee who assess the clinical learning environment, explain expectations, and share opportunities for improvement. As the purpose of these visits is intended to be formative, information gathered is being tracked and analyzed but currently has no impact on institutional accreditation. Aggregated information from site visits, along with emerging research, are used to optimize the program.
The 6 focus areas of CLER performance evaluation include patient safety, QI, care transitions, supervision, duty hours and fatigue management and mitigation, and professionalism. Released in early 2014, the CLER Pathways to Excellence is a guide addressing each of these focus areas. It incorporates findings and input from the initial site visits in order to provide support for the development of these educational initiatives going forward. Much like the core competencies of the NAS, the 6 focus areas of the CLER were broken down into a series of defined pathways thought to be essential to creating an optimal clinical learning environment ( Box 2 ). These pathways are further defined by a series of key properties that can be assessed at the resident/fellow, faculty, and system-wide level. In addition to providing specific learning expectations, these pathways will help guide future CLER site visits.
| Focus Area | Pathway |
|---|---|
| Patient safety | Reporting of adverse events, close calls |
| Education on patient safety | |
| Culture of safety | |
| Resident/fellow experience in patient safety investigations and follow-up | |
| Clinical site monitoring of resident/fellow engagement in patient safety | |
| Clinical site monitoring of faculty member engagement in patient safety | |
| Resident/fellow education and experience in disclosure of events | |
| Health care quality | Education on QI |
| Resident/fellow engagement in QI activities | |
| Residents/fellows receive data on quality metrics | |
| Residents/fellow engagement in planning for QI | |
| Resident/fellow and faculty member education on reducing health care disparities | |
| Resident/fellow engagement in clinical site initiatives to address health care disparities |
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