By: Brian M. Wong, MD, FRCPC, assistant professor and director of continuing education and quality improvement, Department of Medicine, and associate director, Centre for Quality Improvement and Patient Safety, University of Toronto
Paul Batalden, one of the most influential leaders who shaped modern quality improvement (QI) efforts in health care, once wrote that “everyone in health care really has two jobs when they come to work every day: to do their work and to improve it.” This couldn’t be more true today, as the Accreditation Council on Graduate Medical Education (ACGME) rolls out its Clinical Learning Environment Review (CLER) program across the country, which has a strong focus on determining how institutions engage residents in QI work to improve system performance.
Unfortunately, most places treat QI like an ‘add-on’ learning experience and typically have residents complete a QI project. For example, a resident might choose to improve immunization rates in patients admitted to the clinical teaching unit (CTU) with chronic obstructive pulmonary disease (COPD). But, throughout the year, the resident will rotate away from the CTU onto other services, taking her away from the place where the project work happens. And since the project is not integrated into the daily work of the CTU, when the resident is on a different rotation, the project stalls.
Residents work harder than ever because they now need to pack the same amount of clinical work into shortened work days and spend their 80-hour work weeks primarily looking after extremely complex patients. Not surprisingly, when residents need to take time to ‘go back’ to the CTU to work on their QI projects on their own time, they quickly start to view this as extra work and frequently complain that there simply isn’t enough time to dedicate to their projects.
Interestingly, you don’t hear residents say, “I don’t have time to see all my patients in clinic today” or “I simply don’t have time to attend patient and family meetings to plan for discharge.” Why is that? Well, seeing patients in clinic and meeting with patients and their families is considered core work, part of the job, what residents do when they come to work every day to make patients better. Imagine if residents truly embraced the notion that they need to come to work prepared to improve how the system delivers care as well. Imagine if residents came to work and thought that caring for the system is part of the job, just like it is to care for their patients.
In their recent study published in Academic Medicine, a group based at the White River Junction Veterans Affairs Medical Center in Vermont, a VA hospital affiliated with the Geisel School of Medicine at Dartmouth, made systems improvement a core resident responsibility when they rotated onto their internal medicine CTU block. Residents were assigned a roster of patients and a quality problem to look after. When they rotated off, in addition to handing off their patients, they handed off the QI project to the incoming residents. So instead of the QI work stalling because the resident leaves his CTU rotation, integrating QI work as a core responsibility makes it more likely that initiatives will be completed.
Here are a few of the clever ways that they supported this daily QI work:
- Analogous to the patient whiteboard that lets residents know who they are responsible for, the group created a QI whiteboard to let residents know about the status of their QI projects, making clear which part of the project they are responsible for while on the rotation.
- When looking after patients, we rely on diagnostic lab tests and imaging to track their clinical improvement. QI is no different–projects need frequent access to performance data at the team level to track systems improvements. The group made a concerted effort to make this performance data readily available. They even hired a dedicated full-time quality analyst to prepare these data reports.
- Rounds are an integral part of how we deliver care to patients on CTUs. To ‘round on the system’, residents regularly meet to do their QI work, and these meetings were part of the weekly routine. Similar to patient care rounds, the senior resident was responsible for directing the QI work, with oversight from the attending physician.
Their efforts have resulted in important improvements in actual patient care outcomes. More patients received appropriate pneumococcal vaccination and VTE prophylaxis. More physicians washed their hands and counseled patients to stop smoking. These results beg the question: Isn’t it about time that residents started rounding on the system?