Re-thinking How We Teach Quality Improvement: Adding Meaning to an ACGME Requirement

Morbidity and Mortality of the Transmetatarsal Amputation: A Comparative NSQIP Analysis

The objective of this investigation was to compare the morbidity and mortality of transmetatarsal amputation to other frequently performed surgical procedures utilizing a large US database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated for the purposes of this investigation. We initially extracted data related to the Current Procedural Terminology (CPT) code 28805 (amputation, foot; transmetatarsal) and the variable labels "estimated probability of morbidity" and "estimated probability of mortality." We subsequently performed a CPT code search for those procedures occurring at a frequency greater than 10,000 in the database, and additionally extracted data for estimated probability of morbidity and estimated probability of mortality for these procedures. This resulted in identification of 17 additional procedures. CPT code 28805 was associated with the highest estimated probability of morbidity of the cohort (0.1360 ± 0.0669), and this demonstrated statistical significance higher than all other CPT codes (p < .001). CPT code 28805 was associated with the second-highest estimated probability of mortality of the cohort (0.0327 ± 0.0596). This demonstrated statistical significance less than that of CPT code 27245 (0.0327 ± 0.0596 vs 0.0547 ± 0.0661; p < .0001), but statistical significance higher than all other CPT codes (p<0.001). The results of this investigation indicate that transmetatarsal amputation carries a substantial risk for morbidity and mortality in comparison to other commonly performed surgical procedures.

Customised knowledge-sharing platform to foster resident quality improvement activities, tracking and scholarship

INTRODUCTION

Meeting accreditation requirements to train resident physicians in quality improvement (QI) may require more than education. Barriers to resident QI engagement underscore the need to demonstrate the impact and value of resident QI work. It is not known whether a platform to track and publicise resident QI projects and scholarship is feasible or acceptable to implement within a residency programme. We aimed to create a searchable online platform and associated programming to promote resident QI work.

METHODS

This intervention targeted resident physicians in an internal medicine residency training programme at a tertiary, academic medical centre. We designed an intervention to track resident QI and related scholarship in a searchable online platform, including practical details of implementing each project. Newsletters and events were used to publicise these project profiles.

RESULTS

During the 2020-2021 academic year, 104 projects were profiled from 238 sourced projects. Average readership was 31.5% across 11 newsletters sent to residents and key faculty.

DISCUSSION

A platform to track and share resident QI work and scholarship can be feasibly and acceptably implemented within a residency programme, serving as a novel way to engage residents around QI.

The Evolving Curriculum in Quality Improvement and Patient Safety in Undergraduate and Graduate Medical Education: A Scoping Review

Quality Improvement and Patient Safety (QIPS) has become an increasingly important area of focus within undergraduate and graduate medical education. A variety of different QIPS curriculums have been developed, but standardization and effectiveness of these curriculums is largely unknown. The authors conducted a scoping review to explore the status of undergraduate and graduate nondegree QIPS curriculum in the United States. A scoping review was performed using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model as a guide. Two databases were screened from January 2019 to March 2022 to identify relevant articles. Forty-seven articles met eligibility criteria, with most articles (n = 38) focused on graduate medical education. Of those 38, 86.8% (33/38) were developed as curriculum specific to a particular specialty. The article highlights similarities and differences in structure, evaluation metrics, and outcomes, and subsequently offers insight into curriculum components that should help guide standardization of successful curriculum development moving forward.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Residents as Leaders: Using a Delphi Process to Conduct an Institutional Preoperative Patient Optimization Quality Improvement Initiative

BACKGROUND

Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives.

STUDY DESIGN

As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation.

RESULTS

Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again.

CONCLUSIONS

We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts.

Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents.

BACKGROUND

There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery.

METHODS

We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully.

RESULTS

There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting.

CONCLUSIONS

The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.

Creating a Framework to Integrate Residency Program and Medical Center Approaches to Quality Improvement and Patient Safety Training

Quality improvement and patient safety (QIPS) are core components of graduate medical education (GME). Training programs and affiliated medical centers must partner to create an environment in which trainees can learn while meaningfully contributing to QIPS efforts, to further the shared goal of improving patient care. Numerous challenges have been identified in the literature, including lack of resources, lack of faculty expertise, and siloed QIPS programs. In this article, the authors describe a framework for integrated QIPS training for residents in the University of Washington Internal Medicine Residency Program, beginning in 2014 with the creation of a dedicated QIPS chief resident position and assistant program director for health systems position, the building of a formal curriculum, and integration with medical center QIPS efforts. The postgraduate year (PGY) 1 curriculum focused on the culture of patient safety and entering traditional patient safety event (PSE) reports. The PGY-2 curriculum highlighted QIPS methodology and how to conduct mentored PSE reviews of cases that were of educational value to trainees and a clinical priority to the medical center. Additional PGY-2/PGY-3 training focused on the active report, presentation, and evaluation of cases during morbidity and mortality conferences while on clinical services, as well as how to lead longitudinal QIPS work. Select residents led mentored QI projects as part of an additional elective. The hallmark feature of this framework was the depth of integration with medical center priorities, which maximized educational and operational value. Evaluation of the program demonstrated improved attitudes, knowledge, and behavior changes in trainees, and significant contributions to medical center QIPS work. This specialty-agnostic framework allowed for training program and medical center integration, as well as horizontal integration across GME specialties, and can be a model for other institutions.

QIPS CURE: Implementing a Quality Improvement and Patient Safety Curriculum and Resident Experience

BACKGROUND

Resident participation in quality improvement and patient safety (QIPS) programs is an essential training experience and Accreditation Council for Graduate Medical Education requirement. However, the most effective approach to achieve this is unclear.

OBJECTIVE

We developed an experiential Quality Improvement and Patient Safety Curriculum and Resident Experience (QIPS CURE) program, which provides internal medicine (IM) residents with foundational QIPS knowledge, and evaluated its effectiveness.

METHODS

After reviewing IM residency QIPS curricula and obtaining input from institutional stakeholders in 2013-2014, we launched a longitudinal QIPS curriculum for all 66 postgraduate year 1-3 IM residents in July 2014. The QIPS CURE included 2 major elements: didactics, delivered through a variety of sources, including online modules and workshops, and hands-on projects. We delivered this curriculum annually from 2014 to 2018. We used project completion and an attitude survey of participants to evaluate it.

RESULTS

Six projects were completed in 2014-2015, and 10 projects completed yearly for the next 3 academic years. Residents presented all projects at regional meetings. Surveyed residents reported improvement in understanding (M = 5.71, SD = 1.07 pre- to M = 6.38, SD = 0.49 post-curriculum, P = .013) and competence (M = 3.31, SD = 1.18 pre- to M = 6.08, SD = 0.77, post-curriculum, P < .001) when comparing graduates of the curriculum with incoming interns. Qualitative analysis revealed perceived acquisition of skills needed to carry out successful QIPS projects.

CONCLUSIONS

This QIPS program was sustainable over 4 years and generally well-received by residents, with many projects completed each year.

Swimming With Sharks: Teaching Residents Value-Based Medicine and Quality Improvement Through Resident-Pitched Projects

BACKGROUND

To create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure.

OBJECTIVE

We created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness.

METHODS

We designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation.

RESULTS

In the first 2 years (2017-2018), 92 trainees participated, and 71 of 76 (93%) recommended the curriculum. Surveys (76 of 92, 83%) show improvement in our learning objectives (12%-60% pre to 62%-97% post; P < .001 for all; Cohen's d effect size 0.7-1.2), which are sustained at 1-year follow-up (57%-95%; P < .01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value.

CONCLUSIONS

Our project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects.