Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety

Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety

BACKGROUND

Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education.

OBJECTIVE

The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University.

METHODS

A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline.

RESULTS

A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described.

CONCLUSIONS

We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

Quality Improvement in Health Care: The Role of Psychologists and Psychology

Quality Improvement (QI) is a health care interprofessional team activity wherein psychology as a field and individual psychologists in health care settings can and should adopt a more robust presence. The current article makes the argument for why psychology's participation in QI is good for health care, is good for our profession, and is the right thing to do for the patients and families we serve. It reviews the varied ways individual psychologists and our profession can integrate quality processes and improve health care through: (1) our approach to our daily work; (2) our roles on health care teams and involvement in organizational initiatives; (3) opportunities for teaching and scholarship; and (4) system redesign and advocacy within our health care organizations and health care environment.

Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety

Academic clinical departments have the opportunity and responsibility to improve the quality and value of care and patient safety by supporting effective quality improvement activities. The pressure to provide high-value care while further developing academic programs has increased the complexity of decision making and change management in academic health systems. Overcoming these challenges will require faculty engagement and leadership; however, most academic departments do not have a sufficient number of individuals with expertise and experience in quality improvement and patient safety (QI/PS). Accordingly, the authors of this article advocate for a targeted and proactive approach to developing faculty working in QI/PS. They propose a strategy predicated on the identification of QI/PS as a strategic priority for academic departments, the creation of enabling resources in QI/PS, and the expansion of rigorous training programs in change management and in improvement and implementation sciences. Professional organizations, health systems, medical schools, and academic departments should recognize successful QI/PS work with awards and promotions. Individual faculty members should expand their collaborative networks, consider the generalizability and scholarly impact of their efforts when designing QI/PS initiatives, and benchmark the outcomes of their performance. Appointments and promotions committees should work proactively with department and QI/PS leaders to ensure that outstanding achievement in QI/PS is defined and recognized. As with the development of physician-investigators and clinician-educators, departments and health systems need a comprehensive approach to support and recognize the contributions of faculty working in QI/PS to meet the considerable needs and opportunities in health care.

Early Experiences After Adopting a Quality Improvement Portfolio Into the Academic Advancement Process

PROBLEM

Academic medical centers (AMCs) and their academic departments are increasingly assuming leadership in the education, science, and implementation of quality improvement (QI) and patient safety efforts. Fostering, recognizing, and promoting faculty leading these efforts is challenging using traditional academic metrics for advancement.

APPROACH

The authors adapted a nationally developed QI portfolio, adopted it into their own department's advancement process in 2012, and tracked its utilization and impact over the first two years of implementation.

OUTCOMES

Sixty-seven QI portfolios were submitted with 100% of faculty receiving their requested academic advancement. Women represented 60% of the submitted portfolios, while the Divisions of General Internal Medicine and Hospital Medicine accounted for 60% of the submissions. The remaining 40% were from faculty in 10 different specialty divisions. Faculty attitudes about the QI portfolio were overwhelmingly positive, with 83% agreeing that it "was an effective tool for helping to better recognize faculty contributions in QI work" and 85% agreeing that it "was an effective tool for elevating the importance of QI work in our department."

NEXT STEPS

The QI portfolio was one part of a broader effort to create opportunities to recognize and support faculty involved in improvement work. Further adapting the tool to ensure that it complements-rather than duplicates-other elements of the advancement process is critical for continued utilization by faculty. This will also drive desired dissemination to other departments locally and other AMCs nationally who are similarly committed to cultivating faculty career paths in systems improvement.

The Department of Medicine in 2030: A Look Ahead

The authors described the features of a hypothetical academic Department of Medicine in 2030 that would be most effective in improving the public health. Future departments of medicine will be compelled to respond to a projected shortage of physicians through augmented training strategies. The clinical programs will be more decentralized and responsive to patient preferences while demonstrating greater value. Departments will create adaptable, accountable structures in which clinicians working in interdisciplinary teams continuously improve processes and outcomes of care, and clinician and patient satisfaction. The restructuring of health care will afford exciting opportunities to align clinical and scholarly activities. The growing ability to link biological and clinical phenotypic information will lead to more effective and efficient clinical care. In view of the funding constraints and the remarkable opportunities for high-impact research, departmental research programs will become increasingly disciplined. Successful research programs will require durable investments in faculty career development, enabling infrastructure, interdisciplinary research teams, and diverse funding sources. The educational programs will demonstrate proficiency of trainees in the 6 current core competencies, as well as in additional areas critical to health care transformation. To improve organizational effectiveness, departments will create more nimble organizational structures led by individuals with diverse backgrounds. Chairs of departments of medicine will be expected to continuously expand their capacity to meet the evolving needs of their departments and institutions. Members of departments of medicine will be continuously fortified by the privilege and obligations of our profession while embracing the risks necessary to meet the extraordinary opportunities in 2030.

The physician mentored implementation model: a promising quality improvement framework for health care change

Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components: (1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering "one-size-fits-all" technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.

Improving the Ambulatory Patient Experience Within an Academic Department of Medicine

Academic departments of medicine (ADOM) can provide an important vehicle to drive the sharing and dissemination of best practices in clinical care delivery. With the increased focus on improving the patient experience, particularly in the ambulatory setting, ADOM also should lead efforts to cultivate improvements in this arena. To address this need, the study ADOM established a Patient Experience Working Group (PEWG) that brought together physician and nonphysician leaders, set improvement goals, and created a structure for sharing and learning. Since initiation, the PEWG has implemented more than 20 performance improvement initiatives, which have resulted in measured positive changes at both the local practice settings and department-wide. Striking the right balance between top-down governance, bottom-up innovation and ownership, and shared goal setting was a key to success. This model is one that could easily be adopted by other ADOM in their own efforts to improve the patient experience.

A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum

BACKGROUND

Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error.

DISCUSSION

To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the month's case reviews are presented, learning points discussed, and corrective actions are proposed.

CONCLUSION

By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.

Integrating patient safety into health professionals' curricula: a qualitative study of medical, nursing and pharmacy faculty perspectives

BACKGROUND

As efforts to integrate patient safety into health professional curricula increase, there is growing recognition that the rate of curricular change is very slow, and there is a shortage of research that addresses critical perspectives of faculty who are on the 'front-lines' of curricular innovation. This study reports on medical, nursing and pharmacy teaching faculty perspectives about factors that influence curricular integration and the preparation of safe practitioners.

METHODS

Qualitative methods were used to collect data from 20 faculty members (n=6 medical from three universities; n=6 pharmacy from two universities; n=8 nursing from four universities) engaged in medical, nursing and pharmacy education. Thematic analysis generated a comprehensive account of faculty perspectives.

RESULTS

Faculty perspectives on key challenges to safe practice vary across the three disciplines, and these different perspectives lead to different priorities for curricular innovation. Additionally, accreditation and regulatory requirements are driving curricular change in medicine and pharmacy. Key challenges exist for health professional students in clinical teaching environments where the culture of patient safety may thwart the preparation of safe practitioners.

CONCLUSIONS

Patient safety curricular innovation depends on the interests of individual faculty members and the leveraging of accreditation and regulatory requirements. Building on existing curricular frameworks, opportunities now need to be created for faculty members to act as champions of curricular change, and patient safety educational opportunities need to be harmonises across all health professional training programmes. Faculty champions and practice setting leaders can collaborate to improve the culture of patient safety in clinical teaching and learning settings.

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the academic hospitalist taskforce

Physicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.

Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory

PURPOSE

Despite an official mandate to incorporate formal quality improvement (QI) and patient safety (PS) training into graduate medical education, many QI/PS curricular efforts face implementation challenges and are not sustained. Educators are increasingly turning to sociocultural theories to address issues such as curricular uptake in medical education. The authors conducted a case study using Bourdieu's concepts of "field" and "habitus" to identify theoretically derived strategies that can promote sustained implementation of QI/PS curricula.

METHOD

From October 2010 through May 2011, the authors conducted semistructured interviews with principal authors of studies included in a systematic review of QI/PS curricula and with key informants (identified by study participants) who did not publish on their QI/PS curricular efforts. The authors purposively sampled to theoretical saturation and analyzed data concurrently with iterative data gathering within Bourdieu's theoretical framework.

RESULTS

The study included 16 participants representing six specialties in the United States and Canada. Data analysis revealed that academic physicians belong to, and compete for legitimate forms of capital within, two separate but related fields associated with QI/PScurricular implementation: the "academic field" and the "health care delivery field." Respondents used specific strategies toexploit and/or redefine the prevailingforms of legitimate capital in each field to encourage changes inacademic physicians' habitus that would legitimizeQI/PS.

CONCLUSIONS

Situating study findings in a sociocultural theory enables articulation of concrete strategies that can legitimize QI/PS in the academic and health care delivery fields. These strategies can promote sustained QI/PS curricula in graduate medical education.

The creation and impact of a dedicated section on quality and patient safety in a clinical academic department

Optimizing the effectiveness, efficiency, integration, and satisfaction associated with delivered health care is not only highly principled but also good business practice in an extremely competitive environment. Programs that foster quality improvement and patient safety efforts while also promoting a scholarly focus can generate the incentives and organizational recognition needed to make patient safety and quality improvement bona fide components of the academic mission. The authors describe the development, implementation, and results of a dedicated Section on Quality and Patient Safety (SQPS) within an academic anesthesiology department. Spearheaded by a physician champion and vigorously supported by the departmental chair, this SQPS engaged core leaders from the Department of Anesthesiology. This departmental quality and patient safety management team adopted quality improvement and performance improvement techniques that have been successfully used in other industries. The SQPS has gained support through data-driven results and reiterative promotion. Transparency and accountability have also been powerful motivators for achieving clinician buy-in and changing behavior. Since its inception in 2007, the SQPS has initiated or managed through to completion more than 25 quality and performance improvement projects, including an intraoperative corneal injury reduction program, a wrong-sided regional anesthesia procedure, a drug-eluting coronary stent protocol, and a practice-improvement initiative for resident physicians. The SQPS has not only robustly promoted a departmental culture of quality patient care and safety but also set the standard for other departments and stakeholders within the authors' health system.