Quality Improvement in Residency Programs

I received an interesting call a few weeks back from Bahnsen Miller, MD. Bahnsen is an assistant professor of medicine at the University of Virginia Health System. He attended LSU School of Medicine and completed his residency training there. After residency training, he completed a quality improvement and patient safety fellowship at Our Lady of the Lake Regional Medical Center in Baton Rouge—this is where he learned about KaiNexus. Since then, Bahnsen has been working with residents and students on various quality improvement and patient safety initiatives.

He asked me if I had ever thought of using KaiNexus to help train physicians during their medical school and/or residency periods. It brought back a flood of memories from how my “improvement story” began.

Many people don't know, but I was first introduced to the principles and methodology of “kaizen” back when I was finishing my emergency medicine residency. I learned about this while I was transitioning to being an attending physician. My chairman handed me the book Kaizen by Masaaki Imai.

Bahnsen and I had a fantastic conversation about the current status of training residents in continuous improvement principles. I thought it might be beneficial for us to sit down with Mark Graban to record a conversation on our current status, thoughts, observations, and ideas on how we could do better. We’ve released that as a podcast, which you can listen to below:

While we talk about engaging physicians in training, I think everyone interested in continuous improvement can learn from our conversation. But before we summarize the key points, it's essential to know what the ACGME is.

The Accreditation Council for Graduate Medical Education (ACGME) is a physician-led organization that sets and monitors the educational standards for residency and fellowship programs. The primary mission of ACGME is to prepare residents and fellows to deliver high quality and safe medical care.

As part of ACGME’s Next Accreditation System, the Clinical Learning Environment Review (CLER) program was developed. This program provides US teaching hospitals with feedback on six focus areas. One of the focus areas includes resident participation in QI initiatives/projects.

Some of the highlights of the conversation include:

What are some challenges residents and students face with quality improvement work?

1. Residency training is a very busy and hectic time, so quality improvement work is often viewed as an additional task that has to be completed. QI work often is not integrated into the resident workflow, causing less resident buy-in and project sustainability.
2. Most institutions lack a robust faculty group who have formal training or interest in quality improvement. Other faculty members may not have dedicated time to mentor and coach residents. Without adequately trained faculty, residents may not have the tools available to learn or complete quality improvement projects.
3. Residency programs and hospital leadership may have different visions or goals regarding opportunities for process and quality improvements. This may create confusion among residents and faculty and prevent the full allocation of resources.
   
   

How can we increase resident engagement with quality improvement work?

1. Implement QI into the resident’s workflow. Residents get pulled in many different directions. If specific projects or initiatives supported resident workflow while improving patient care, residents might be more inclined to participate in QI work on a day-to-day basis.
2. Have residents on the frontlines decide what QI projects they should work on. Giving residents this opportunity allows them to lead or participate in a project that they’re passionate about. The more passion and buy-in you have from the residents, the more successful the project will be.
3. Utilizing technology to help facilitate QI projects. Residents often rotate to different clinical environments monthly, so having a centralized location for projects may drive resident collaboration, provide visibility, and simplify QI work with providing basic QI tools. Technology may also facilitate interdisciplinary projects.
   
   

Significant progress has been made on the resident education front for QI, but more needs to be done with integrating residents with QI initiatives. In order for physicians to become more involved in continuous improvement in healthcare, and even become the de facto leaders in pushing this forward, there needs to be a thread throughout the journey of physician training, including medical school and residency, that focuses on the importance of QI and the long-term impact it has on patients.