Innovation Report
Building the Pipeline: The Creation of a Residency Training Pathway for Future Physician Leaders in Health Care Quality Neha Patel, MD, MS, P.J. Brennan, MD, Joshua Metlay, MD, PhD, Lisa Bellini, MD, Richard P. Shannon, MD, and Jennifer S. Myers, MD
Abstract Problem Many health care organizations seek physicians to lead quality improvement (QI) efforts, yet struggle to find individuals with the necessary expertise. Although most residency programs incorporate QI and patient safety principles into their curricula, few provide a specialized training program for residents exploring careers as physician leaders in quality.
This longitudinal, two-year graduate medical education (GME) track aligns with the quality goals of the University of Pennsylvania Health System and includes a core curriculum, integration into an interprofessional health care leadership team that is accountable for quality and safety outcomes on a hospital unit, a capstone QI project, and mentorship.
Approach Recognizing this training void, the authors designed and implemented the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System in 2010.
Outcomes Early evaluation has demonstrated the feasibility and efficacy of the track diverse graduate medical education training programs. Using Yardley and Dornan’s interpretation of the
Problem
even encounter resistance from medical doctors.2 Because today’s trainees are tomorrow’s physicians, one strategy to increase physician leadership in health care quality is to focus on the residency training years as an opportune time to identify, train, and develop the next generation of physician leaders in health care quality. To address the paucity of QI/PS training in graduate medical education (GME), we designed the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System (UPHS). In this Innovation Report, we describe the infrastructure, resources, curriculum, outcomes, and key lessons learned related to this experience.
In the decade since the Institute of Medicine published Crossing the Quality Chasm, quality improvement (QI) and patient safety (PS) have become top priorities in U.S. health care.1 This report, coupled with the complexity of health care reform and financing, has led medical educators to recognize the need for major curriculum reform in order to produce physicians who are well prepared to meet the needs of the changing U.S. health care system and an evolving society. Physician leadership is critical to the success of these initiatives, yet many organizations struggle to engage physicians in health care improvement efforts, and some Please see the end of this article for information about the authors. Correspondence should be sent to Dr. Patel, 3400 Spruce St., Penn Tower, Suite 2009, Philadelphia, PA 19104; telephone: (215) 662-3797; e-mail: neha. [email protected]. Acad Med. 2015;90:185–190. First published online October 28, 2014 doi: 10.1097/ACM.0000000000000546 Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A239 and http://links.lww.com/ACADMED/A248.
Academic Medicine, Vol. 90, No. 2 / February 2015
Approach
Overview of the HLQ track The HLQ track at UPHS (which employs 772 residents [not including fellows] in 26 different residency programs) was created in 2010. The track is a two-year longitudinal training pathway embedded within a standard residency program. It is designed for residents who aspire to careers in health care quality and PS or who wish to
Kirkpatrick framework, the authors have demonstrated the track’s impact on four levels of educational and organizational outcomes. Next Steps Building on their early experiences, the authors are integrating project and time management skills into the core curriculum, and they are focusing more effort on faculty development in QI mentorship. Additionally, the authors plan to follow HLQ track graduates to determine whether they seek leadership roles in quality and safety and to assess the influence of the program on their careers.
acquire a deeper knowledge of the field and incorporate QI work into their residency training. Track directors recruit residents via e-mail or in person at educational conferences during the middle of the trainees’ first or second year of residency. Residents who decide to pursue the HLQ track begin the following year. Each resident is required to devote a minimum of seven weeks of elective time to the track curriculum and activities and to participate in longitudinal HLQ track experiences. Chart 1 illustrates how the HLQ track is integrated into residency training for a resident who enters the tracking his or her second or third postgraduate year. The track, designed to require no additional postgraduate training time, comprises four major components: (1) the core curriculum, (2) integration into a QI leadership team, (3) a capstone QI project, and (4) mentorship. The core curriculum The core curriculum is approximately 120 hours of instruction delivered over three weeks to each cohort. The first two weeks of the curriculum occur during the first year of the track and include a wide variety of topics designed to introduce
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Innovation Report
Chart 1 Longitudinal Curriculum for the University of Pennsylvania Health System Residency Track in Healthcare Leadership in Quality Year of residency and track component
Quarter 1: July-Sept
Quarter 2: Oct-Dec
Quarter 3: Jan-March
Quarter 4: April-June
First Recruitment for track and selection of UBCL team for each resident Second Core curriculum
2 weeks
QI / PS team integration Capstone QI project Mentorship
Longitudinal participation on UBCL team Project selection
Ongoing project work
Longitudinal: Mentorship trioa; quarterly dinner meetings with track directors
Third Core curriculum QI / PS team integration Capstone QI project Mentorship
1 week Longitudinal participation on UBCL team Ongoing project work
Project presentation (local + regional or national)
Longitudinal: Mentorship trioa; quarterly dinner meetings with track directors
Abbreviations: UBCL indicates unit-based clinical leadership; QI, quality improvement; PS, patient safety. a Mentorship trio = UBCL physician, nurse, quality manager mentors; QI research mentor; track codirector mentors.
residents to the history and national landscape and to the methods and tools of QI and PS (e.g., variations in health care delivery, Donabedian’s model for quality measures).3 The third week of the core curriculum occurs during the second year of the track and provides instruction in more advanced topics, such as human factors engineering and the culture of safety (see Supplemental Digital Table 1, http://links.lww.com/ ACADMED/A239). Instruction is provided by the track directors (N.P. and J.S.M.) and health system quality and safety leaders, including the chief medical officer (P.J.B), nurse leaders, the chief medical information officer, the vice president for quality and safety, patient safety officers, performance improvement experts, and select department chairs (R.P.S). Educational strategies include lectures, required readings, videos, smallgroup activities, selected online modules, and facilitated discussion. To provide residents with the local knowledge that they will need to identify QI/PS problems and opportunities, we present tutorials on how quality data can be accessed at our institution specifically. Additionally, we incorporate a two-day, hands-on training session in process improvement tools into the curriculum. Instruction occurs partially in the hospital or clinic, where residents learn how, for example, to solicit the “voice of the customer” by performing short
186
interviews with employees and patients and where they practice observing work as a process so that they can identify wastes and opportunities for improvement. Other health care professionals including nurses, pharmacists, and social workers are colearners with the track residents during this component of the curriculum, which allows for modeling the interprofessional leadership and teamwork necessary for QI work. Integration into a QI leadership team Because QI work is an active process, the foundation of the track is experiential. Residents work longitudinally with geographically based QI leadership teams known as unit-based clinical leadership (UBCL) teams.4 Composed of a physician leader, nurse manager, and quality and safety project manager, each team meets weekly to provide local leadership for health system initiatives in QI/PS, to review safety event reports, and to identify opportunities on their units for improving patient care. Participation in the UBCL meetings provides a unique opportunity for track residents to experience the longitudinal challenges of QI work and to witness strategies for success at the front line. One or two residents are assigned to each UBCL team, and each resident’s UBCL team aligns with his or her clinical interests so as to facilitate the resident’s
career evolution, to promote mentoring relationships, to maximize attendance at UBCL team meetings, and to support the completion of each resident’s capstone QI project. Capstone QI project Each resident or pair of residents designs and leads a capstone QI project within their UBCL team. Although many other medical student and resident elective QI/PS experiences have been described,5 the HLQ track experience is unique in that it provides each resident with an opportunity to contribute to and improve a component of the health care system over a period of years rather than weeks or months. This long-term effort affords the residents a sense of project ownership and allows them not only to design and communicate a vision for the project but also to lead the project through several Plan-Do-Study-Act cycles to, ideally, sustained change. Scholarship is incorporated into the track expectations, and residents are encouraged to disseminate their work locally or nationally through presentations, abstracts, or peer-reviewed publications. Examples of capstone projects from HLQ track residents are shown in Table 1. Mentorship Residents receive individualized, longitudinal mentorship from the
Academic Medicine, Vol. 90, No. 2 / February 2015
Academic Medicine, Vol. 90, No. 2 / February 2015
General medicine inpatient
Cardiac care
Internal medicine ambulatory clinic
8, 9, 10
11, 12
13, 14
Emergency department
Medicine intensive care
General medicine unit
Inpatient dialysis unit
Labor and delivery
Radiology department
Labor and delivery
17, 18
19, 20
21
22, 23
24
25, 26
27
Improving safety culture through team debriefings after deliveries
Creating and implementing a longitudinal quality and safety curriculum for radiology residents
Investigating what clinical factors predict readmission for persistent hypertensive disease in women with preeclampsia
Improving hospital discharge communication for patients with chronic hemodialysis using a novel checklist
Creating an innovative system to improve and track outpatient medication adherence
Comparing nurse and speech therapist screening for dysphagia after extubation
Improving communication between the emergency department and the neurology consultation service
Assessing patient satisfaction in “real time” using mobile technology
Increasing rates of screening colonoscopy in the ambulatory setting
Predicting length of stay to improve transition-of-care inpatient activities
Improving the review and accuracy of medication lists at discharge
Redesigning and improving the universal protocol process to improve safety for nonoperative bedside procedures
Abbreviation: QI indicates quality improvement. a Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine at the University of Pennsylvania.
Surgery and general medicine inpatient
15, 16
2012–2014 resident cohort
All medicine inpatient units
7
2011–2013 resident cohort
Medical intensive care
4, 5, 6
Implementing an interdisciplinary postintubation time-out to improve patient safety
Reducing door-to-balloon time: a failure mode effects analysis
Cardiac care
2, 3
QI focus Improving discharge medication reconciliation
Hospital unit
2010–2012 resident cohort 1 General medicine inpatient
Resident
Hospital Units, Quality Projects, and Career Paths for Residents in the University of Pennsylvania Health System Healthcare Leadership in Quality Track
Table 1
27. Urogynecology fellowship
25. Breast radiology fellowship 26. Abdominal imaging fellowship
24. Maternal fetal medicine fellowship
22. Nephrology fellowship 23. Hospitalist
21. Oncology fellowship
19. Pulmonary and critical care fellowship 20. Pulmonary and critical care fellowship
17. Emergency medicine 18. Emergency medicine
15. Transplant surgery fellowship 16. Oncology fellowship
13. Primary care 14. Primary care
11. Chief resident and cardiology fellowship 12. Cardiology fellowship
8. Oncology fellowship 9. Infectious disease fellowship 10. Gastroenterology fellowship
7. Hospitalist research fellowship
4. Robert Wood Johnson Clinical Scholar 5. Chief resident and gastroenterology fellowship 6. Cardiology fellowship
2. Cardiology fellowship 3. Cardiology fellowship
1. Endocrinology and quality and safety fellowshipa
Career path
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Poster at national meeting?
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Innovation Report
track directors, their UBCL team leaders, research mentors, and other content experts in quality and safety (such as medical informatics faculty, departmental QI/PS faculty, nursing leaders, or pharmacy quality leaders). This interprofessional approach to mentorship provides the residents with guidance informed by a variety of health care perspectives and allows them to explore different leadership styles and physician career paths in quality and safety. Institutional goal alignment, program leadership, and funding UPHS employs a Blueprint for Quality and Patient Safety to focus QI improvement within the large health care system on five imperatives, one of which is to increase provider engagement, leadership, and advocacy for quality (see Supplemental Digital Table 2, http:// links.lww.com/ACADMED/A248). The HLQ track was designed specifically to align with this blueprint in the domain of resident engagement in our quality and safety mission. Executive sponsorship and financial support for the program come from the Office of the Chief Medical Officer of UPHS and from the Department of Medicine at Perelman School of Medicine at the University of Pennsylvania. In 2012, the track expanded to include trainees from other residency programs and is now recognized and offered as a GME training pathway at the University of Pennsylvania.
Outcomes
We have used the Kirkpatrick framework, as interpreted by Yardley and Dornan,6 to evaluate the impact of our educational innovation (see Table 2). Yardley and Dornan consider participation to be a Level 1 Kirkpatrick result. Over four years, 66 residents have matriculated in the HLQ track (7, 8, 13, 21, and 17 residents in, respectively 2010, 2011, 2012, 2013, and 2014). All but 1 of the residents from the 2010, 2011, and 2012 cohorts, plus 3 additional residents from the 2013 cohort, have successfully completed the track; 34 residents are currently enrolled in the track; and only 3 residents have, for personal reasons, withdrawn. All 15 residents from the first two cohorts, including the 14 who completed the track, were internal medicine trainees. The 2012 cohort included residents from emergency medicine, obstetrics–gynecology, radiology, and general surgery; in 2013, the track was opened to trainees from all residency programs. Kirkpatrick Level 2a outcomes include the attitudes of the learners. Of the 30 HLQ residents who have completed the track, 23 have completed an evaluation of the curriculum block. They have rated the core curriculum highly, strongly agreeing that the content is valuable (mean 4.95, where 1 = strongly disagree and 5 = strongly agree) and necessary to their training (mean 4.96). All 14 residents from the 2010 and 2011 cohorts
Table 2 Program Evaluation Elements for the University of Pennsylvania Health System Healthcare Leadership in Quality Track Kirkpatrick level, as interpreted by Yardley and Dornan6
HLQ program evaluation elements
1: Participation 2a: Attitudes
• Number of residents enrolled in the HLQ • Postcurriculum and end-of-program satisfaction surveys
2b: Knowledge and/or skills
• QIKAT
3: Behavior
• Completion of capstone project • Resident participation in other quality initiatives
4a: Organizational practice
• Completion of capstone project • HLQ resident influence on their peers and residency programs related to QI engagementa • D epartment, residency program, unit-based clinical leadership team, and hospital feedback re: impact and value of the HLQa
4b: Benefits to patients/ societal transfer
• Capstone project outcomes • Future quality leadership roles of residentsa
Abbreviations: HLQ indicates Healthcare Leadership in Quality; QIKAT, Quality Improvement Knowledge Assessment Test.8 a These items were not objectively evaluated. Some are being planned as future evaluation components.
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who completed the track reported that they believe that the program would influence their ability to lead QI/PS activities in their future careers (mean 4.93), and all either agreed (n = 1) or strongly agreed (n = 13) that they plan to pursue a quality/safety leadership position in the future. Kirkpatrick Level 2b outcomes relate to knowledge acquired. We assess HLQ track participants’ knowledge with the Quality Improvement Knowledge Assessment Tool, in which the learner responds to three clinical scenarios by identifying an aim statement, quality measures, and possible improvement ideas.7 Each response is scored from 0 (low) to 5 (high) by the track directors, generating a cumulative score of 0 to 15 points. Comparing the pretrack scores (obtained during the first-year curriculum block) and posttrack scores (obtained during the second-year curriculum block), for the first cohort, the mean improvement in score was 3 points (standard deviation [SD] = 3) on the 15-point scale, and for the second cohort, the mean improvement in score was 4 points (SD = 1.6). Kirkpatrick Level 3 outcomes measure behavior. Thus far, all 30 residents who have graduated from the track have successfully completed their capstone QI project demonstrating actual transfer of learning to the work environment. We plan to evaluate the effect of the track on organizational practice, a Kirkpatrick Level 4a outcome, by designing tools to measure the residents’ influence on their peers; the impact their work has had within their residency programs; and the value the HLQ track adds to the UBCL teams, the University of Pennsylvania’s GME programs, and the UPHS. A Kirkpatrick Level 4b outcome represents a benefit to patients and/or transfer to society. Most of the capstone projects have resulted in improvements in health care delivery at UPHS, which we believe has benefited our patients. The track is having an effect on the individual participants’ scholarly productivity (Kirkpatrick Level 4a) and on the organization’s collective understanding of QI (Kirkpatrick Level 4b) since 22 of 27 residents from cohort 2010, 2011, and 2012 have presented abstracts at national meetings (Table 1), and 5 have written or submitted manuscripts for publication.
Academic Medicine, Vol. 90, No. 2 / February 2015
Innovation Report
Career paths for physicians interested in health systems improvement are still poorly defined,8 and we believe that at a time when residents are making important decisions concerning their careers, the HLQ track allows those who show early interest in quality and safety to develop a unique skill set while effecting local system changes and experimenting with a career focused on QI/PS. Although a limitation of the HLQ track is that it reaches a minority of trainees, we are experiencing the unique benefits of identifying the early adopters for our institutional resident engagement efforts. First, these residents, their projects, and the scholarship associated with them are highly visible within our departments and residency programs, normalizing resident participation in QI/PS and helping to legitimize this work within the academic culture.9 Further, the HLQ track has exposed institutional leaders to the breadth of work that residents can lead and the powerful positive influence for QI/PS that they can exert on those around them. Next Steps
Despite these successes, we have faced several challenges in the development of this pathway. Improvement work takes ongoing attention and cannot be left dormant for long periods of time. Outside of the dedicated elective time for the track, some residents have faced challenges in staying connected with their UBCL teams when they are on busy clinical rotations. We intend to build project and time management skills into the core curriculum and work with our UBCL teams to support the residents’ clinical schedules. Identifying faculty mentors for our residents’ capstone QI projects can be challenging. Indeed, the lack of faculty development in quality and safety has been identified as a major barrier to the advancement of medical education efforts in this field, and lack of QI project mentorship is one dimension of this problem.10 Moving forward, we seek to draw more upon the talent of the nonphysician QI experts within our institution while providing training opportunities for faculty who wish to develop QI/PS skills in order to become expert teachers and coaches of this work.
Academic Medicine, Vol. 90, No. 2 / February 2015
To determine the ultimate success of the HLQ track, measuring the impact is vital. We plan to use quantitative and qualitative methods to determine the value of the track for the institution, for the individual departments and local quality teams, and, most important, for the residents. We plan to assess the longitudinal integration of residents into quality activities at UPHS, and we intend to follow HLQ track graduates both to determine whether they seek activities and career paths that include quality and safety leadership and to ascertain their perceptions of the influence of the HLQ track training on their careers. Finally, as all GME programs in the United States will need to demonstrate resident competence in quality, safety, teamwork, and cost-conscious care in the Accreditation Council for Graduate Medical Education’s Next Accreditation System, the HLQ track will provide a learning laboratory in which to experiment with new ways to engage residents that could be adaptable to trainees in other programs. In summary, we found that a longitudinal training pathway for residents interested in health care leadership, quality, and safety is attractive to certain residents, beneficial to institutional QI and physician engagement efforts, and logistically feasible in an academic medical center. We hope that the graduates of the HLQ track will emerge as vibrant champions of quality and safety, well poised to effect improvements and become future leaders in the health care system. Acknowledgments: The authors wish to thank Brooke McDonnell, Christopher Klock, Michael Posencheg, and Patricia Harris for their contributions to the quality improvement methodology training, as well as Patricia G. Sullivan, PhD, vice president for quality and safety, and Jeffrey S. Berns, MD, associate dean for graduate medical education, at Perelman School of Medicine at the University of Pennsylvania for their support of the training pathway. They would also like to thank Ilona Lorincz, Isaac Whitman, Ryan McConnell, Shashank Sinha, Faraz Ahmad, and Mitesh Patel, the pioneering residents in the Healthcare Leadership in Quality track, for their invaluable feedback and inspiration. Funding/Support: The Healthcare Leadership in Quality track is supported by the Office of the Chief Medical Officer of the University of Pennsylvania Health System and the Department of Medicine at the Perelman School of Medicine
at the University of Pennsylvania. Dr. Myers is supported in part by a grant from the Josiah Macy Jr. Foundation. Other disclosures: None reported. Ethical approval: All evaluation methods were reviewed and granted exemption by the institutional review board at the University of Pennsylvania. Previous presentations: An earlier version of this work was presented in abstract form at the AAMC Integrating Quality meeting in June 2011 in Chicago, Illinois, and in presentation form at the UHC (University HealthSystem Consortium) meeting in October 2013. Dr. Patel is assistant professor of clinical medicine, Department of Medicine, director of quality, Section of Hospital Medicine, and codirector, Healthcare Leadership in Quality track, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Brennan is professor of medicine, Perelman School of Medicine, University of Pennsylvania, and senior vice president and chief medical officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania. Dr. Metlay is chief, General Medicine Division, Massachusetts General Hospital, Boston, Massachusetts. Dr. Bellini is professor of medicine and vice chair for education, Department of Medicine, and vice dean for faculty affairs, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Shannon is Louise Nerancy Professor of Health Policy Science and executive vice president for health affairs, University of Virginia Health System, Charlottesville, Virginia. Dr. Myers is associate professor of clinical medicine, Department of Medicine, associate designated institutional official, Quality and Safety in Graduate Medical Education, and codirector, Healthcare Leadership in Quality track, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
References 1 Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 2 Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21:722–728. 3 Donabedian, A. Evaluating the quality of medical care. Milbank Q. 2005;83:691–729. 4 Agency for Healthcare Research and Quality, Health Care Innovations Exchange. Improvement projects led by unit-based teams of nurse, physician, and quality leaders reduce infections, lower costs, improve patient satisfaction, and nurse-physician communication. http://www.innovations. ahrq.gov/content.aspx?id=2719&tab=1. Accessed August 29, 2014. 5 Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement
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Innovation Report and patient safety to trainees: A systematic review. Acad Med. 2010;85:1425–1439. 6 Yardley S, Dornan T. Kirkpatrick’s levels and education “evidence.” Med Educ. 2012;46:97–106. 7 Vinci LM, Oyler J, Johnson JK, Arora VM. Effect of a quality improvement curriculum on resident knowledge and skills
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in improvement. Qual Saf Health Care. 2010;19:351–354. 8 Ackerly DC, Parekh A, Stein D. A framework for career paths in health systems improvement. Acad Med. 2013;88:56–60. 9 Wong BM, Kuper A, Hollenberg E, Etchells EE, Levinson W, Shojania KG. Sustaining quality improvement and patient safety training in
graduate medical education: Lessons from social theory. Acad Med. 2013;88:1149–1156. 10 Association for American Medical Colleges. Teaching for Quality: Integrating Quality Improvement and Patient Safety Across the Continuum of Medical Education. https:// www.aamc.org/initiatives/cei/te4q/. Accessed August 29, 2014.
Academic Medicine, Vol. 90, No. 2 / February 2015
Building the Pipeline: The Creation of a Residency Training Pathway for Future Physician Leaders in Health Care Quality Neha Patel, MD, MS, P.J. Brennan, MD, Joshua Metlay, MD, PhD, Lisa Bellini, MD, Richard P. Shannon, MD, and Jennifer S. Myers, MD
Abstract Problem Many health care organizations seek physicians to lead quality improvement (QI) efforts, yet struggle to find individuals with the necessary expertise. Although most residency programs incorporate QI and patient safety principles into their curricula, few provide a specialized training program for residents exploring careers as physician leaders in quality.
This longitudinal, two-year graduate medical education (GME) track aligns with the quality goals of the University of Pennsylvania Health System and includes a core curriculum, integration into an interprofessional health care leadership team that is accountable for quality and safety outcomes on a hospital unit, a capstone QI project, and mentorship.
Approach Recognizing this training void, the authors designed and implemented the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System in 2010.
Outcomes Early evaluation has demonstrated the feasibility and efficacy of the track diverse graduate medical education training programs. Using Yardley and Dornan’s interpretation of the
Problem
even encounter resistance from medical doctors.2 Because today’s trainees are tomorrow’s physicians, one strategy to increase physician leadership in health care quality is to focus on the residency training years as an opportune time to identify, train, and develop the next generation of physician leaders in health care quality. To address the paucity of QI/PS training in graduate medical education (GME), we designed the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System (UPHS). In this Innovation Report, we describe the infrastructure, resources, curriculum, outcomes, and key lessons learned related to this experience.
In the decade since the Institute of Medicine published Crossing the Quality Chasm, quality improvement (QI) and patient safety (PS) have become top priorities in U.S. health care.1 This report, coupled with the complexity of health care reform and financing, has led medical educators to recognize the need for major curriculum reform in order to produce physicians who are well prepared to meet the needs of the changing U.S. health care system and an evolving society. Physician leadership is critical to the success of these initiatives, yet many organizations struggle to engage physicians in health care improvement efforts, and some Please see the end of this article for information about the authors. Correspondence should be sent to Dr. Patel, 3400 Spruce St., Penn Tower, Suite 2009, Philadelphia, PA 19104; telephone: (215) 662-3797; e-mail: neha. [email protected]. Acad Med. 2015;90:185–190. First published online October 28, 2014 doi: 10.1097/ACM.0000000000000546 Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A239 and http://links.lww.com/ACADMED/A248.
Academic Medicine, Vol. 90, No. 2 / February 2015
Approach
Overview of the HLQ track The HLQ track at UPHS (which employs 772 residents [not including fellows] in 26 different residency programs) was created in 2010. The track is a two-year longitudinal training pathway embedded within a standard residency program. It is designed for residents who aspire to careers in health care quality and PS or who wish to
Kirkpatrick framework, the authors have demonstrated the track’s impact on four levels of educational and organizational outcomes. Next Steps Building on their early experiences, the authors are integrating project and time management skills into the core curriculum, and they are focusing more effort on faculty development in QI mentorship. Additionally, the authors plan to follow HLQ track graduates to determine whether they seek leadership roles in quality and safety and to assess the influence of the program on their careers.
acquire a deeper knowledge of the field and incorporate QI work into their residency training. Track directors recruit residents via e-mail or in person at educational conferences during the middle of the trainees’ first or second year of residency. Residents who decide to pursue the HLQ track begin the following year. Each resident is required to devote a minimum of seven weeks of elective time to the track curriculum and activities and to participate in longitudinal HLQ track experiences. Chart 1 illustrates how the HLQ track is integrated into residency training for a resident who enters the tracking his or her second or third postgraduate year. The track, designed to require no additional postgraduate training time, comprises four major components: (1) the core curriculum, (2) integration into a QI leadership team, (3) a capstone QI project, and (4) mentorship. The core curriculum The core curriculum is approximately 120 hours of instruction delivered over three weeks to each cohort. The first two weeks of the curriculum occur during the first year of the track and include a wide variety of topics designed to introduce
185
Innovation Report
Chart 1 Longitudinal Curriculum for the University of Pennsylvania Health System Residency Track in Healthcare Leadership in Quality Year of residency and track component
Quarter 1: July-Sept
Quarter 2: Oct-Dec
Quarter 3: Jan-March
Quarter 4: April-June
First Recruitment for track and selection of UBCL team for each resident Second Core curriculum
2 weeks
QI / PS team integration Capstone QI project Mentorship
Longitudinal participation on UBCL team Project selection
Ongoing project work
Longitudinal: Mentorship trioa; quarterly dinner meetings with track directors
Third Core curriculum QI / PS team integration Capstone QI project Mentorship
1 week Longitudinal participation on UBCL team Ongoing project work
Project presentation (local + regional or national)
Longitudinal: Mentorship trioa; quarterly dinner meetings with track directors
Abbreviations: UBCL indicates unit-based clinical leadership; QI, quality improvement; PS, patient safety. a Mentorship trio = UBCL physician, nurse, quality manager mentors; QI research mentor; track codirector mentors.
residents to the history and national landscape and to the methods and tools of QI and PS (e.g., variations in health care delivery, Donabedian’s model for quality measures).3 The third week of the core curriculum occurs during the second year of the track and provides instruction in more advanced topics, such as human factors engineering and the culture of safety (see Supplemental Digital Table 1, http://links.lww.com/ ACADMED/A239). Instruction is provided by the track directors (N.P. and J.S.M.) and health system quality and safety leaders, including the chief medical officer (P.J.B), nurse leaders, the chief medical information officer, the vice president for quality and safety, patient safety officers, performance improvement experts, and select department chairs (R.P.S). Educational strategies include lectures, required readings, videos, smallgroup activities, selected online modules, and facilitated discussion. To provide residents with the local knowledge that they will need to identify QI/PS problems and opportunities, we present tutorials on how quality data can be accessed at our institution specifically. Additionally, we incorporate a two-day, hands-on training session in process improvement tools into the curriculum. Instruction occurs partially in the hospital or clinic, where residents learn how, for example, to solicit the “voice of the customer” by performing short
186
interviews with employees and patients and where they practice observing work as a process so that they can identify wastes and opportunities for improvement. Other health care professionals including nurses, pharmacists, and social workers are colearners with the track residents during this component of the curriculum, which allows for modeling the interprofessional leadership and teamwork necessary for QI work. Integration into a QI leadership team Because QI work is an active process, the foundation of the track is experiential. Residents work longitudinally with geographically based QI leadership teams known as unit-based clinical leadership (UBCL) teams.4 Composed of a physician leader, nurse manager, and quality and safety project manager, each team meets weekly to provide local leadership for health system initiatives in QI/PS, to review safety event reports, and to identify opportunities on their units for improving patient care. Participation in the UBCL meetings provides a unique opportunity for track residents to experience the longitudinal challenges of QI work and to witness strategies for success at the front line. One or two residents are assigned to each UBCL team, and each resident’s UBCL team aligns with his or her clinical interests so as to facilitate the resident’s
career evolution, to promote mentoring relationships, to maximize attendance at UBCL team meetings, and to support the completion of each resident’s capstone QI project. Capstone QI project Each resident or pair of residents designs and leads a capstone QI project within their UBCL team. Although many other medical student and resident elective QI/PS experiences have been described,5 the HLQ track experience is unique in that it provides each resident with an opportunity to contribute to and improve a component of the health care system over a period of years rather than weeks or months. This long-term effort affords the residents a sense of project ownership and allows them not only to design and communicate a vision for the project but also to lead the project through several Plan-Do-Study-Act cycles to, ideally, sustained change. Scholarship is incorporated into the track expectations, and residents are encouraged to disseminate their work locally or nationally through presentations, abstracts, or peer-reviewed publications. Examples of capstone projects from HLQ track residents are shown in Table 1. Mentorship Residents receive individualized, longitudinal mentorship from the
Academic Medicine, Vol. 90, No. 2 / February 2015
Academic Medicine, Vol. 90, No. 2 / February 2015
General medicine inpatient
Cardiac care
Internal medicine ambulatory clinic
8, 9, 10
11, 12
13, 14
Emergency department
Medicine intensive care
General medicine unit
Inpatient dialysis unit
Labor and delivery
Radiology department
Labor and delivery
17, 18
19, 20
21
22, 23
24
25, 26
27
Improving safety culture through team debriefings after deliveries
Creating and implementing a longitudinal quality and safety curriculum for radiology residents
Investigating what clinical factors predict readmission for persistent hypertensive disease in women with preeclampsia
Improving hospital discharge communication for patients with chronic hemodialysis using a novel checklist
Creating an innovative system to improve and track outpatient medication adherence
Comparing nurse and speech therapist screening for dysphagia after extubation
Improving communication between the emergency department and the neurology consultation service
Assessing patient satisfaction in “real time” using mobile technology
Increasing rates of screening colonoscopy in the ambulatory setting
Predicting length of stay to improve transition-of-care inpatient activities
Improving the review and accuracy of medication lists at discharge
Redesigning and improving the universal protocol process to improve safety for nonoperative bedside procedures
Abbreviation: QI indicates quality improvement. a Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine at the University of Pennsylvania.
Surgery and general medicine inpatient
15, 16
2012–2014 resident cohort
All medicine inpatient units
7
2011–2013 resident cohort
Medical intensive care
4, 5, 6
Implementing an interdisciplinary postintubation time-out to improve patient safety
Reducing door-to-balloon time: a failure mode effects analysis
Cardiac care
2, 3
QI focus Improving discharge medication reconciliation
Hospital unit
2010–2012 resident cohort 1 General medicine inpatient
Resident
Hospital Units, Quality Projects, and Career Paths for Residents in the University of Pennsylvania Health System Healthcare Leadership in Quality Track
Table 1
27. Urogynecology fellowship
25. Breast radiology fellowship 26. Abdominal imaging fellowship
24. Maternal fetal medicine fellowship
22. Nephrology fellowship 23. Hospitalist
21. Oncology fellowship
19. Pulmonary and critical care fellowship 20. Pulmonary and critical care fellowship
17. Emergency medicine 18. Emergency medicine
15. Transplant surgery fellowship 16. Oncology fellowship
13. Primary care 14. Primary care
11. Chief resident and cardiology fellowship 12. Cardiology fellowship
8. Oncology fellowship 9. Infectious disease fellowship 10. Gastroenterology fellowship
7. Hospitalist research fellowship
4. Robert Wood Johnson Clinical Scholar 5. Chief resident and gastroenterology fellowship 6. Cardiology fellowship
2. Cardiology fellowship 3. Cardiology fellowship
1. Endocrinology and quality and safety fellowshipa
Career path
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Poster at national meeting?
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Innovation Report
track directors, their UBCL team leaders, research mentors, and other content experts in quality and safety (such as medical informatics faculty, departmental QI/PS faculty, nursing leaders, or pharmacy quality leaders). This interprofessional approach to mentorship provides the residents with guidance informed by a variety of health care perspectives and allows them to explore different leadership styles and physician career paths in quality and safety. Institutional goal alignment, program leadership, and funding UPHS employs a Blueprint for Quality and Patient Safety to focus QI improvement within the large health care system on five imperatives, one of which is to increase provider engagement, leadership, and advocacy for quality (see Supplemental Digital Table 2, http:// links.lww.com/ACADMED/A248). The HLQ track was designed specifically to align with this blueprint in the domain of resident engagement in our quality and safety mission. Executive sponsorship and financial support for the program come from the Office of the Chief Medical Officer of UPHS and from the Department of Medicine at Perelman School of Medicine at the University of Pennsylvania. In 2012, the track expanded to include trainees from other residency programs and is now recognized and offered as a GME training pathway at the University of Pennsylvania.
Outcomes
We have used the Kirkpatrick framework, as interpreted by Yardley and Dornan,6 to evaluate the impact of our educational innovation (see Table 2). Yardley and Dornan consider participation to be a Level 1 Kirkpatrick result. Over four years, 66 residents have matriculated in the HLQ track (7, 8, 13, 21, and 17 residents in, respectively 2010, 2011, 2012, 2013, and 2014). All but 1 of the residents from the 2010, 2011, and 2012 cohorts, plus 3 additional residents from the 2013 cohort, have successfully completed the track; 34 residents are currently enrolled in the track; and only 3 residents have, for personal reasons, withdrawn. All 15 residents from the first two cohorts, including the 14 who completed the track, were internal medicine trainees. The 2012 cohort included residents from emergency medicine, obstetrics–gynecology, radiology, and general surgery; in 2013, the track was opened to trainees from all residency programs. Kirkpatrick Level 2a outcomes include the attitudes of the learners. Of the 30 HLQ residents who have completed the track, 23 have completed an evaluation of the curriculum block. They have rated the core curriculum highly, strongly agreeing that the content is valuable (mean 4.95, where 1 = strongly disagree and 5 = strongly agree) and necessary to their training (mean 4.96). All 14 residents from the 2010 and 2011 cohorts
Table 2 Program Evaluation Elements for the University of Pennsylvania Health System Healthcare Leadership in Quality Track Kirkpatrick level, as interpreted by Yardley and Dornan6
HLQ program evaluation elements
1: Participation 2a: Attitudes
• Number of residents enrolled in the HLQ • Postcurriculum and end-of-program satisfaction surveys
2b: Knowledge and/or skills
• QIKAT
3: Behavior
• Completion of capstone project • Resident participation in other quality initiatives
4a: Organizational practice
• Completion of capstone project • HLQ resident influence on their peers and residency programs related to QI engagementa • D epartment, residency program, unit-based clinical leadership team, and hospital feedback re: impact and value of the HLQa
4b: Benefits to patients/ societal transfer
• Capstone project outcomes • Future quality leadership roles of residentsa
Abbreviations: HLQ indicates Healthcare Leadership in Quality; QIKAT, Quality Improvement Knowledge Assessment Test.8 a These items were not objectively evaluated. Some are being planned as future evaluation components.
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who completed the track reported that they believe that the program would influence their ability to lead QI/PS activities in their future careers (mean 4.93), and all either agreed (n = 1) or strongly agreed (n = 13) that they plan to pursue a quality/safety leadership position in the future. Kirkpatrick Level 2b outcomes relate to knowledge acquired. We assess HLQ track participants’ knowledge with the Quality Improvement Knowledge Assessment Tool, in which the learner responds to three clinical scenarios by identifying an aim statement, quality measures, and possible improvement ideas.7 Each response is scored from 0 (low) to 5 (high) by the track directors, generating a cumulative score of 0 to 15 points. Comparing the pretrack scores (obtained during the first-year curriculum block) and posttrack scores (obtained during the second-year curriculum block), for the first cohort, the mean improvement in score was 3 points (standard deviation [SD] = 3) on the 15-point scale, and for the second cohort, the mean improvement in score was 4 points (SD = 1.6). Kirkpatrick Level 3 outcomes measure behavior. Thus far, all 30 residents who have graduated from the track have successfully completed their capstone QI project demonstrating actual transfer of learning to the work environment. We plan to evaluate the effect of the track on organizational practice, a Kirkpatrick Level 4a outcome, by designing tools to measure the residents’ influence on their peers; the impact their work has had within their residency programs; and the value the HLQ track adds to the UBCL teams, the University of Pennsylvania’s GME programs, and the UPHS. A Kirkpatrick Level 4b outcome represents a benefit to patients and/or transfer to society. Most of the capstone projects have resulted in improvements in health care delivery at UPHS, which we believe has benefited our patients. The track is having an effect on the individual participants’ scholarly productivity (Kirkpatrick Level 4a) and on the organization’s collective understanding of QI (Kirkpatrick Level 4b) since 22 of 27 residents from cohort 2010, 2011, and 2012 have presented abstracts at national meetings (Table 1), and 5 have written or submitted manuscripts for publication.
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Career paths for physicians interested in health systems improvement are still poorly defined,8 and we believe that at a time when residents are making important decisions concerning their careers, the HLQ track allows those who show early interest in quality and safety to develop a unique skill set while effecting local system changes and experimenting with a career focused on QI/PS. Although a limitation of the HLQ track is that it reaches a minority of trainees, we are experiencing the unique benefits of identifying the early adopters for our institutional resident engagement efforts. First, these residents, their projects, and the scholarship associated with them are highly visible within our departments and residency programs, normalizing resident participation in QI/PS and helping to legitimize this work within the academic culture.9 Further, the HLQ track has exposed institutional leaders to the breadth of work that residents can lead and the powerful positive influence for QI/PS that they can exert on those around them. Next Steps
Despite these successes, we have faced several challenges in the development of this pathway. Improvement work takes ongoing attention and cannot be left dormant for long periods of time. Outside of the dedicated elective time for the track, some residents have faced challenges in staying connected with their UBCL teams when they are on busy clinical rotations. We intend to build project and time management skills into the core curriculum and work with our UBCL teams to support the residents’ clinical schedules. Identifying faculty mentors for our residents’ capstone QI projects can be challenging. Indeed, the lack of faculty development in quality and safety has been identified as a major barrier to the advancement of medical education efforts in this field, and lack of QI project mentorship is one dimension of this problem.10 Moving forward, we seek to draw more upon the talent of the nonphysician QI experts within our institution while providing training opportunities for faculty who wish to develop QI/PS skills in order to become expert teachers and coaches of this work.
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To determine the ultimate success of the HLQ track, measuring the impact is vital. We plan to use quantitative and qualitative methods to determine the value of the track for the institution, for the individual departments and local quality teams, and, most important, for the residents. We plan to assess the longitudinal integration of residents into quality activities at UPHS, and we intend to follow HLQ track graduates both to determine whether they seek activities and career paths that include quality and safety leadership and to ascertain their perceptions of the influence of the HLQ track training on their careers. Finally, as all GME programs in the United States will need to demonstrate resident competence in quality, safety, teamwork, and cost-conscious care in the Accreditation Council for Graduate Medical Education’s Next Accreditation System, the HLQ track will provide a learning laboratory in which to experiment with new ways to engage residents that could be adaptable to trainees in other programs. In summary, we found that a longitudinal training pathway for residents interested in health care leadership, quality, and safety is attractive to certain residents, beneficial to institutional QI and physician engagement efforts, and logistically feasible in an academic medical center. We hope that the graduates of the HLQ track will emerge as vibrant champions of quality and safety, well poised to effect improvements and become future leaders in the health care system. Acknowledgments: The authors wish to thank Brooke McDonnell, Christopher Klock, Michael Posencheg, and Patricia Harris for their contributions to the quality improvement methodology training, as well as Patricia G. Sullivan, PhD, vice president for quality and safety, and Jeffrey S. Berns, MD, associate dean for graduate medical education, at Perelman School of Medicine at the University of Pennsylvania for their support of the training pathway. They would also like to thank Ilona Lorincz, Isaac Whitman, Ryan McConnell, Shashank Sinha, Faraz Ahmad, and Mitesh Patel, the pioneering residents in the Healthcare Leadership in Quality track, for their invaluable feedback and inspiration. Funding/Support: The Healthcare Leadership in Quality track is supported by the Office of the Chief Medical Officer of the University of Pennsylvania Health System and the Department of Medicine at the Perelman School of Medicine
at the University of Pennsylvania. Dr. Myers is supported in part by a grant from the Josiah Macy Jr. Foundation. Other disclosures: None reported. Ethical approval: All evaluation methods were reviewed and granted exemption by the institutional review board at the University of Pennsylvania. Previous presentations: An earlier version of this work was presented in abstract form at the AAMC Integrating Quality meeting in June 2011 in Chicago, Illinois, and in presentation form at the UHC (University HealthSystem Consortium) meeting in October 2013. Dr. Patel is assistant professor of clinical medicine, Department of Medicine, director of quality, Section of Hospital Medicine, and codirector, Healthcare Leadership in Quality track, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Brennan is professor of medicine, Perelman School of Medicine, University of Pennsylvania, and senior vice president and chief medical officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania. Dr. Metlay is chief, General Medicine Division, Massachusetts General Hospital, Boston, Massachusetts. Dr. Bellini is professor of medicine and vice chair for education, Department of Medicine, and vice dean for faculty affairs, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Shannon is Louise Nerancy Professor of Health Policy Science and executive vice president for health affairs, University of Virginia Health System, Charlottesville, Virginia. Dr. Myers is associate professor of clinical medicine, Department of Medicine, associate designated institutional official, Quality and Safety in Graduate Medical Education, and codirector, Healthcare Leadership in Quality track, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
References 1 Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 2 Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21:722–728. 3 Donabedian, A. Evaluating the quality of medical care. Milbank Q. 2005;83:691–729. 4 Agency for Healthcare Research and Quality, Health Care Innovations Exchange. Improvement projects led by unit-based teams of nurse, physician, and quality leaders reduce infections, lower costs, improve patient satisfaction, and nurse-physician communication. http://www.innovations. ahrq.gov/content.aspx?id=2719&tab=1. Accessed August 29, 2014. 5 Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement
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Innovation Report and patient safety to trainees: A systematic review. Acad Med. 2010;85:1425–1439. 6 Yardley S, Dornan T. Kirkpatrick’s levels and education “evidence.” Med Educ. 2012;46:97–106. 7 Vinci LM, Oyler J, Johnson JK, Arora VM. Effect of a quality improvement curriculum on resident knowledge and skills
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in improvement. Qual Saf Health Care. 2010;19:351–354. 8 Ackerly DC, Parekh A, Stein D. A framework for career paths in health systems improvement. Acad Med. 2013;88:56–60. 9 Wong BM, Kuper A, Hollenberg E, Etchells EE, Levinson W, Shojania KG. Sustaining quality improvement and patient safety training in
graduate medical education: Lessons from social theory. Acad Med. 2013;88:1149–1156. 10 Association for American Medical Colleges. Teaching for Quality: Integrating Quality Improvement and Patient Safety Across the Continuum of Medical Education. https:// www.aamc.org/initiatives/cei/te4q/. Accessed August 29, 2014.
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