COMMENTARY

Educating for Quality: Quality Improvement as an Activity of Daily Learning to Improve Educational and Patient Outcomes John Patrick T. Co, MD, MPH From the Office of Graduate Medical Education, Partners HealthCare, and the Department of Pediatric Outpatient Quality and Safety, MassGeneral Hospital for Children, Boston, Mass The author declares that he has no conflict of interest. Address correspondence to John Patrick T. Co, MD, MPH, MassGeneral Hospital for Children, 7 Whittier Place, Suite 108, Boston, MA 02114 (e-mail: [email protected]). Received for publication November 6, 2013; accepted November 6, 2013.

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THE QUALITY OF care delivered to children is subopti-

Craig et al surveyed pediatric residents to gain a better understanding of their perspective on QI education delivered during residency training.10 In contrast to program directors, a majority of residents thought that their program’s curricula met their learning needs, and three quarters felt ready to use QI methods in practice. The discordance between program director and resident perceptions could be due to the difference in institutions sampled, as well as the fact that the resident survey was done more than one year after the program director survey, providing programs more time and opportunities to strengthen their QI curricula. Residents with prior QI experience had significantly higher confidence in applying QI methods and a stronger intention to use QI after graduation, highlighting the importance of an integrated approach to QI education across the continuum.11 Although most residents indicated that they had performed QI projects, over 30% reported that they failed to study QI outcomes, and only about half indicated that their curricula included important aspects of the QI process such as making an aim statement and using plan–do–study–act (PDSA) cycles. Residents felt that a pervasive QI culture in a hospital was very important, with the most commonly mentioned factor for success in QI projects being access to QI-experienced faculty, underscoring the importance of faculty development in this area. What curricular approaches have GME programs undertaken? Philibert et al6 and Gupta et al12 describe challenges and facilitators for effectively educating residents and fellows in QI, as well as two programs’ approaches to integrate QI education with institutional and/or departmental approaches to improving care quality. Philibert et al describe how Cincinnati Children’s Hospital created a 1-month general pediatrics inpatient resident rotation that included QI activities such as safety huddles that were integrated into day-to-day activities so that residents could be active learners from their own experiences in real time. Gupta et al described the design and implementation of a quality and safety educational module into a neonatology fellowship. The module is spread over 3 years and integrated

mal, with opportunities for improving quality and value across care settings and conditions.1,2 Leading health care organizations have recognized that quality improvement (QI) should play a vital role in improving the quality of care delivered to all populations, including children. For this strategy to succeed, all health professionals, including physicians, should become proficient in QI. Recognizing the need for widespread and dramatic improvements in health care delivery systems, the American Board of Pediatrics (ABP) designed their program of Maintenance of Certification3 to include that all diplomates must at a minimum be active participants in critically analyzing and improving the care of the patients they care for.4 Most recently, the Accreditation Council for Graduate Medical Education (ACGME) developed specific milestones for competencies related to QI5 and instituted the Clinical Learning Environment Review (CLER) Program to help identify and disseminate best practices on how residents and fellows can become better engaged in institutional safety and QI to enhance their training while simultaneously improving care for the patient populations they care for.6,7 What is the state of QI education in pediatric graduate medical education? Mann et al conducted a survey to better understand the perspective of pediatric residency program directors.8 In recent years, an increasing proportion of program directors report providing education in QI, and that curricula typically include several elements conducive to learning QI,9 including an experiential component. Program directors reported a variety of process improvement methodologies as the basis of their curriculum. However, only a minority of resident QI projects had support for project management. As institutional resources become more constrained, it will become even more challenging to support QI in areas that are exciting to trainees but are not aligned with institutional priority areas. Only a minority of program directors reported being satisfied with their QI curricula. ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association

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Figure. Achieving higher-quality outcomes through improved quality improvement educational outcomes (educational outcomes from Batalden et al14).

with existing neonatal intensive care unit quality and safety activities. This longitudinal approach to teaching QI affords the opportunity for fellows to develop projects that require more time for planning and execution, including QI research that can become an area of academic focus. As QI teaching in residency programs improves to consistently produce program graduates that achieve level 4 (or higher) milestones for QI related competencies,4 subspecialty fellowships can provide an ideal setting for fellows to refine their skills and attain higher-level milestones and become QI leaders in their clinical specialties. How will those completing graduate medical education training programs utilize their skills in QI? The evolving health care environment and rapid implementation of best practices demand continuous assessment, refinement, and in some cases redesign of care processes to achieve improved patient outcomes. For those who seek to lead QI initiatives at the practice, department, or organizational level, advanced training can help the learner advance his or her level of competency from proficient to expert. Kaminski et al describe one institution’s effort to provide a comprehensive educational model for improving improvement capability, capacity, and engagement for their own and other institutions.13 They assert that to create the optimal environment for improvement, everyone in the organization must know some basic concepts and be engaged in QI. Through intermediate and advanced educational programs, learners can attain the capability to lead QI initiatives, develop and lead QI programs at both the local and national level, and develop academic careers in QI. As observed by Kaminski et al, the current paucity of QI expert faculty appears to hinder QI education. What role should academic health centers (AHCs) take in QI education? Aside from all physicians needing to do QI as part of the Maintenance of Certification, the need for AHCs to provide effective education in QI is imperative for several reasons:  AHCs directly benefit from trainees improving the systems of care for their patients, who often represent the most vulnerable and sickest populations and could greatly benefit from QI interventions.

 AHCs are training grounds for academic physicians who will need to integrate QI into how they teach.  AHCs train physicians who will practice in community settings that often lack QI infrastructure and will therefore need to rely heavily on the QI skills attained during their residency and/or fellowship. Those seeking to develop QI training programs should rigorously evaluate their effectiveness. Those responsible for teaching QI to medical students, residents, fellows, or practicing clinicians should become expert14 in QI to better ensure their learners are able to improve systems of care, the health of their individual patients, and collectively the quality outcomes of children as a population (Figure). Finally, leaders in pediatric graduate medical education must partner with experts in quality and safety and their institutions as a whole to develop effective, replicable, and sustainable models that promote QI education being less episodic and more of an activity of daily learning in order to realize the ultimate desired outcome of improved child health both for current and future generations of children.

REFERENCES 1. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8:479–485. 2. Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523. 3. American Board of Pediatrics Maintenance of Certification Program, part IV. Available at: http://www.abp.org. Accessed October 27, 2013. 4. Miles PV, Moyer VA. Quality improvement and maintenance of certification. Acad Pediatr. 2013;13:S14–S15. 5. Pediatric Milestones Project. Available at: http://www.acgme-nas.org/ assets/pdf/Milestones/PediatricsMilestones.pdf. Accessed October 27, 2013. 6. Philibert I, Gonzalez del Rey JA, Lannon C, et al. Quality improvement skills for pediatric residents: from lecture to implementation and sustainability. Acad Pediatr. 2014;14:40–46. 7. ACGME clinical learning environment review program. Available at: http://www.acgme-nas.org/cler.html. Accessed October 27, 2013. 8. Mann KJ, Craig MS, Moses JM. A survey of pediatric program directors concerning quality improvement educational practices in pediatric residency programs. Acad Pediatr. 2014;14:23–28.

ACADEMIC PEDIATRICS 9. Ogrinc G, Headrick LA, Mutha S, et al. A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review. Acad Med. 2003;78:748–756. 10. Craig MS, Garfunkel LC, Baldwin CD, et al. Pediatric resident education in quality improvement (QI): a national survey. Acad Pediatr. 2014;14:54–61. 11. Association of American Medical Colleges. Teaching for quality. Available at: https://www.aamc.org/initiatives/cei/te4q/. Accessed October 27, 2013.

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12. Gupta M, Ringer S, Tess A, et al. Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program. Acad Pediatr. 2014;14:47–53. 13. Kaminski GM, Schoettker PJ, Alessandrini EA, et al. A comprehensive model to build improvement capability in a pediatric academic medical center. Acad Pediatr. 2014;14:29–39. 14. Batalden P, Leach D, Swing S, et al. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002;21:103–111.

Educating for quality: quality improvement as an activity of daily learning to improve educational and patient outcomes.

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