Commentary

Graduate Medical Education’s New Focus on Resident Engagement in Quality and Safety: Will It Transform the Culture of Teaching Hospitals? Jennifer S. Myers, MD, and David B. Nash, MD, MBA

Abstract The Accreditation Council for Graduate Medical Education recently announced its Clinical Learning Environment Review (CLER) program, which is designed to catalyze and promote the engagement of physician trainees in health care quality and patient safety activities that are essential to the delivery of high-quality patient care in U.S. teaching hospitals.

describe residents’ influence via their social networks on the behaviors and attitudes of peers and other health care providers and highlight this as a powerful driver for culture change in teaching hospitals. They also consider some of the potential unintended consequences of the CLER program and offer strategies to avoid them.

In this Commentary, the authors argue that a strong organizational culture in quality improvement and patient safety is a necessary foundation for resident engagement in these areas. They

The authors suggest that the CLER program provides an opportunity for health care and graduate medical education leaders to closely examine organizational quality and safety culture

In 2012, the Accreditation Council for

Graduate Medical Education (ACGME) unveiled the Next Accreditation System (NAS), which shifted the focus of residency training from educational processes to educational outcomes.1 An important component of the NAS is the Clinical Learning Environment Review (CLER) program, which asks U.S. teaching hospitals to engage residents in six important areas that affect patient outcomes: patient safety, health care quality, transitions in care, supervision, professionalism, and duty hours and

Dr. Myers is associate professor of clinical medicine, Department of Medicine, director of quality and safety education, and associate designated institutional official for quality and safety in graduate medical education, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Nash is Dr. Raymond C. and Doris N. Grandon Professor of Health Policy and founding dean, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania. Correspondence should be addressed to Dr. Myers, 3400 Spruce St., Penn Tower, Suite 2009, Philadelphia, PA 19104; telephone: (215) 662-2729; e-mail: [email protected]. Acad Med. 2014;89:1328–1330. First published online July 22, 2014 doi: 10.1097/ACM.0000000000000435

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fatigue.2 One of us (D.B.N.) served on the ACGME Patient Safety and Quality Advisory Committee, which played a vital role in laying the groundwork for the development of the CLER program. In the 14 years since the Institute of Medicine released its seminal reports on the state of health care quality,3,4 the U.S. health care system has been learning to apply the principles of quality, safety, and continuous improvement that are embedded in other high-risk industries. In doing so, health care leaders have realized the powerful impact of organizational culture and have encountered resistance to change. In teaching hospitals, residents provide a large amount of direct patient care and influence organizational culture through their behaviors and attitudes. Is it possible that residents, who are positioned near the bottom of the hierarchy in medicine, hold the key to culture change in teaching hospitals? To address this question, we will first explore what drives the culture of patient safety and continuous quality improvement (CQI) in the teaching hospital learning environment. Then, we will examine the CLER program’s

and the degree to which their residents are integrated in these efforts. They highlight the importance of developing collaborative interprofessional strategies to reach common goals to improve patient care. By sharpening the focus on patient safety, supervision, professionalism, patient care transitions, and the overall quality of health care delivery in the clinical learning environment during residents’ formative training years, the hope is that the CLER program will inspire a new generation of physicians who possess and value these skills.

potential to accelerate culture change as well as its possible unintended consequences. Organizational culture is commonly defined as the values, beliefs, and behaviors that contribute to an organization’s social and psychological environment. Over the past decade—and independent of the CLER program— hospitals have been implementing strategies to change organizational culture. Indeed, the concept of safety culture originated outside health care through study of other so-called highreliability organizations that manage to consistently minimize adverse events while carrying out highly complex and interdependent tasks. In the field of patient safety, examples of initiatives designed to change culture include promoting no-blame patient safety event reporting; analyzing safety events using root cause analysis tools and human factors engineering principles; teaching and embedding teamwork principles in interprofessional health care teams while attempting to reduce authority gradients; and using patient safety culture surveys as measurement and improvement tools. Similarly, efforts to advance the culture of CQI include developing performance

Academic Medicine, Vol. 89, No. 10 / October 2014

Commentary

dashboards to drive improvement and teaching performance improvement skills to health care workers. It is important that teaching hospital and graduate medical education (GME) leaders understand the existing culture of safety and CQI in their organization before embarking on initiatives to address the CLER program because this culture is the foundation on which they will build their resident education and engagement efforts. Organizations that have a weak safety culture and lack a CQI mindset will struggle to engage residents in these areas because residents will not see evidence of quality and safety practices in the clinical learning environment. In other words, while resident education and engagement efforts are necessary, they are not sufficient. Despite the flurry of activity around quality and safety in teaching hospitals, residents have been completely uninvolved in the efforts in many health care organizations. This is ironic because residents deliver an enormous percentage of direct patient care in these institutions and have the potential to affect patient care outcomes through their knowledge, skills, and attitudes. Further, as a group, residents are a powerful force for changing hospital culture given their large numbers and natural ability to influence one another through social networks. They are positioned at the hub of our complex adaptive systems, where they see the problems and opportunities with the current care delivery system while they interact with and influence nurses, other health care professionals, medical students, and faculty. Thus, there is great potential for CLER-fueled residency program education and engagement efforts to accelerate teaching hospitals’ organizational quality and safety efforts and cultural change. However, if residents are taught the principles of quality and safety through a formal curriculum but are immersed in a learning environment with an informal and hidden curriculum that does not practice or promote those principles, the opportunity to engage these key health care providers in cultural change will be lost. Indeed, formal teaching in safety and quality that is not reinforced or is contradicted by the activities of peers or supervisors in the learning environment could lead to unintended consequences.

Academic Medicine, Vol. 89, No. 10 / October 2014

The health care quality and safety movement has been filled with numerous examples of unintended consequences.5 For instance, well-intentioned health care providers who are trying to meet performance goals for a Joint Commission core measure quality of care indicator may inadvertently create new quality problems while trying to fix existing issues: Consider that the measure intended to ensure timely administration of antibiotics for patients presenting to the emergency department with pneumonia has led to the overuse of antibiotics in patients with possible, but not confirmed, pneumonia in some settings.6 In another example, hospitals’ implementation of event reporting systems to identify safety problems is intended to promote transparency and focus attention on systems problems rather than people. However, these event reporting systems are sometimes used to place blame or report on someone rather than something, which consequently undermines safety culture at its core. Further, since checklists were shown to reduce central line-associated bloodstream infections,7 they have been used increasingly to solve other safety problems that rely on human memory. Yet when the use of checklists is forced rather than valued, there is a risk that they will be devalued and completed mindlessly, and their completion could create a false sense of security in the patient care environment. In light of these examples, we must ask ourselves, What are the potential unintended consequences of the CLER program, and how can we avoid them? First, residents are likely to perceive required participation in quality and safety curricula as a distraction when such instruction, designed to satisfy ACGME requirements and meet CLER goals, is separated in time and space from their patient care activities. An unintended consequence of this approach may be that trainees will quickly learn to become physicians who think about quality, safety, and cost only when they are forced to do so. To avoid this, we should seek to embed residents in real-life quality improvement and patient safety experiences as well as to identify opportunities for faculty to role model quality and safety practices in the learning environment. Examples of the latter include just-in-time teaching and learning experiences in the context

of providing patient care such as entering a safety event report as a team after rounds; reviewing the unit’s health-careassociated infection rates at the start of a rotation while committing to perfect hand washing and isolation practices; and using morning report as an opportunity to ask residents, “What could we have done better last night?” If residency programs successfully incorporate these and other strategies, we believe that they will more easily foster resident engagement in their institutional quality and safety efforts. Fundamental to the delivery of highquality patient care is interprofessional collaboration. To create physicians who are well prepared to lead and participate in quality and safety initiatives, we must train residents in an environment that fosters and values this type of collaboration. Thus, another threat to the CLER program is the development of resident engagement activities in isolation from other professions. This will lead to ineffective or weak quality improvement efforts because only one perspective on problems will be explored. Health care is delivered by teams; therefore, its quality and safety problems must be tackled by teams. To avoid this potential unintended consequence, we will need to take deliberate steps to engage residents in quality and safety activities that involve nurses, advanced practitioners, pharmacists, and other health care professionals. Potential interprofessional engagement activities include simulation, debriefings after unanticipated events, root cause analyses, and quality improvement projects. A double-edged unintended consequence will arise if we focus on engaging the residents but not the faculty in the training environment. Given the enormous influence of the informal curriculum in the hierarchical medical culture, if residents are taught one thing but see another, the consequence will be that residents’ level of engagement in quality and safety will remain stagnant or regress. This is particularly problematic because many faculty are not prepared for or comfortable with teaching and role modeling quality and safety skills; indeed, this is the rate-limiting step in the CLER equation. Although a recent Association of American Medical Colleges expert panel report outlined a pathway for faculty to follow to become

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proficient—and even expert—in quality and safety, progress in training faculty in these areas remains slow.8 Teaching hospitals and GME programs will need to work together strategically if they wish to change the culture of the learning environment. Strategies to achieve faculty proficiency in quality and safety could include rewarding and supporting faculty who lead resident and fellow teaching in these areas; exploring models of co-learning among residents, fellows, and faculty; and designing faculty development programs. We also submit that developing career pathways for residents, fellows, and faculty with interest in health care quality and patient safety is a strategy to address the faculty development gap and to build a cadre of physicians engaged in quality improvement efforts and in quality and safety education. Recently, a framework has been described for thinking about health systems improvement career pathways in research, policy, and management and the intersections in between,9 but these pathways are new and are still being defined. Another engagement strategy in academic environments is to show residents and fellows how they can turn their quality and safety work into scholarship and the opportunities for quality improvement research. Although we have focused in part on what could go wrong as we embark on this new era in GME, there is enormous potential for the CLER program to lead to improvements in residency education, hospital culture, and patient care. We believe that the CLER program will cause teaching hospitals and their companion GME programs to critically evaluate and expand the ways in which they engage residents in the health care system’s quality and safety activities. At

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some hospitals, the CLER program will bring validation to early, innovative, resident engagement work. Indeed, the New York-Presbyterian Hospital/Weill Cornell Medical Center’s Housestaff Quality Council, which was recently presented with the John M. Eisenberg Patient Safety and Quality Award, is a testament to what can be accomplished when health care quality leaders partner with residents from diverse clinical departments to solve important quality problems.10 At hospitals that have had the will to change but little infrastructure to support it, the CLER efforts may facilitate new partnerships and collaborations to align the quality and safety goals of the hospital with those of GME. At still other hospitals, the CLER program may enable residents to take part in the quality and safety conversation for the first time. In each of these scenarios, the CLER program offers opportunities to draw residents more deeply into the quality and safety equation and provides a means to evaluate all of the structures, processes, and people who influence them. Will the CLER program’s focus on resident engagement in quality and safety transform the culture of teaching hospitals? We believe it will, if efforts are embedded in the context of existing institutional initiatives aimed at building a culture of quality and safety, foster resident collaboration with other health care professionals, and are implemented thoughtfully to avoid unintended consequences such as those described in this Commentary. If hospital and GME leaders address all of these factors, resident engagement efforts have the potential to be transformative for the quality and safety of care that is delivered to patients in our teaching hospitals.

Funding/Support: Dr. Myers is supported in part by a grant from the Josiah Macy Jr. Foundation. Other disclosures: Dr Nash served on the Accreditation Council for Graduate Medical Education’s Patient Safety and Quality Advisory Committee, which helped lay the groundwork for the development of the Clinical Learning Environment Review program. Ethical approval: Reported as not applicable.

References 1 Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051–1056. 2 Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: The foundation of graduate medical education. JAMA. 2013;309:1687–1688. 3 Kohn KT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 4 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 5 Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005;293:1239–1244. 6 Pines JM, Hollander JE, Datner EM, Metlay JP. Pay for performance for antibiotic timing in pneumonia: Caveat emptor. Jt Comm J Qual Patient Saf. 2006;32:531–535. 7 Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732. 8 Association of 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/366184/ te4qreportarticle.html. Published 2013. Accessed June 5, 2014. 9 Ackerly DC, Parekh A, Stein D. A framework for career paths in health systems improvement. Acad Med. 2013;88:56–60. 10 Fleischut PM, Faggiani SL, Evans AS, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The effect of a novel Housestaff Quality Council on quality and patient safety. Innovation in patient safety and quality at the local level. Jt Comm J Qual Patient Saf. 2012;38:311–317.

Academic Medicine, Vol. 89, No. 10 / October 2014

Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?

The Accreditation Council for Graduate Medical Education recently announced its Clinical Learning Environment Review (CLER) program, which is designed...
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