569270
research-article2015
AJMXXX10.1177/1062860615569270American Journal of Medical QualityBlanchard et al
Article
Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives
American Journal of Medical Quality 1–6 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615569270 ajmq.sagepub.com
Rebecca D. Blanchard, PhD1,2, Kimberly Pierce-Boggs, MA3, Paul F. Visintainer, PhD1,2, and Kevin T. Hinchey, MD1,2,3
Abstract Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey. Keywords graduate medical education, quality improvement, academic medical center, organizational change Just as a relatively simple vision is needed to guide people through a major change, so a vision of the change process can reduce the error rate. And fewer errors can spell the difference between success and failure. John P. Kotter1
Quality and safety initiatives (QI) are national priorities for health care, propelled forward by the Institute of Medicine (IOM)2 and the Institute for Healthcare Improvement3 in the past decade. Although these groups ensured their importance for providers, they did not carve out a path for addressing their priorities, nor did they consider the role of residents, who make up a significant number of the frontline providers in academic medical centers. This is a considerable oversight: The educational environments in which they are trained affect residents’ future clinical outcomes.4 Yet QI and graduate medical education (GME) efforts continue to be compartmentalized, with most residents viewing QI as individual provider events rather than as system-wide events that involve multiple team members and factors.5 Now, with the IOM calling for payment reform in GME that recognizes performance improvement (including QI),6 GME and QI can no longer
afford to be separate. Patient-centered care and future funding require their integration. The Alliance of Independent Academic Medical Centers (AIAMC) is a group of 80 major medical centers across the United States affiliated with medical schools but independent of medical school ownership or governance. Representing more than 825 senior academic leaders, the AIAMC added its own voice to the national call for quality improvement by arguing for engagement of frontline academic center providers in the move to action. Engaging residents in the process, the AIAMC noted, is an important mechanism for both addressing the national issue and integrating it into academic teaching hospitals. In the view of the AIAMC, residents’ daily interactions provide opportunities not only to engage in QI themselves but also to stimulate action from faculty.7 1
Baystate Health, Springfield, MA Tufts University School of Medicine, Boston, MA 3 The Alliance of Independent Academic Medical Centers, Chicago, IL 2
Corresponding Author: Kimberly Pierce-Boggs, MA, AIAMC, 401 N Michigan Ave, Suite 1200, Chicago, IL 60611. Email: [email protected]
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Table 1. AIAMC National Initiatives. National Initiative
Dates
I
2007-2008
II
2009-2011
III
2011-2013
IV
2013-2015
Participants 19 Member institutions
Activities
Focus
Individual leaders met in person 5 times and telephonically on a monthly basis over 18 months
Handoffs, infection control, and transitions of care aligned with institutional goals and IHI’s 5 Million Lives Campaign 35 Teams from member Local teams, led by residents and Communication, handoffs, infection institutions faculty, met in person 4 times and control, readmissions, and telephonically on a monthly basis transitions of care 35 Teams from member Local teams, led by residents and Faculty/leadership development institutions faculty, met in person 4 times and telephonically on a monthly basis 34 Teams, including Local teams, led by residents and Emphasis on the ACGME CLER both member and faculty, met in person 4 times and program. Focus on patient nonmember institutions telephonically on a monthly basis safety, quality improvement, professionalism, and care transitions
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; AIAMC, Alliance for Independent Academic Medical Centers; CLER, Clinical Learning Environment Review; IHI, Institute for Healthcare Improvement.
Most of the recent literature exploring GME and quality improvement reports on residents’ QI projects.8-11 These efforts compartmentalize QI into individual resident projects rather than promoting a general environment of QI. In an effort to promote institution-wide QI, limiting QI efforts to resident projects might send the message that quality is a resident effort rather than an integral aspect of doctoring.12 Others have explored the role that clinician educators play13 but stop short of offering practical guidelines for organization-wide integration. Little information exists on institution-wide integration strategies, but one institution has reported its experience using financial incentives to motivate QI across the GME programs.14 Although these articles are guided by the urgency of integrating GME with QI, they are limited in their description of how that might work. Wong et al15 do propose a view of sustained integration of GME and QI at an institutional level, describing strategies that might sustain QI and patient safety curricula from a social theory perspective. Although helpful as a compass, their theoretical perspective does not serve as a map. Current literature posits how institutions might integrate GME with QI, but there is a dearth of practical “how to” guidance toward this goal at the institutional level. To fill that gap, the AIAMC called for tangible efforts toward improving safety and quality across their member institutions. Realizing the important role of residents in patient care and that lack of input from this critical group would hamper any improvement effort, the AIAMC gathered hospitals to share best practices for incorporating QI into GME at an institutional level.
AIAMC National Initiatives In early 2007, the AIAMC launched their first National Initiative (NI). This first NI focused on integrating GME and the QI offices. More than 7 years later, the AIAMC has led 4 NIs. Each NI has been 18 months in length and structured to include 4 in-person learning sessions as well as monthly collaborative calls between participants. This structure provided discussion and networking opportunities around specific quality improvement initiatives (Table 1) and allowed participants to discuss barriers, potential resources, and ways to empower residencies through each institution’s projects. The first NI featured QI activities tied to institutional strategic goals and aligned with the Institute for Healthcare Improvement’s 5 Million Lives Campaign.3 On-site learning sessions featured national leaders in QI, and discussion was targeted toward systems-wide thinking and changing culture by bringing GME and QI together. In all these strategic efforts, participants targeted ways to put the patient first and to improve the QI of patient care by harnessing the unique position of residents on the front lines. The AIAMC NIs established relationships and presented a forum for best practices, and many innovative approaches to quality integration were developed by sharing interinstitutional experiences. For example, discussions and work at the NI meetings prompted Drs Fleischut and Evans from New York-Presbyterian16 to create the resident quality council. Several other examples of integration initiatives examined institutional processes. One of the authors (KTH) was involved in another initiative that was driven by participation in the NIs. At the
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Blanchard et al time, at Baystate Medical Center, many errors occurred by using the evening handover tool. Because the internal medicine residency program director at Baystate was an early participant in the NIs, he saw the opportunity to improve the residency program’s handover tool as a mechanism for improving quality. However, the AIAMC NI stressed the importance of integration into the institutional mission and collaboration. As a result, the program director reached out to the nursing department, which also was experiencing difficulties with its handover process. Through collaboration, a new handover tool was built jointly by nursing and the internal medicine residency program. This tool was part of the medical record, so the problem list and medications were always up to date, thereby overcoming problems with the former paper tool. Residents reported decreases in errors using the new handover tool, and nurses on the medical floors found the sign-out information included by residents on the tool to be valuable to their practice and included the tool for its valueadded benefit. This example from Baystate represents one way in which the AIAMC NIs have encouraged integration of GME and quality. Anecdotally, however, such integration has been difficult for GME leaders, and barriers to integrating quality with GME—as well as opportunities to overcome those barriers—are valuable lessons for those beginning the process. In an effort to understand more about such difficulties and lessons learned, the authors asked NI participants to reflect on their experiences.
A Survey on AIAMC Institutions and NI: Reflections and Perceptions of Efficacy To understand the efficacy of the NIs and members’ perceptions of their efforts to integrate quality into GME, the authors developed a focused evaluation to capture the reflections of AIAMC members who were NI participants. Authors based survey items on the content of the NIs and their personal experience in integrating quality in GME. A 14-item evaluation was designed to capture demographic information, institutional goals, activities to achieve these goals, barriers encountered, lessons learned in hindsight, and advice for others (see online Appendix A, available at http://ajmq.sagepub.com/supplemental). The survey included both open- and closed-response items. To facilitate validity of the responses and to ensure that participants understood each question as it was intended, the survey was piloted with a small group of AIAMC members who, therefore, were potential respondents. This group guided revisions to item wording and content, which facilitated clarification and completeness in responses.
Table 2. Role and National Initiative (NI) Participation of Respondents. Measure Role at institution DIO Program director Faculty member Administrator (GME) Nurse Director/Medical director Other Participation NI I NI II NI III NI IV
Percentage
n
30.9 13.2 11.8 7.4 4.4 4.4 27.9
21 9 8 5 3 3 19
27.9 38.2 50.0 70.6
19 26 34 48
Abbreviations: DIO, designated institutional official; GME, graduate medical education.
The survey was administered via REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Tufts University.17 REDCap is a secure Webbased application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources. The director of the AIAMC (KPB) e-mailed the survey to the organization’s distribution list, which included 304 total recipients from 55 institutions. Most distribution list members were designated institutional officials (DIOs) or program directors, but the list also included GME managers, faculty members, and nurses. One author (RDB) analyzed open-response items by question, using constant comparative analysis in which themes emerge based on patterns in the data.18 In this case, comments are compared across respondents within each of the a priori categories of goals, barriers, and lessons learned. This project did not require approval from the institutional review board.
Results Out of 304 total NI participants, 68 (22.3%) responded to the evaluation. Despite the low response rate, the respondents were representative of typical NI participants, including DIOs, faculty, nurses, and GME administrators. In addition, respondents participated in a range of NIs (Table 2). Thus, even despite the low response rate, the sample did represent the types of respondents whose evaluations of this process could provide insight and
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value to different stakeholders attempting to integrate GME and quality. Overall, respondents’ comments reflected the difficulty of being asked to not only introduce the concept of integrating quality with GME at their local institutions but also to serve as agents of change. The AIAMC NIs focused on development and dissemination of tools and opportunities to integrate quality with GME across a broad range of institutions, and survey responses identified key themes that supported the challenge and opportunity associated with this organizational change. The comments presented in the following sections are attributed to respondents by their self-reported role and number (out of a total of 4) of AIAMC NIs in which they participated.
Goals Respondents viewed organizational change as their goal, but their targets varied. In articulating their goals for integrating quality with GME, they identified whether their activities were to be carried out at the department or the institution level. For most, the goal was either to align the priorities of medical education with those of the institution or to improve medical education by including quality improvement activities. Some of these goals included the following: Improve care of patients by resident and faculty education and participation in performance improvement projects aligned with institutional goals/objectives. (Faculty member, 2) Resident and faculty education in patient safety and quality improvement. (DIO, 3) Enhancement of trainees’ knowledge regarding health care that they provide and linking it to the quality of the care/ patient safety that they provide. (DIO, 3)
Other respondents set their sights on changing the culture of the institution: Additionally, to create an institutional environment that fosters [quality improvement] for residents, faculty, nursing, medical students, etc. (DIO, 3) To change the culture of the institution and make it part of the daily routine. (Program director, 1)
Other respondents’ goals included specific patient care indicators, improving knowledge, and/or meeting the needs of an external expectation, such as ACGME or Clinical Learning Environment Review. Still others saw the goal as an opportunity to demonstrate the “worthiness”
of GME to the institution by developing “GME as a strategic asset” (DIO, 3).
Barriers For its part, AIAMC leadership emphasized that the most important and effective driver for integrating GME with QI was the assumption that linking quality improvement with GME is entirely about the patient; and respondents’ goals reflect such ambition. Yet this patient-centered perspective requires an institutional approach. Myers and Nash12 point out that QI initiatives compartmentalized as separate, mandatory curricula invite residents to view them “as a distraction . . . designed to satisfy an ACGME requirement” rather than as integral aspects of their patient care. So, although the AIAMC pushed for institution-wide integration, many NI participants reported that the biggest barriers to integration were associated with institutional change. Respondents identified that the most frequently encountered barrier in both developing and implementing quality in GME was establishing buy-in from key stakeholders, which included the challenge of convincing colleagues, residents, faculty, and even leadership of the priority of engaging medical education in QI efforts. Respondents noted that even “getting the attention of leadership” (DIO, 2) was a challenge. An administrator (3) wrote that one particular challenge was “changing culture of faculty to view quality and safety as something everyone must own.” Toward that end, a faculty member lamented a number of barriers, including “stakeholders, resistance to change, lack of recognition, and underestimation of the problem” (Faculty member, 3). Respondents also frequently commented on the difficulty associated with prioritizing their goals. Still other responses included traditional barriers to change and innovation in academic medical centers and GME, including lack of resources, such as time, staffing, and funding, for implementing new activities.
Lessons Learned Overcoming these barriers is the only way to ensure an opportunity for meeting the goals. Respondents reflected on the lessons they learned, which offer insight into the way in which others might overcome many of these barriers. First and foremost, respondents noted that overcoming barriers and marking success required fortitude—approaching the journey of quality integration as a marathon, not a sprint. Respondents noted that starting small and establishing continuous momentum were critical for success.
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Blanchard et al Start Small. Respondents articulated the importance of a clear goal, within an appropriate scope. According to one DIO (4), institutions should “think institutionally, but act departmentally (ie, think big but start small).” Echoed in this sentiment is the idea that small projects may yield early successes, a big bonus toward encouraging faculty engagement. Another DIO (4) reflected that early successes required “narrowing the scope of projects. Teams in general want to do ‘meaningful’ work and it is important that beginning meaningful work is successful.” Establish Continuous Momentum. Early successes also might play a part in supporting continuous momentum, which is a reasonable consideration for projects that may take years to implement in a culture that may be fairly rigid. Some participants reflected that they wish they had “a bit more patience” (Educationalist, 1) when beginning and “better plans for keeping initiatives going” (DIO, 3). Establishing continuous momentum was encouraged through regular meetings “even for only 20 minutes” (Program director, 4) or by including it as an agenda item in other meetings (DIO, 1). Engage Others. Respondents were asked to reflect on what they would have done differently in integrating quality with GME and for their advice to other institutions about to embark on the journey. They primarily urged collaboration and engagement of key stakeholders. For respondents, the act of engaging stakeholders meant both identifying key stakeholders and establishing engagement among those involved. Buy-in from key stakeholders was important, particularly with department and institutional leaders. Key stakeholders also included the project “champions” for these initiatives, such as residents, faculty, and quality/performance improvement staff. One respondent advised, “Ask residents for their insights, and engage the [performance improvement] department and c-suite right away” (DIO, 4). Asking residents for their insights reflected the need to establish engagement among stakeholders. Respondents suggested involving stakeholders in decision making early on by, for example, “choose[ing] projects that residents, faculty, departments identify as areas of need” (DIO, 4). Other ways to integrate team members included offering financial incentives or ensuring clear communication. One DIO (3) noted, “All players must learn the language of performance improvement which is not taught in medical school.” Just Do It. Themes less frequent among respondents included the call to provide mandatory faculty development or education sessions for team members as a way to train together and begin to work and learn together about quality improvement. Others maintained that strong
leadership was a must-have for institutions beginning the process. Still other institutions maintained that at some point, action just had to be taken despite the barriers. Three respondents offered simple advice to institutions considering the process: “Just do it!”
Discussion The reflections of NI participants provide some insight into the opportunities and challenges associated with change in an organization. Kotter1 laid out a model of organizational change that incorporates some of the themes identified in participants’ responses, including forming a powerful coalition (engaging stakeholders), removing obstacles, and creating short-term wins. Kotter also noted the importance of creating urgency, and the IOM-recommended payment reform is one argument toward that end. One of the final steps of Kotter’s organizational change model is to “anchor the changes in corporate culture.” By bringing together teams of NI participants to identify their own steps toward success, the AIAMC fostered the opportunity for culturally sensitive solutions to uniform problems. The AIAMC NIs promoted tactical advancement toward integration of QI and GME for academic medical centers. Their efforts establish AIAMC itself as a change agent, aligning academic medical centers toward a common goal and then supporting continued advancement toward that goal, despite great challenges. Rather than promoting the policies established by national discourse, the AIAMC led its members in the nuanced progression of change, identifying opportunities and mitigating challenges, with successful integration institution wide, one NI participant at a time. There are a growing number of institutions and external pressures mounting behind the argument toward integration of QI and GME, and the AIAMC’s efforts to support this patient-centered and institution-wide integration have resonated with NI participants. Also, their reflections provide practical insight and inspiring advice for others embarking on the journey. The low response rate to this evaluation is a limitation, but the representativeness of the respondents and their deep integration into the process (with most having been through at least 2 NIs) gives weight to their perspectives at the institutional level. There also was a great deal of consistency in their responses, reflecting that although the nuances of integration vary by institution, aspects of the nature of organizational change are similar. Given this and the authors’ historical experience, the authors believe that the perspectives presented here are incredibly valuable for GME institutions. Respondents’ comments give insight into the value of an organized, national, aligned effort to integrate quality
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with GME. The results of this evaluation will provide strategic focus on overcoming identified, common barriers as new institutions become partners in the project.
Conclusion For some NI participants, the road to integrate quality with GME is more than 7 years in the making. Sharing their experiences and expertise provides ample opportunity to expand the chances for others’ success. This article presents the elements of successful efforts, advice to those just beginning the process, and the barriers commonly experienced along the way. These GME administrators, faculty, nurses, and others are leaders in the national effort to integrate QI initiatives into GME. Their perspectives shed light on this process for all those who have yet to make the journey. And, although integrating quality with GME is a long road, and barriers to cultural and institutional change require considerable effort and continuous momentum, to institutions on the precipice of aligning their frontline providers in QI efforts, we say, “Just do it!” Acknowledgments The authors would like to thank Patricia J. McArdle, EdD, for her insight and edits during development of this article.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Kotter JP. Leading change: why transformation efforts fail. https://hbr.org/2007/01/leading-change-why-transformationefforts-fail/ar/1. Accessed January 5, 2015. 2. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 3. McCannon CJ, Hackbarth AD, Griffin FA. Miles to go: an introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf. 2007;33:477-484. 4. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302:1277-1283.
5. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370:991-993. 6. Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. 7. Welling R, Grannan K, Boberg J, Pierce-Boggs K, Engel A. Graduate medical education as the driver for quality improvement and patient safety: a national initiative of independent academic medical centers. J Surg Educ. 2009;66:336-339. 8. Stevens DP, Bowen JL, Johnson JK, et al. A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices. J Gen Intern Med. 2010;25(suppl 4):S574-S580. 9. Nabors C, Peterson SJ, Sule S, et al. Tracking outpatient continuity and chronic disease indicators: a novel use of the new innovations clinic module. Am J Ther. 2012;19:76-80. 10. Panait L, Hogle NJ, Fowler DL, Bell RL, Roberts KE, Duffy AJ. Completion of a novel, virtual-reality-based, advanced laparoscopic curriculum improves advanced laparoscopic skills in senior residents. J Surg Educ. 2011;68:121-125. 11. Rogers SC, Dudley NC, McDonnell W, Scaife E, Morris S, Nelson D. Lights, camera, action . . . spotlight on trauma video review: an underutilized means of quality improvement and education. Pediatr Emerg Care. 2010;26: 803-807. 12. Myers JS, Nash DB. Graduate medical education’s new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals? Acad Med. 2014;89:1328-1330. 13. Stevens DP, Kirkland KB. The role for clinician educators in implementing healthcare improvement. J Gen Intern Med. 2010;25(suppl 4):S639-S643. 14. Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. Acad Med. 2014;89:460-468. 15. 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. 16. Fleischut PM, Faggiani SL, Evans AS, et al. 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. 17. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-381. 18. Lingard L. When I say . . . grounded theory. Med Educ. 2014;48:748-749.
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research-article2015
AJMXXX10.1177/1062860615569270American Journal of Medical QualityBlanchard et al
Article
Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives
American Journal of Medical Quality 1–6 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615569270 ajmq.sagepub.com
Rebecca D. Blanchard, PhD1,2, Kimberly Pierce-Boggs, MA3, Paul F. Visintainer, PhD1,2, and Kevin T. Hinchey, MD1,2,3
Abstract Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey. Keywords graduate medical education, quality improvement, academic medical center, organizational change Just as a relatively simple vision is needed to guide people through a major change, so a vision of the change process can reduce the error rate. And fewer errors can spell the difference between success and failure. John P. Kotter1
Quality and safety initiatives (QI) are national priorities for health care, propelled forward by the Institute of Medicine (IOM)2 and the Institute for Healthcare Improvement3 in the past decade. Although these groups ensured their importance for providers, they did not carve out a path for addressing their priorities, nor did they consider the role of residents, who make up a significant number of the frontline providers in academic medical centers. This is a considerable oversight: The educational environments in which they are trained affect residents’ future clinical outcomes.4 Yet QI and graduate medical education (GME) efforts continue to be compartmentalized, with most residents viewing QI as individual provider events rather than as system-wide events that involve multiple team members and factors.5 Now, with the IOM calling for payment reform in GME that recognizes performance improvement (including QI),6 GME and QI can no longer
afford to be separate. Patient-centered care and future funding require their integration. The Alliance of Independent Academic Medical Centers (AIAMC) is a group of 80 major medical centers across the United States affiliated with medical schools but independent of medical school ownership or governance. Representing more than 825 senior academic leaders, the AIAMC added its own voice to the national call for quality improvement by arguing for engagement of frontline academic center providers in the move to action. Engaging residents in the process, the AIAMC noted, is an important mechanism for both addressing the national issue and integrating it into academic teaching hospitals. In the view of the AIAMC, residents’ daily interactions provide opportunities not only to engage in QI themselves but also to stimulate action from faculty.7 1
Baystate Health, Springfield, MA Tufts University School of Medicine, Boston, MA 3 The Alliance of Independent Academic Medical Centers, Chicago, IL 2
Corresponding Author: Kimberly Pierce-Boggs, MA, AIAMC, 401 N Michigan Ave, Suite 1200, Chicago, IL 60611. Email: [email protected]
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Table 1. AIAMC National Initiatives. National Initiative
Dates
I
2007-2008
II
2009-2011
III
2011-2013
IV
2013-2015
Participants 19 Member institutions
Activities
Focus
Individual leaders met in person 5 times and telephonically on a monthly basis over 18 months
Handoffs, infection control, and transitions of care aligned with institutional goals and IHI’s 5 Million Lives Campaign 35 Teams from member Local teams, led by residents and Communication, handoffs, infection institutions faculty, met in person 4 times and control, readmissions, and telephonically on a monthly basis transitions of care 35 Teams from member Local teams, led by residents and Faculty/leadership development institutions faculty, met in person 4 times and telephonically on a monthly basis 34 Teams, including Local teams, led by residents and Emphasis on the ACGME CLER both member and faculty, met in person 4 times and program. Focus on patient nonmember institutions telephonically on a monthly basis safety, quality improvement, professionalism, and care transitions
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; AIAMC, Alliance for Independent Academic Medical Centers; CLER, Clinical Learning Environment Review; IHI, Institute for Healthcare Improvement.
Most of the recent literature exploring GME and quality improvement reports on residents’ QI projects.8-11 These efforts compartmentalize QI into individual resident projects rather than promoting a general environment of QI. In an effort to promote institution-wide QI, limiting QI efforts to resident projects might send the message that quality is a resident effort rather than an integral aspect of doctoring.12 Others have explored the role that clinician educators play13 but stop short of offering practical guidelines for organization-wide integration. Little information exists on institution-wide integration strategies, but one institution has reported its experience using financial incentives to motivate QI across the GME programs.14 Although these articles are guided by the urgency of integrating GME with QI, they are limited in their description of how that might work. Wong et al15 do propose a view of sustained integration of GME and QI at an institutional level, describing strategies that might sustain QI and patient safety curricula from a social theory perspective. Although helpful as a compass, their theoretical perspective does not serve as a map. Current literature posits how institutions might integrate GME with QI, but there is a dearth of practical “how to” guidance toward this goal at the institutional level. To fill that gap, the AIAMC called for tangible efforts toward improving safety and quality across their member institutions. Realizing the important role of residents in patient care and that lack of input from this critical group would hamper any improvement effort, the AIAMC gathered hospitals to share best practices for incorporating QI into GME at an institutional level.
AIAMC National Initiatives In early 2007, the AIAMC launched their first National Initiative (NI). This first NI focused on integrating GME and the QI offices. More than 7 years later, the AIAMC has led 4 NIs. Each NI has been 18 months in length and structured to include 4 in-person learning sessions as well as monthly collaborative calls between participants. This structure provided discussion and networking opportunities around specific quality improvement initiatives (Table 1) and allowed participants to discuss barriers, potential resources, and ways to empower residencies through each institution’s projects. The first NI featured QI activities tied to institutional strategic goals and aligned with the Institute for Healthcare Improvement’s 5 Million Lives Campaign.3 On-site learning sessions featured national leaders in QI, and discussion was targeted toward systems-wide thinking and changing culture by bringing GME and QI together. In all these strategic efforts, participants targeted ways to put the patient first and to improve the QI of patient care by harnessing the unique position of residents on the front lines. The AIAMC NIs established relationships and presented a forum for best practices, and many innovative approaches to quality integration were developed by sharing interinstitutional experiences. For example, discussions and work at the NI meetings prompted Drs Fleischut and Evans from New York-Presbyterian16 to create the resident quality council. Several other examples of integration initiatives examined institutional processes. One of the authors (KTH) was involved in another initiative that was driven by participation in the NIs. At the
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Blanchard et al time, at Baystate Medical Center, many errors occurred by using the evening handover tool. Because the internal medicine residency program director at Baystate was an early participant in the NIs, he saw the opportunity to improve the residency program’s handover tool as a mechanism for improving quality. However, the AIAMC NI stressed the importance of integration into the institutional mission and collaboration. As a result, the program director reached out to the nursing department, which also was experiencing difficulties with its handover process. Through collaboration, a new handover tool was built jointly by nursing and the internal medicine residency program. This tool was part of the medical record, so the problem list and medications were always up to date, thereby overcoming problems with the former paper tool. Residents reported decreases in errors using the new handover tool, and nurses on the medical floors found the sign-out information included by residents on the tool to be valuable to their practice and included the tool for its valueadded benefit. This example from Baystate represents one way in which the AIAMC NIs have encouraged integration of GME and quality. Anecdotally, however, such integration has been difficult for GME leaders, and barriers to integrating quality with GME—as well as opportunities to overcome those barriers—are valuable lessons for those beginning the process. In an effort to understand more about such difficulties and lessons learned, the authors asked NI participants to reflect on their experiences.
A Survey on AIAMC Institutions and NI: Reflections and Perceptions of Efficacy To understand the efficacy of the NIs and members’ perceptions of their efforts to integrate quality into GME, the authors developed a focused evaluation to capture the reflections of AIAMC members who were NI participants. Authors based survey items on the content of the NIs and their personal experience in integrating quality in GME. A 14-item evaluation was designed to capture demographic information, institutional goals, activities to achieve these goals, barriers encountered, lessons learned in hindsight, and advice for others (see online Appendix A, available at http://ajmq.sagepub.com/supplemental). The survey included both open- and closed-response items. To facilitate validity of the responses and to ensure that participants understood each question as it was intended, the survey was piloted with a small group of AIAMC members who, therefore, were potential respondents. This group guided revisions to item wording and content, which facilitated clarification and completeness in responses.
Table 2. Role and National Initiative (NI) Participation of Respondents. Measure Role at institution DIO Program director Faculty member Administrator (GME) Nurse Director/Medical director Other Participation NI I NI II NI III NI IV
Percentage
n
30.9 13.2 11.8 7.4 4.4 4.4 27.9
21 9 8 5 3 3 19
27.9 38.2 50.0 70.6
19 26 34 48
Abbreviations: DIO, designated institutional official; GME, graduate medical education.
The survey was administered via REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Tufts University.17 REDCap is a secure Webbased application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources. The director of the AIAMC (KPB) e-mailed the survey to the organization’s distribution list, which included 304 total recipients from 55 institutions. Most distribution list members were designated institutional officials (DIOs) or program directors, but the list also included GME managers, faculty members, and nurses. One author (RDB) analyzed open-response items by question, using constant comparative analysis in which themes emerge based on patterns in the data.18 In this case, comments are compared across respondents within each of the a priori categories of goals, barriers, and lessons learned. This project did not require approval from the institutional review board.
Results Out of 304 total NI participants, 68 (22.3%) responded to the evaluation. Despite the low response rate, the respondents were representative of typical NI participants, including DIOs, faculty, nurses, and GME administrators. In addition, respondents participated in a range of NIs (Table 2). Thus, even despite the low response rate, the sample did represent the types of respondents whose evaluations of this process could provide insight and
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value to different stakeholders attempting to integrate GME and quality. Overall, respondents’ comments reflected the difficulty of being asked to not only introduce the concept of integrating quality with GME at their local institutions but also to serve as agents of change. The AIAMC NIs focused on development and dissemination of tools and opportunities to integrate quality with GME across a broad range of institutions, and survey responses identified key themes that supported the challenge and opportunity associated with this organizational change. The comments presented in the following sections are attributed to respondents by their self-reported role and number (out of a total of 4) of AIAMC NIs in which they participated.
Goals Respondents viewed organizational change as their goal, but their targets varied. In articulating their goals for integrating quality with GME, they identified whether their activities were to be carried out at the department or the institution level. For most, the goal was either to align the priorities of medical education with those of the institution or to improve medical education by including quality improvement activities. Some of these goals included the following: Improve care of patients by resident and faculty education and participation in performance improvement projects aligned with institutional goals/objectives. (Faculty member, 2) Resident and faculty education in patient safety and quality improvement. (DIO, 3) Enhancement of trainees’ knowledge regarding health care that they provide and linking it to the quality of the care/ patient safety that they provide. (DIO, 3)
Other respondents set their sights on changing the culture of the institution: Additionally, to create an institutional environment that fosters [quality improvement] for residents, faculty, nursing, medical students, etc. (DIO, 3) To change the culture of the institution and make it part of the daily routine. (Program director, 1)
Other respondents’ goals included specific patient care indicators, improving knowledge, and/or meeting the needs of an external expectation, such as ACGME or Clinical Learning Environment Review. Still others saw the goal as an opportunity to demonstrate the “worthiness”
of GME to the institution by developing “GME as a strategic asset” (DIO, 3).
Barriers For its part, AIAMC leadership emphasized that the most important and effective driver for integrating GME with QI was the assumption that linking quality improvement with GME is entirely about the patient; and respondents’ goals reflect such ambition. Yet this patient-centered perspective requires an institutional approach. Myers and Nash12 point out that QI initiatives compartmentalized as separate, mandatory curricula invite residents to view them “as a distraction . . . designed to satisfy an ACGME requirement” rather than as integral aspects of their patient care. So, although the AIAMC pushed for institution-wide integration, many NI participants reported that the biggest barriers to integration were associated with institutional change. Respondents identified that the most frequently encountered barrier in both developing and implementing quality in GME was establishing buy-in from key stakeholders, which included the challenge of convincing colleagues, residents, faculty, and even leadership of the priority of engaging medical education in QI efforts. Respondents noted that even “getting the attention of leadership” (DIO, 2) was a challenge. An administrator (3) wrote that one particular challenge was “changing culture of faculty to view quality and safety as something everyone must own.” Toward that end, a faculty member lamented a number of barriers, including “stakeholders, resistance to change, lack of recognition, and underestimation of the problem” (Faculty member, 3). Respondents also frequently commented on the difficulty associated with prioritizing their goals. Still other responses included traditional barriers to change and innovation in academic medical centers and GME, including lack of resources, such as time, staffing, and funding, for implementing new activities.
Lessons Learned Overcoming these barriers is the only way to ensure an opportunity for meeting the goals. Respondents reflected on the lessons they learned, which offer insight into the way in which others might overcome many of these barriers. First and foremost, respondents noted that overcoming barriers and marking success required fortitude—approaching the journey of quality integration as a marathon, not a sprint. Respondents noted that starting small and establishing continuous momentum were critical for success.
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Blanchard et al Start Small. Respondents articulated the importance of a clear goal, within an appropriate scope. According to one DIO (4), institutions should “think institutionally, but act departmentally (ie, think big but start small).” Echoed in this sentiment is the idea that small projects may yield early successes, a big bonus toward encouraging faculty engagement. Another DIO (4) reflected that early successes required “narrowing the scope of projects. Teams in general want to do ‘meaningful’ work and it is important that beginning meaningful work is successful.” Establish Continuous Momentum. Early successes also might play a part in supporting continuous momentum, which is a reasonable consideration for projects that may take years to implement in a culture that may be fairly rigid. Some participants reflected that they wish they had “a bit more patience” (Educationalist, 1) when beginning and “better plans for keeping initiatives going” (DIO, 3). Establishing continuous momentum was encouraged through regular meetings “even for only 20 minutes” (Program director, 4) or by including it as an agenda item in other meetings (DIO, 1). Engage Others. Respondents were asked to reflect on what they would have done differently in integrating quality with GME and for their advice to other institutions about to embark on the journey. They primarily urged collaboration and engagement of key stakeholders. For respondents, the act of engaging stakeholders meant both identifying key stakeholders and establishing engagement among those involved. Buy-in from key stakeholders was important, particularly with department and institutional leaders. Key stakeholders also included the project “champions” for these initiatives, such as residents, faculty, and quality/performance improvement staff. One respondent advised, “Ask residents for their insights, and engage the [performance improvement] department and c-suite right away” (DIO, 4). Asking residents for their insights reflected the need to establish engagement among stakeholders. Respondents suggested involving stakeholders in decision making early on by, for example, “choose[ing] projects that residents, faculty, departments identify as areas of need” (DIO, 4). Other ways to integrate team members included offering financial incentives or ensuring clear communication. One DIO (3) noted, “All players must learn the language of performance improvement which is not taught in medical school.” Just Do It. Themes less frequent among respondents included the call to provide mandatory faculty development or education sessions for team members as a way to train together and begin to work and learn together about quality improvement. Others maintained that strong
leadership was a must-have for institutions beginning the process. Still other institutions maintained that at some point, action just had to be taken despite the barriers. Three respondents offered simple advice to institutions considering the process: “Just do it!”
Discussion The reflections of NI participants provide some insight into the opportunities and challenges associated with change in an organization. Kotter1 laid out a model of organizational change that incorporates some of the themes identified in participants’ responses, including forming a powerful coalition (engaging stakeholders), removing obstacles, and creating short-term wins. Kotter also noted the importance of creating urgency, and the IOM-recommended payment reform is one argument toward that end. One of the final steps of Kotter’s organizational change model is to “anchor the changes in corporate culture.” By bringing together teams of NI participants to identify their own steps toward success, the AIAMC fostered the opportunity for culturally sensitive solutions to uniform problems. The AIAMC NIs promoted tactical advancement toward integration of QI and GME for academic medical centers. Their efforts establish AIAMC itself as a change agent, aligning academic medical centers toward a common goal and then supporting continued advancement toward that goal, despite great challenges. Rather than promoting the policies established by national discourse, the AIAMC led its members in the nuanced progression of change, identifying opportunities and mitigating challenges, with successful integration institution wide, one NI participant at a time. There are a growing number of institutions and external pressures mounting behind the argument toward integration of QI and GME, and the AIAMC’s efforts to support this patient-centered and institution-wide integration have resonated with NI participants. Also, their reflections provide practical insight and inspiring advice for others embarking on the journey. The low response rate to this evaluation is a limitation, but the representativeness of the respondents and their deep integration into the process (with most having been through at least 2 NIs) gives weight to their perspectives at the institutional level. There also was a great deal of consistency in their responses, reflecting that although the nuances of integration vary by institution, aspects of the nature of organizational change are similar. Given this and the authors’ historical experience, the authors believe that the perspectives presented here are incredibly valuable for GME institutions. Respondents’ comments give insight into the value of an organized, national, aligned effort to integrate quality
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with GME. The results of this evaluation will provide strategic focus on overcoming identified, common barriers as new institutions become partners in the project.
Conclusion For some NI participants, the road to integrate quality with GME is more than 7 years in the making. Sharing their experiences and expertise provides ample opportunity to expand the chances for others’ success. This article presents the elements of successful efforts, advice to those just beginning the process, and the barriers commonly experienced along the way. These GME administrators, faculty, nurses, and others are leaders in the national effort to integrate QI initiatives into GME. Their perspectives shed light on this process for all those who have yet to make the journey. And, although integrating quality with GME is a long road, and barriers to cultural and institutional change require considerable effort and continuous momentum, to institutions on the precipice of aligning their frontline providers in QI efforts, we say, “Just do it!” Acknowledgments The authors would like to thank Patricia J. McArdle, EdD, for her insight and edits during development of this article.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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