525031
research-article2014
AJMXXX10.1177/1062860614525031American Journal of Medical QualityBaron et al
Commentary
Teaching for Quality: Where Do We Go From Here?
American Journal of Medical Quality 2014, Vol. 29(3) 256–258 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614525031 ajmq.sagepub.com
Robert B. Baron, MD, MS,1 Nancy L. Davis, PhD,2 David A. Davis, MD,2 and Linda A. Headrick, MD, MS3 In January 2013, an expert panel convened by the Association of American Medical Colleges (AAMC) recommended a systematic strategy to build a critical mass of academic health center faculty who are ready, able, and willing to lead and implement education in quality improvement, patient safety, and reduction of health care costs. The full report, Teaching for Quality, is available at www.aamc.org/te4q. The purpose of this commentary, at the 1-year anniversary of the report, is to reflect on the recommendations themselves, describe current progress toward their achievement, and strategize about concrete next steps. The expert panel began its work by recognizing the increasing emphasis from all sectors of the health care system and health professions education community to improve practice and teaching in quality improvement, patient safety (QI/PS), and cost reduction. The last year has seen a further expansion of efforts in this regard. They include several of note: an $11 million dollar grant program initiated by the American Medical Association to develop new curriculums in US medical schools1; new entrustable professional activities for graduating medical students that include competence in QI/PS2; new quality and safety questions on the 2014 US Medical Licensing Examination3; the completion of the first complete year of Clinical Learning Environment Reviews by the Accreditation Council for Graduate Medical Education (ACGME) and the publication of Pathways to Excellence describing elements of an optimal learning environment4; the development and expansion of institution-based systems to maintain physician certification5; the development by more than 50 specialty societies of lists of tests and procedures that may be unnecessary as part of the Choosing Wisely initiative6; and continued quality, safety, cost, and patient satisfaction payment incentives by the Centers for Medicare & Medicaid Services. Despite these efforts in clinical care and health professions education to promote efforts in QI/PS and cost reduction, the issue at the center of the Teaching for Quality report remains: US medical schools and teaching hospitals do not have an adequate supply of skilled faculty to lead these efforts. For example, for each US institution that sponsors graduate medical education programs to have 3 expert faculty, more than 2000 faculty will be
required. Double that number will be required to embed even one expert faculty in each institution to which residents rotate.7 Teaching for Quality describes 3 core recommendations to remedy this situation: Recommendation 1: In order to achieve QI/PS goals for education and practice, the medical schools, teaching hospitals, accreditation bodies, examination organizations, and specialty bodies should ensure the integration of QI/PS concepts into meaningful learning experiences across the continuum of physician professional development and into the summative evaluations used for professional certification and licensure.
Of particular importance is the need for the Liaison Committee on Medical Education to require this content for medical school accreditation, similar to existing accreditation requirements for graduate and continuing medical education. All national examination bodies need to include this content in their exams and provide content-specific feedback to learners, medical schools, and training programs. Recommendation 2: In order to improve the processes and outcomes of care, medical schools and teaching hospitals should expect all clinical faculty to be proficient in QI/PS competencies and to be able to identify, develop, and support a critical mass of faculty as expert educators to create, implement, and evaluate training and education in QI/PS for students, residents, and colleagues.
Faculty contributions in QI/PS, whether educational, clinical, or scholarly, should be recognized as part of institutional promotion and tenure policies.
1
University of California–San Francisco School of Medicine, San Francisco, CA 2 Association of American Medical Colleges, Washington, DC 3 University of Missouri–Columbia School of Medicine, Columbia, MO Corresponding Author: Robert B. Baron, MD, MS, Office of Graduate Medical Education, 500 Parnassus Avenue, Suite MUE 250, San Francisco, CA 94143-0474. Email: [email protected]
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Baron et al Recommendation 3: Academic and clinical leadership should share a common commitment to QI/PS and demonstrate a concrete alignment of the academic and clinical enterprises in a manner that produces the excellent health outcomes valued by health care professionals and the public.
National organizations should expand efforts to recognize outstanding QI/PS contributions by individuals and institutions in education and research. To help achieve these recommendations, Teaching for Quality outlines core competencies in QI/PS for clinical faculty. Using the Dreyfus model describing learners’ progress from novice to master,8 the report defines 3 stages of development for faculty: proficient—all clinically active faculty will need to be practicing and teaching QI/PS in the context of everyday work; expert—some faculty will need to be skilled in formal QI/PS principles and able to create, disseminate, and evaluate curricula; and master—in addition to their expert status, a few faculty will need to be scholars in QI/PS, conducting research in QI/PS education. In the last year, substantial progress has been made in accomplishing these goals. The AAMC has launched a national, institution-based, faculty development initiative to train expert faculty. This comprehensive program includes an interactive experiential learning workshop, Web-based resources, a national community of learners, implementation of educational initiatives, and dissemination of outcomes. Furthermore, webinars, publications, and other efforts from AAMC have enhanced sharing of successful practices in designing effective clinical learning environments across the continuum. For example, several institutions have developed and shared strategies for including QI/PS activity in promotion and tenure criteria. The AAMC’s Aligning and Educating for Quality initiative has assisted 25 academic health centers to align clinical and academic leadership to meet new requirements for quality improvement in graduate and continuing medical education. The AAMC’s Research on Care Community has developed a collaborative effort of more than 100 institutions in clinical effectiveness and implementation science research. The AAMC’s Integrating Quality (IQ) Initiative will convene its sixth national meeting this spring, and the IQ iCollaborative collection offers more than 100 resources presented at previous IQ meetings. The ACGME’s new requirements to assess and report learner milestones in each competency have generated new methods to assess resident skills in practice-based learning and improvement and systems-based practice.9 Twenty-five diverse institutions now link QI/PS efforts with faculty-required maintenance of certification under
the Multi-specialty Maintenance of Certification Portfolio Approval Program across 16 American Board of Medical Specialties Member Boards.5 Other national organizations also have increased faculty development efforts in QI/PS. For example, the Institute for Healthcare Improvement has developed live faculty development programs and is developing facultyspecific modules for their Open School. The Interprofessional Education Collaborative conducts interprofessional faculty development institutes. The Quality and Safety Educators Academy, sponsored by the Society of Hospital Medicine and the Alliance for Internal Medicine, offers annual multiday faculty development programs. Advanced programs to train faculty for the Dreyfus model master level have played an extremely important role in developing scholars and leaders in QI/PS. Examples include graduate degree programs at the Jefferson School of Population Health, Northwestern University, University of Illinois at Chicago, George Washington University, and the University of Toronto, and fellowship programs such as the Veterans Administration Quality Scholars Fellowship Program and the Harvard Medical School Fellowship in Patient Safety and Quality. These collective efforts have been necessary, but they are not yet sufficient. Several additional steps need to be taken in 2014. Institutions need to rapidly increase the uptake of faculty development efforts. Clinical faculty who have had no formal training in QI/PS, but are expected to role-model, teach, and assess learners, must quickly expand their educational skills and become proficient. Each institution also will need a core group of faculty with expert-level skills to lead educational efforts. Institutions must recognize faculty efforts in these domains. Programs and institutions must rapidly expand efforts to teach about and provide cost-conscious care. Only the intensified efforts of all stakeholders will collectively achieve the Teaching for Quality vision that, by 2022, “U.S. medical schools and teaching hospitals are successfully leading enormous changes in health care, aided by educational programs that embed QI/PS across the continuum of physician development.”10 References 1. American Medical Association. Accelerating change in medical education. http://www.ama-assn.org/ama/pub/ about-ama/strategic-focus/accelerating-change-in-medical-education.page. Accessed January 20, 2014. 2. AAMC MedEd Portal. Core entrustable professional activities for entering residency. https://www.mededportal.org/ icollaborative/resource/887. Accessed January 20, 2014. 3. United States Medical Licensing Examination. Changes to USMLE 2014-2015. http://www.usmle.org/pdfs/Changes_
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American Journal of Medical Quality 29(3)
to_USMLE_2014-2015_handout_FINAL.pdf. Accessed January 20, 2014. 4. Accreditation Council for Graduate Medical Education. Clinical Learning Environment Review (CLER) Program. https://www.acgme.org/acgmeweb/tabid/436/ ProgramandInstitutionalAccreditation/NextAccreditation System/ClinicalLearningEnvironmentReviewProgram. aspx. Accessed January 20, 2014. 5. American Board of Medical Specialties. Multi-specialty MOC Portfolio Approval Program. http://mocportfolioprogram.org. Accessed January 20, 2014. 6. ABIM Foundation. Choosing wisely. http://www.choosingwisely.org. Accessed January 20, 2014. 7. Accreditation Council for Graduate Medical Education. Data Resource Book: Academic Year 2012-2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/
PublicationsBooks/2012-2013_ACGME_DATABOOK_ DOCUMENT_Final.pdf. Accessed January 20, 2014. 8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010:13-38. 9. Accreditation Council for Graduate Medical Education. Milestones. http://www.acgme.org/acgmeweb/tabid/430/ ProgramandInstitutionalAccreditation/Milestones.aspx. Accessed January 14, 2014. 10. Association of American Medical Colleges. Teaching for quality: integrating quality improvement and patient safety across the continuum of medical education: report of an expert panel (Page 4). https://www.aamc.org/initiatives/ cei/te4q/366184/te4qreportarticle.html. Accessed February 1, 2014.
Downloaded from ajm.sagepub.com at NANYANG TECH UNIV LIBRARY on May 26, 2015
research-article2014
AJMXXX10.1177/1062860614525031American Journal of Medical QualityBaron et al
Commentary
Teaching for Quality: Where Do We Go From Here?
American Journal of Medical Quality 2014, Vol. 29(3) 256–258 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614525031 ajmq.sagepub.com
Robert B. Baron, MD, MS,1 Nancy L. Davis, PhD,2 David A. Davis, MD,2 and Linda A. Headrick, MD, MS3 In January 2013, an expert panel convened by the Association of American Medical Colleges (AAMC) recommended a systematic strategy to build a critical mass of academic health center faculty who are ready, able, and willing to lead and implement education in quality improvement, patient safety, and reduction of health care costs. The full report, Teaching for Quality, is available at www.aamc.org/te4q. The purpose of this commentary, at the 1-year anniversary of the report, is to reflect on the recommendations themselves, describe current progress toward their achievement, and strategize about concrete next steps. The expert panel began its work by recognizing the increasing emphasis from all sectors of the health care system and health professions education community to improve practice and teaching in quality improvement, patient safety (QI/PS), and cost reduction. The last year has seen a further expansion of efforts in this regard. They include several of note: an $11 million dollar grant program initiated by the American Medical Association to develop new curriculums in US medical schools1; new entrustable professional activities for graduating medical students that include competence in QI/PS2; new quality and safety questions on the 2014 US Medical Licensing Examination3; the completion of the first complete year of Clinical Learning Environment Reviews by the Accreditation Council for Graduate Medical Education (ACGME) and the publication of Pathways to Excellence describing elements of an optimal learning environment4; the development and expansion of institution-based systems to maintain physician certification5; the development by more than 50 specialty societies of lists of tests and procedures that may be unnecessary as part of the Choosing Wisely initiative6; and continued quality, safety, cost, and patient satisfaction payment incentives by the Centers for Medicare & Medicaid Services. Despite these efforts in clinical care and health professions education to promote efforts in QI/PS and cost reduction, the issue at the center of the Teaching for Quality report remains: US medical schools and teaching hospitals do not have an adequate supply of skilled faculty to lead these efforts. For example, for each US institution that sponsors graduate medical education programs to have 3 expert faculty, more than 2000 faculty will be
required. Double that number will be required to embed even one expert faculty in each institution to which residents rotate.7 Teaching for Quality describes 3 core recommendations to remedy this situation: Recommendation 1: In order to achieve QI/PS goals for education and practice, the medical schools, teaching hospitals, accreditation bodies, examination organizations, and specialty bodies should ensure the integration of QI/PS concepts into meaningful learning experiences across the continuum of physician professional development and into the summative evaluations used for professional certification and licensure.
Of particular importance is the need for the Liaison Committee on Medical Education to require this content for medical school accreditation, similar to existing accreditation requirements for graduate and continuing medical education. All national examination bodies need to include this content in their exams and provide content-specific feedback to learners, medical schools, and training programs. Recommendation 2: In order to improve the processes and outcomes of care, medical schools and teaching hospitals should expect all clinical faculty to be proficient in QI/PS competencies and to be able to identify, develop, and support a critical mass of faculty as expert educators to create, implement, and evaluate training and education in QI/PS for students, residents, and colleagues.
Faculty contributions in QI/PS, whether educational, clinical, or scholarly, should be recognized as part of institutional promotion and tenure policies.
1
University of California–San Francisco School of Medicine, San Francisco, CA 2 Association of American Medical Colleges, Washington, DC 3 University of Missouri–Columbia School of Medicine, Columbia, MO Corresponding Author: Robert B. Baron, MD, MS, Office of Graduate Medical Education, 500 Parnassus Avenue, Suite MUE 250, San Francisco, CA 94143-0474. Email: [email protected]
Downloaded from ajm.sagepub.com at NANYANG TECH UNIV LIBRARY on May 26, 2015
257
Baron et al Recommendation 3: Academic and clinical leadership should share a common commitment to QI/PS and demonstrate a concrete alignment of the academic and clinical enterprises in a manner that produces the excellent health outcomes valued by health care professionals and the public.
National organizations should expand efforts to recognize outstanding QI/PS contributions by individuals and institutions in education and research. To help achieve these recommendations, Teaching for Quality outlines core competencies in QI/PS for clinical faculty. Using the Dreyfus model describing learners’ progress from novice to master,8 the report defines 3 stages of development for faculty: proficient—all clinically active faculty will need to be practicing and teaching QI/PS in the context of everyday work; expert—some faculty will need to be skilled in formal QI/PS principles and able to create, disseminate, and evaluate curricula; and master—in addition to their expert status, a few faculty will need to be scholars in QI/PS, conducting research in QI/PS education. In the last year, substantial progress has been made in accomplishing these goals. The AAMC has launched a national, institution-based, faculty development initiative to train expert faculty. This comprehensive program includes an interactive experiential learning workshop, Web-based resources, a national community of learners, implementation of educational initiatives, and dissemination of outcomes. Furthermore, webinars, publications, and other efforts from AAMC have enhanced sharing of successful practices in designing effective clinical learning environments across the continuum. For example, several institutions have developed and shared strategies for including QI/PS activity in promotion and tenure criteria. The AAMC’s Aligning and Educating for Quality initiative has assisted 25 academic health centers to align clinical and academic leadership to meet new requirements for quality improvement in graduate and continuing medical education. The AAMC’s Research on Care Community has developed a collaborative effort of more than 100 institutions in clinical effectiveness and implementation science research. The AAMC’s Integrating Quality (IQ) Initiative will convene its sixth national meeting this spring, and the IQ iCollaborative collection offers more than 100 resources presented at previous IQ meetings. The ACGME’s new requirements to assess and report learner milestones in each competency have generated new methods to assess resident skills in practice-based learning and improvement and systems-based practice.9 Twenty-five diverse institutions now link QI/PS efforts with faculty-required maintenance of certification under
the Multi-specialty Maintenance of Certification Portfolio Approval Program across 16 American Board of Medical Specialties Member Boards.5 Other national organizations also have increased faculty development efforts in QI/PS. For example, the Institute for Healthcare Improvement has developed live faculty development programs and is developing facultyspecific modules for their Open School. The Interprofessional Education Collaborative conducts interprofessional faculty development institutes. The Quality and Safety Educators Academy, sponsored by the Society of Hospital Medicine and the Alliance for Internal Medicine, offers annual multiday faculty development programs. Advanced programs to train faculty for the Dreyfus model master level have played an extremely important role in developing scholars and leaders in QI/PS. Examples include graduate degree programs at the Jefferson School of Population Health, Northwestern University, University of Illinois at Chicago, George Washington University, and the University of Toronto, and fellowship programs such as the Veterans Administration Quality Scholars Fellowship Program and the Harvard Medical School Fellowship in Patient Safety and Quality. These collective efforts have been necessary, but they are not yet sufficient. Several additional steps need to be taken in 2014. Institutions need to rapidly increase the uptake of faculty development efforts. Clinical faculty who have had no formal training in QI/PS, but are expected to role-model, teach, and assess learners, must quickly expand their educational skills and become proficient. Each institution also will need a core group of faculty with expert-level skills to lead educational efforts. Institutions must recognize faculty efforts in these domains. Programs and institutions must rapidly expand efforts to teach about and provide cost-conscious care. Only the intensified efforts of all stakeholders will collectively achieve the Teaching for Quality vision that, by 2022, “U.S. medical schools and teaching hospitals are successfully leading enormous changes in health care, aided by educational programs that embed QI/PS across the continuum of physician development.”10 References 1. American Medical Association. Accelerating change in medical education. http://www.ama-assn.org/ama/pub/ about-ama/strategic-focus/accelerating-change-in-medical-education.page. Accessed January 20, 2014. 2. AAMC MedEd Portal. Core entrustable professional activities for entering residency. https://www.mededportal.org/ icollaborative/resource/887. Accessed January 20, 2014. 3. United States Medical Licensing Examination. Changes to USMLE 2014-2015. http://www.usmle.org/pdfs/Changes_
Downloaded from ajm.sagepub.com at NANYANG TECH UNIV LIBRARY on May 26, 2015
258
American Journal of Medical Quality 29(3)
to_USMLE_2014-2015_handout_FINAL.pdf. Accessed January 20, 2014. 4. Accreditation Council for Graduate Medical Education. Clinical Learning Environment Review (CLER) Program. https://www.acgme.org/acgmeweb/tabid/436/ ProgramandInstitutionalAccreditation/NextAccreditation System/ClinicalLearningEnvironmentReviewProgram. aspx. Accessed January 20, 2014. 5. American Board of Medical Specialties. Multi-specialty MOC Portfolio Approval Program. http://mocportfolioprogram.org. Accessed January 20, 2014. 6. ABIM Foundation. Choosing wisely. http://www.choosingwisely.org. Accessed January 20, 2014. 7. Accreditation Council for Graduate Medical Education. Data Resource Book: Academic Year 2012-2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/
PublicationsBooks/2012-2013_ACGME_DATABOOK_ DOCUMENT_Final.pdf. Accessed January 20, 2014. 8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010:13-38. 9. Accreditation Council for Graduate Medical Education. Milestones. http://www.acgme.org/acgmeweb/tabid/430/ ProgramandInstitutionalAccreditation/Milestones.aspx. Accessed January 14, 2014. 10. Association of American Medical Colleges. Teaching for quality: integrating quality improvement and patient safety across the continuum of medical education: report of an expert panel (Page 4). https://www.aamc.org/initiatives/ cei/te4q/366184/te4qreportarticle.html. Accessed February 1, 2014.
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