The Educational Toolbox: Kick Start Your Educational Program in Quality Improvement Rebecca L. Hoffman, MD,*,† Rachel L. Medbery, MD,‡ Thomas J. Vandermeer, MD,§ Jon B. Morris, MD,* and Rachel R. Kelz, MD, MSCE*,† *

Department of Surgery, Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania; Center for Surgery and Health Economics, Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania; ‡Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; and §Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania †

OBJECTIVE: To disseminate materials and learning from

the proceedings of the Association of Program Directors 2014 Annual Meeting workshop on the integration of quality improvement (QI) education into the existing educational infrastructure. BACKGROUND: Modern surgical practice demands an understanding of QI methodology. Yet, today's surgeons are not formally educated in QI methodology. Therefore, it is hard to follow the historical mantra of “see one, do one, teach one” in the quality realm.

necessitated the development of QI education programs for use in surgical education. To continue to make surgery safer and ensure optimal patient outcomes, surgical educators must teach each resident to adopt quality science C methodology in a meaningful way. ( J Surg ]:]]]-]]]. J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: workshop, quality improvement, surgical

education, barriers COMPETENCIES: Systems Based Practice, Practice-Based

METHODS: Participants were given a brief introduction to

Learning and Improvement

QI approaches. A number of concrete examples of how to incorporate QI education into training programs were presented, followed by a small group session focused on the identification of barriers to incorporation. Participants were provided with a worksheet to help navigate the initial incorporation of QI education in 3 steps.


RESULTS: Participants were representative of all types of training programs, with differing levels of existing QI integration. Barriers to QI education included lack of resident interest/buy-in, concerns over the availability of educational resources (i.e., limited time to devote to QI), and a limited QI knowledge among surgical educators. The 3 steps to kick starting the educational process included (1) choosing a specific method of QI education, (2) incorporation via barrier, infrastructure, and stakeholder identification, and (3) implementation and ongoing assessment. CONCLUSIONS: Recent changes in the delivery of surgical care along with the new accreditation system have

Correspondence: Inquiries to Rebecca L. Hoffman, MD, Department of Surgery, 3400 Spruce Street, 4 Maloney, Philadelphia, PA 19104; fax: (215) 662-7983; E-mail: [email protected], [email protected]

Modern surgical practice demands an understanding of quality improvement (QI) methodology. Numerous approaches to QI exist, and each depends on the use of data to measure performance and track improvements. Moreover, a familiarity with QI processes adopted from industry can be used to form a strong foundation for QI in health care.1,2 The regulatory agencies, including the Accreditation Council for Graduate Medical Education and The Joint Commission, require programs and hospitals to share data with their health care providers to affect a culture of continuous QI.3,4 The new Clinical Learning Environment Review Program will ensure that excellence in clinical outcomes can be demonstrated to maintain accreditation.5,6 Outcomes have been an integral part of surgical education, as evidenced by the rigorous adherence to a weekly morbidity and mortality conference across all surgical programs.7 The techniques used to review cases often include self-reflection, public reporting, and peer review. These techniques are also are the corner stone to a robust

Journal of Surgical Education  & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved.


QI program. However, they are not enough in the current health care environment. The knowledge gap between currently utilized QI processes and traditional practices in surgical education creates an uncomfortable barrier to the advancement of surgical QI. Surgeons teach the majority of surgical education in the United States, yet most of today's surgeon educators have not been formally taught QI methodology themselves. Therefore, it is hard to follow the historical mantra of “see one, do one, teach one” when it comes to the quality realm. To aid in the process of teaching QI methodology while respecting the surgical culture, we present the content from a 2014 Association of Program Directors in Surgery (APDS) workshop designed for this purpose. The readers would gain a better understanding of the nature of QI education, learn strategies to engage residents in organizational quality and safety goals, identify surgery-specific QI lessons that blend with their current curriculum, and identify barriers to the integration of quality education and mechanisms to overcome them.

METHODS In 2014, the workshop “Kick Start Education in Quality Improvement Using 3 Easy Steps” was offered at the annual APDS meeting to facilitate the expansion of education into the QI domain. The facilitators of the workshop were inspired to organize the session because of the early successes in the integration of QI that they had achieved by taking small steps within their own programs. A brief presentation was included to first summarize the practice-

based learning and improvement milestone, the stated purpose of the Clinical Learning Environment Review Program, and the definition of quality and current practices in QI education (Fig. 1), and then to provide a suggested list of opportunities for the expansion of a QI program. Following the presentation, participants were divided into 4 groups based on hospital structure for detailed discussion. Participant roles, hospital-affiliation, and surgical specialty were recorded at the beginning of the small group session. Information on the level of QI knowledge among participants was not discussed so as to foster an open and inclusive dialogue centered on education. A surgical trainee or faculty member with a particular interest/expertise in QI facilitated each of the small groups. Before the workshop, each facilitator was prepared to lead the group using a guide adapted from a previous workshop, complete with space to record qualitative comments during the small group round table discussion (Fig. 2). Using unpublished data from a survey of program directors on QI education, the facilitators were encouraged to start the discussion focused on barriers to implementation.8 Facilitators were directed to synthesize the qualitative remarks into distinct, common themes immediately on completion of the workshop. Each participant was provided with an interactive participant guide, which included concrete examples of QI integration strategies and provocative questions to facilitate this integration at their home institution (Figs. 3 and 4). The participant guide was designed to parallel the facilitator guide. Each participant left the session with a plan for the adoption of 2 strategies for the implementation of QI education into their standing surgical curriculum. Planned group report outs were scheduled for the last 15 minutes of the session, and then a facilitator debriefing

FIGURE 1. Practice-based learning and improvement (PBLI3). (Reprinted from SurgeryMilestones.pdf, page 13.) 2

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General Outline: • What is intimidating to you about getting started? • Review Key Concepts o Principles of QI Lean Six Sigma Find the “teachable moments” • Does not have to be centered on an adverse event o Do you have a blueprint for patient safety? o What is the structure of your M&M conference? Do you have standardized presentations? Do you present aggregated data? Do your residents complete a ishbone (Ishikawa) diagram with regularity? Do you have 10 minutes, 4 times/year to do an interesting QI case? o Do you have unit based clinical leadership teams? o Milestones meetings Relection? o Simulation—Procedural training

FIGURE 2. Brief outline of the facilitator guide used for the workshop.

occurred immediately following the workshop. A summary of the findings was then shared with the APDS task force for open comments before dissemination to the participants. After incorporating comments, workshop findings were distributed to participants via e-mail. In addition, participants were provided with the Quality Improvement Proposal Assessment Tool and a primer on the available courses from the Institute for Healthcare Improvement.9

RESULTS There were 26 participants in the workshop; 17 (65%) of them were program directors/assistant program directors, 2 (8%) were identified as directors of educational affairs, 1 (4%) was a chairman, and the remainder were faculty/ attending surgeons (6/26, 23%). Overall, 4 specialties were represented (general surgery, orthopedics, urology, and family medicine). There were no residents who attended as participants. Additionally, university-based (12, 46%), hybrid (8, 31%), and independent (6, 23%) programs were represented. Program size ranged from 2 to 10 categorical surgical residents per year, and program length ranged from 5 to 7 depending on the incorporation of research time. A list of “barriers” to the adoption of QI education was generated. Several common themes emerged, and included lack of resident interest/buy-in, an unavailability of data to share, concerns over the availability of educational resources (i.e., limited time to devote to QI), difficulty in identifying the “teachable moments,” lack of departmental leadership focus or interest in QI, and a limited QI knowledge amongst surgical educators. These themes were present Journal of Surgical Education  Volume ]/Number ]  ] 2015

regardless of hospital size, and were, in general, present regardless of the degree to which QI was already beginning to be implemented in programs. Owing to the ongoing discussion and active participant engagement, the decision was made to forgo the scheduled large group debrief and pursue the distribution of summary information and resources to participants via e-mail. In response to this discussion, the task force offered 3 approaches to overcoming these barriers. 1. Identify data to engage the residents: Data exist in each health system and should be used to stimulate resident interest in QI. The data does not have to be specific to residents to interest them, but it should have comparison to peers. For example, use the hospital compare website (http://www.medicare. gov/hospitalcompare) or any claims data set to show how your group performs compared to your peer institutions. Alternatively, show identified or deidentified data on individual providers for measures that you are targeting within your sponsor hospitals. 2. Make time within your current educational framework: Remove lectures that are low yield and add 2 to 3 QI lectures to start. Make the “lectures” case based using examples from your institution. Add an interesting case to morbidity and mortality conference that highlights the QI process instead of the disease process. In addition, change your Morbidity and Mortality presentation format so that the residents incorporate a QI tool or approach into the presentation (like the Plan-Do-Study-Act cycle or the Ishikawa [Fishbone] diagram). 3. The Institute for Healthcare Improvement open school is a great resource for generic (i.e., non– surgery specific) education on QI. The link to the website is: Starting with non–surgeryspecific information is very useful to get to know the very basics of QI, to understand the mindset of QI strategy, and to help you think outside the box regarding the utility of QI. Understanding the basics will build the important groundwork needed to translate QI strategies nto surgery.

DISCUSSION Recent changes in the delivery of surgical care along with the new accreditation system have necessitated the development of QI education programs across surgical specialties. Participants enrolled in the workshop to learn how to overcome barriers in their home institutions and to identify existing resources to teach residents about QI. On workshop completion, participants from a variety of different program types returned to their home institutions with 2 new concrete strategies for implementation. 3


3 Easy Steps to Get Started Step 1: What will you use to “kick start” QI educaon in your program? • • • • • • • • • • •

Interesng QI case presented at M&M Share YOUR instuonal quality infrastructure and goals Highlight the role of house staff in the process Provide regular progress reports throughout the year Review YOUR INSTITUTIONAL outcomes data Discuss the approach to measurement and quality improvement Embed Housestaff into UBCL/CUSP Resident parcipaon in RCA Resident parcipaon in QI Projects Milestones PD Meengs should include REFLECTION Add Timeout to Simulaon Training/Procedural Training o 1.__________________ o 2.__________________

Step 2: How will you incorporate these? • • • •

Who do you need in your team to accomplish this? Who are the stakeholders? What are the barriers to implementaon? Does your infrastructure support this iniave? When will you start?

Step 3: Do it! • •

• •

What QI tools can you use? Visualize the “future state” o What does resident educaon look like with this iniave in place? o Is it well received? What would make it sck with your audience? o How does everyone benefit? Assess How is it going? Start at Step 1 and do it again!

M&M-morbidity and mortality; UBCL-Unit Based Clinical Leadership; CUSP-Comprehensive unit-based safety program; RCA-Root cause analysis; QI-Quality improvement.

FIGURE 3. Participant guide provided to workshop attendees. It provides a template for incorporation of QI education.

Through group discussion, participants quickly realized that though the implementation of a robust QI program within the existing educational paradigm may take years, resources exist to facilitate resident engagement in discrete steps. With the introduction of the Accreditation Council for Graduate Medical Education milestones, the task seems less arduous than previously presented. Not all residents must achieve a level 4 (Fig. 1) in each milestone to become a surgeon. As such, the goal of the QI education must shift from each resident completing a QI project to each resident recognizing opportunities for improvement for every patient, every day, while learning to understand measurement and metrics for the assessment of the quality of care provided to surgical patients.

A lack of formally trained quality scientists exists across all program types and variable resources across institution types pose a substantial barrier to the adoption of QI education into the curriculum. In many cases, programmatic success has been easier to achieve with a faculty and resident pairing rather than through the targeted identification of an expert faculty member alone. Using the workshop as an example, the inclusion of faculty and resident facilitators readily demonstrated the particular expertise that can be lent by surgical trainees. Although broad QI education modules exist, surgeryspecific materials are still under development. Recently, the American College of Surgeons National Surgical Quality Improvement Program—Quality in Training Initiative


Journal of Surgical Education  Volume ]/Number ]  ] 2015

Building a Quality Improvement Educaon Team

Quality Team Member

____ Name____________

*NSQIP-Naonal Surgical Quality Improvement Program

FIGURE 4. Identification of key stakeholders in the integration process is crucial to the successful implementation of QI education into the existing educational infrastructure.

launched a QI Primer designed to help with this challenge.10 The Practical QI Primer provides surgical trainees with the background necessary to participate in QI and to understand the current health care delivery environment and its implications on surgical care. As adult learners, residents and faculty alike should be encouraged to use these resources to expand their knowledge in areas not traditionally taught. Resources available for the implementation of a QI program vary by program size and structure. In recognition of this fact, participants were divided based on structural elements of their program (i.e., size and affiliation). This design was useful in helping participants identify strategies for implementation suitable to their local environment via the sharing of common barriers and the brainstorming of specific strategies. For example, a program director from a small independent residency program participating in the National Surgical Quality Improvement Program had not realized that resident-specific reports could be generated outside university-affiliated programs. Workshop success is often predicated on engagement of participants. In this case, the tremendous enthusiasm and constructive discussion among the small groups exceeded the expectations of the organizing members. As such, flexibility in the design of the workshop can be helpful. We were able to accommodate a more lively discussion and plan for postworkshop outreach and resource sharing because we had gathered all of the contact information at the beginning of the session. Built-in flexibility can enable workshop facilitators to better meet the needs of participants. In addition, the utilization of a participant handout

allowed participants to take notes in structured fashion—so that even though no formal debrief occurred, participants left with a tangible, personalized summary. Ideally, while a short wrap up at the conclusion of the session may leave participants feeling more satisfied, participants in this case were content with an electronic debriefing. For future workshops, facilitators should be cognizant of collecting important contact information so that the flow and discussion of the workshop can be modified accordingly and follow up information can be distributed. Surgical quality has improved substantially over the last century. To continue to make surgery safer and ensure optimal patient outcomes, surgical educators must teach each resident to adopt quality science methodology in a meaningful way. The QI concepts are fundamental to the discipline of surgery; we must simply learn to articulate them.

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ACKNOWLEDGMENTS We would like to acknowledge Keith Delman, MD, and Rajesh Aggarwal, MD, for their support to the program and contributions to workshop development.

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Journal of Surgical Education  Volume ]/Number ]  ] 2015

The Educational Toolbox: Kick Start Your Educational Program in Quality Improvement.

To disseminate materials and learning from the proceedings of the Association of Program Directors 2014 Annual Meeting workshop on the integration of ...
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