Hope lies with the residents

I remain relatively new to the health care field, but even in that short time, it has become evident to me that the pace of quality and safety enhancements and front-line driven process improvement in hospitals is inadequate given the scale and scope of harm that occurs to patients.  Indeed, it can be viewed as a paradox that the doctors of America, a group of dedicated, well-intentioned, intelligent, and highly trained individuals, constitute one of the top-ranked public health hazards in the county when as they work together in the nation’s hospitals.  That they collectively have not made much of a dent in the problem of reducing harm is, I believe, a product of their training.

As Brent James, Jay Kaplan, and others have noted, doctors are trained to be artists, to apply their intellect, creativity, intuition, and judgment to the care of each patient. That is well and good when the case is complex, but the vast majority of medical care is not complex.  It calls for standardization, adoption of protocols, and scientific experiments of process improvement to modify those protocols to enhance care and reduce harm.

The medical schools have, in great measure, ignored the science of process improvement in their training programs.  This failure of undergraduate medical education is unlikely to be remedied.  Those in charge of the curriculum taught in medical schools are inflexible in their conviction that their job is to teach biological science, not process science.  Some have said to me, too, that the topic of process improvement is just not that interesting.

And so it falls to hospital based education programs -- mainly graduate medical education for the residency programs and, to a lesser extent, clinical rotations for the undergraduate medical students -- to address this deficit.  I have lately started to see progress in this regard.  Much of it is driven by the residents themselves, for when they are presented with subject matter in this arena, they love it.  Back at BIDMC, for example, when we would conduct Lean training for residents, the response was often, “This is the best course I have taken during my medical education.”  Why?  For one thing, residents are motivated by the usefulness and practicality of what they are taught, and these subjects are incredibly useful and practical.

Beyond that, though, residents and students have come to understand that the study of process improvement is academically interesting.  It is based on the scientific method and is therefore intellectually engaging.  More and more of them are using the research phase of their training programs to investigate and then report on how better to incorporate training in this discipline into the GME program and the undergraduate rotations.

A paper along these lines, entitled “A Resident-Led Institutional Patient Safety and Quality Improvement Process,” by Jeremy Stueven and others from the University of New Mexico, was published on February 16, 2012, in the American Journal of Medical Quality.  The authors note:

Because residents and medical students have unique perspectives on patient safety and spend considerable time in the hospital, even under current duty hour limits, their inclusion in quality improvement activities is appropriate.

A mechanism to engage residents and students in quality improvement and patient safety that is effective, efficient, and does not add substantially to current educational requirements could be of great value from both an educational and a clinical quality perspective.

The authors then describe a four-year institution-wide process of resident and student engagement in quality improvement at UNM.  The process incorporated resident-generated surveys for prioritization of safety and quality issues, participation in large group retreats  and small workgroup meetings (like the session about which I recently wrote), and reassessment of progress using the PDSA methodology.  Here’s the key:

The educational theory of the project is based on social-cultural models that emphasize the importance of context to learning and the importance of participation and action toward problem solving to stimulate learning.  Residents were engaged in identification of safety problems and participated in problem solving with administrators, nurses, and faculty who are responsible for the quality of clinical care . . . and make up parts of the social and cultural context of the clinical care team. 

And look at the paper’s findings!

The collaboration and leadership of an interdepartmental group of residents addressing institutional issues associated with quality has the additional potential to identify themes in institutional quality that overlap and extend beyond departmental boundaries.  Such themes can drive priorities for institutional engagement and have a powerful impact on overall institutional quality and safety.

In other words, we start by teaching them, and it ends -- as education always does -- with the students teaching the faculty!

I hope to write more about this topic in the future, as it lies at the heart of progress in improving quality and safety in hospitals.  I invite residents and medical students to send me additional case studies, articles, or merely anecdotes in this arena -- whether those stories indicate progress or lack of progress -- so I can share them with the broad audience reading this blog.  Just leave a comment here with your contact information, and I will be back in touch.  Or join me on Facebook or Twitter, and I will also respond.