Thursday, March 01, 2012

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.


Allison said...

I wish I had a story to leave here, but I'm on medical leave from my M1 year and have limited experience. I do remain involved with a student run group called Open Source Medicine at Wayne State University School of Medicine ( Innovations to improve healthcare and implemented by students, or anyone in medicine, is exactly what we are all about. I'm looking forward to hearing the responses about improvement of quality and safety in hospitals.

Thanks for bringing Stueven's publication to my attention!

Anonymous said...

Paul, I would revise the quote below somewhat:

"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." urge that, instead of just being 'included', housestaff should be designated as the primary physician champions of these efforts, in collaboration with the other non-M.D. team members. For many reasons, they are in the best position and have the most passion to lead such efforts.

However, no effort will succeed unless a clear and unequivocal message is sent by the attending physicians and chiefs of service that this is priority work, and unless specific time is designated to accomplish it - not just a few hours here and there when they can spare it, or when they are off duty and should be sleeping.

That is where the leadership of the hospital, from the CEO to the Chief of Staff, absolutely must convey their expectation that this work be a priority. Otherwise, we are all spitting in the wind.

nonlocal MD

e-Patient Dave said...

First, I agree - time after time I find the greatest resistance to improvement comes from clinicians who are devoted to their "craft," as if medicine were like woodworking, where it's all about the artisan's expression. I love the art of medicine, but as you say, a lot is now understood to the point where art is no longer needed.

And yet, last year I worked with a large physician group where a major concern was that the physicians want their autonomy. I get that, but when there's so much evidence that other approaches work better - or are safer - then I'd say that autonomy is toxic.

Yet I empathize with people who were trained in that approach, got good at it, and must give it up. It reminds me of the people in my old profession, typesetting, for whom there simply isn't much work anymore - or, worse, younger inexperienced people have new skills that they don't.

And yes, when I participated in BID's Lean week a few years ago, I saw that residents were eager to learn & adopt new thinking.


> it ends -- as education always does --
> with the students teaching the faculty!

That might be a bit more precise if it said "as *good* education always does. I've seen plenty of cases where the education was one-way.

Including, I might add, most patient education... :)

dsblanchard said...

Dear Paul,

The statement that shouted out to me when I read this was

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

Teaching baccalaureate students in nursing, I have always found this to be true. In fact, my blog is about that very issue today.

After reading your blog for a year now, I know this will be meaningful to you. I hope you click on over. Nurses, like residents, are in the clinical setting all the time and, thus, have a powerful contribution to make in terms of the lean process.

Dawn Blanchard, PhD, RN

David Joyce MD MBA said...

The only education offered to residents in Maryland is personal finance delivered by a self interested financial planner or practice management. We have a company whose mission is to deliver MBA level business content in 3 hour packages to residents. These packages include strategic planning, finance, leadership and management, and process improvement. The residency directors, so far, do not want to spend money on this type of content and the residents are left to themselves to finance it. When surveyed we have found results similar to Chicago, residents want the information and feel it is a valuable use of there time to obtain it. Hope is not lost on this next generation.

Anonymous said...

An article from U. Minnesota medical school, written under the auspices of the Association of Professors of Medicine, notes that training in quality improvement and evidence-based medicine is now nationally required for residents by the graduate medical education accrediting body. The article notes several challenges in providing such education, but concludes:

"Medical education must be transformed. In the 20th century, science replaced clinical experience as the basis of medical practice. Now, systems thinking needs to be integrated into medicine. Students need to know that medical practice is a collaborative endeavor, requiring the input of many professionals working in systems that enable them to interact effectively."

Link is here:

With such training being a requirement since 2006, one wonders why further progress has not been made. Is the requirement not being enforced by the ACGME?

76 Degrees in San Diego said...

It is encouraging to see GME as a vehicle for professional improvement and patient safety. This entry values constructive healthcare culture; hope for the future.

KY said...

Paul, many thanks for your attention to this issue. I very much look forward to your future comments on the subject of integrating process improvement science into both undergraduate and graduate medical education. My circuitous path to medicine exposed me to a variety of other arenas prior to medical school (military, federal government agency, private & non-profit sectors). During four years of medical education, I've been shocked to see the lack of 'systems thinking' in almost every health professions training paradigm and clinical environment to which I've been exposed. I've been trying to read one-off papers about performance improvement, design thinking, 'lean' strategies, etc. on my own but would be greatly indebted if you could post or share any coherent, concise syllabi or core resources/ references which might constitute a "primer" or introduction to this subject. I've also been thinking about writing a paper on how these subjects might be integrated into a holistic view of emerging "medical professionalism" curricula - a subject often raised with negative, disciplinary connotations - and would be interested in your thoughts on this idea. I'll reach out via FB to continue the conversation.

Anonymous said...

Paul and readers:

I started teaching patient safety and human factors engineering to residents in 1987; continued with teaching medical, nursing, and pharmacy students from 1992-1999; and continued at Univ. Michigan since 2005.

ADVICE #1: do NOT wait for someone to create some "grand plan" or "integrated, top-down synergies". Just do it! Nursing and other allied health schools are often interested in guest speakers. Medical schools have relatively brief requirments for to offer patient safety "electives".

ADVICE #2: develop your ideas in the context of THEIR world. They already have adverse event stories from their friends, family, etc.

ADVICE #3: inspire through participation in re-design. This seems backward (putting "treatment" before "diagnosis"), but safety redesign group exercises are often so captivating that people refuse to leave for lunch

More can be heard/read at AAMC-IQ meetings (in fourth year),