Quality improvement and patient safety (QIPS) have evolved tremendously since the start of the “quality movement” in the United States after the release of To Err is Human in 2000 by the Institute of Medicine (IOM, now the National Academy of Medicine [NAM]).(1)
Effective prevention strategies for hospital-acquired infections have become prioritized in nearly all hospitals, computerized clinical decision support for ordering medications has reduced the rates of adverse drug events, and surgical checklists have decreased the rate of adverse events and mortality.(2) Significant opportunities for improvement remain. Establishing a culture of quality and safety is paramount to continued advancement, which requires education in QIPS throughout the continuum of medical education.
Fostering this culture in the emergency department can be challenging, but it is necessary. Emergency physicians practice in a unique high-volume, high-acuity environment with many unknowns and must make quick decisions with limited information. Consequently, policies and practices that minimize provider practice variability and standardize emergency care have repeatedly shown to improve patient outcomes.(3-5)
As the healthcare industry moves to focus more heavily on utilization management, we must recognize that decisions made in the emergency department often determine a patient’s course of care, and that meaningful change must begin at triage. Incorporating QIPS into post-graduate medical training is a sensible approach to accomplishing cultural change.
In 1999, the Accreditation Council for Graduate Medical Education (ACGME) established the six domains of clinical competency to be used by all EM programs to assess resident performance. Among these competencies is “Practice-based Learning and Improvement,” in which “residents must demonstrate competence in: …‘systematically analyzing practice using quality improvement methods, and implementing changes with the goal of practice improvement.’ ”(6,7)
Additionally, the Association of American Medical Colleges (AAMC) launched the series “New and Emerging Areas in Medicine.”(8) This series of competencies focuses on the latest changes in healthcare and serves as a guide to developers of curricula in medical education. QIPS, the first of these competencies, encompasses the following five domains: patient safety, quality improvement, health equity in QIPS, patients and families as QIPS partners, and teamwork, collaboration, and coordination.(8)
The AAMC provides a roadmap for medical educators, outlining progressively more advanced goals for three tiers of physician development: entry to residency or recent medical school graduate, entry to practice or recent residency graduate, and experienced faculty physician or three to five years post-residency. This framework is intended to facilitate, in a coordinated manner, a common language in QIPS among healthcare providers in training, with the goal of enhancing systems-based practices and prioritizing patient safety. Non-clinical professional organizations also offer QI development courses and assessment tools for interested participants; however, these are not commonly incorporated into residency curricula.(9,10)
In response to efforts made by the AAMC and ACGME to promote a culture of quality improvement in medicine, some residency programs have developed their own QI educational programs.(11-17) Systematic reviews, however, conclude that these efforts have mostly been for doctors in training outside of the ED setting and have variable levels of success in improving understanding of QI methodology and generating meaningful change in the workplace.(18-21) In fact, there is an overall lack of formal teaching on the subject matter in emergency medicine residency training.(22,23)
Fortunately, emergency medicine residents have indicated a strong desire for increased QIPS teaching.(24) Evidence has shown that when a formal QIPS curriculum is initiated, emergency medicine residents have gained comfort and confidence in designing and conducting quality improvement projects.(25)
Because no national standard curriculum exists for training EM residents, we introduced a novel resident-led QIPS curriculum in an EM residency to meet the education requirements stated above and to prepare our residents better for changes that are taking place in our current healthcare environment. We believe this curriculum is particularly effective in training EM practitioners and can be instituted easily at any academic institution.
Methods
The NewYork-Presbyterian Emergency Medicine residency is a four-year academic program with 12 residents enrolled per year. Residents work at two New York City quaternary care centers: Columbia University Irving Medical Center in Washington Heights and Weill Cornell Medical Center on the Upper East Side, both in Manhattan. Since 2013, our residents have participated in two yearly conferences titled “Quality and Patient Safety Theme Days” lasting four hours each, during which a mock root-cause analysis (RCA) is performed within the program. To supplement these conferences and provide residents with a more robust and comprehensive educational experience, a broadened QI curriculum was created and implemented.
A resident-led QIPS Council was first synthesized by a Quality Improvement Champion resident and by QI leadership. This council included managerial representatives from nursing, advanced practice providers (physician assistants and nurse practitioners) and pharmacy, all of whom would serve as co-process owners of and contributors to all quality initiatives. An assembly of ED quality leadership, including the director of quality assurance and the vice chair of quality and patient safety, with the support of the residency program director, then defined the scope and expectations of the council and the educational intervention it would provide to the residency.
Curriculum didactics (Table 1) were developed by the QIPS Council based on subject material offered by the Institute for Healthcare Improvement (IHI) Open School program and online NewYork-Presbyterian (Enterprise) Quality Assurance education modules required for all employed quality managers.
A grassroots effort was made to recruit residents who were interested in learning more about EM quality outcomes and performance measures. Enrollment in this curriculum was purely voluntary; this was a novel curriculum for our program that greatly exceeded the ACGME and AAMC baseline requirements for QPS education. Participation was, therefore, not used by residency program administration to evaluate participants in any way.
Initial recruitment efforts took place over six months during conferences and on shift by word of mouth. Given the extent of residents’ existing educational and clinical demands, we were elated that nearly half of our residents showed interest in participating.
The quality improvement champion lectured participants individually at a time fitting their schedules to encourage high-quality interactions and discussion, while concurrently creating a low-stress, distraction-free environment. Through the QIPS Council, residents were able to apply their knowledge of QI fundamentals toward participation in QI projects either underway or in development.
Finally, residents were assisted in publishing their findings at local and regional conferences. This QI curriculum was instituted during one academic postgraduate year between 2020 and 2021.
Curriculum
Residents were first presented with Session 1 and Session 2 didactics (Table 1). They were then given a printed “Quality Improvement Guidebook” to reinforce lessons learned during these initial didactic sessions. The guidebook outlines an 11-step process of completing a quality improvement project beginning with the identification of a clinical concern, followed by how to create project-specific process maps and fishbone diagrams (with associated instructions for using free online chart templates), and how to gather and analyze data using Pareto and Run charts.
EM residents with this knowledge of QI fundamentals were subsequently offered the chance to become involved centrally as resident lead, or peripherally, as support staff in available departmental and/or enterprise-wide quality initiatives. Initiative topics were driven by resident interest and department needs and supported by faculty process owners. All projects were metrics-driven and focused on quality issues spanning topics from the need for clinical documentation improvement to the development of new comprehensive practice protocols (Table 2).
Resident involvement in QPS projects provided a real-time opportunity to see how QI fundamental principles are incorporated into active healthcare change processes and were not meant to provide a measure of curriculum efficacy. As residents advanced in their projects, they were given didactic Session 3 to provide them a better understanding of how and why certain projects are decided upon (Table 1).
Didactic Session 4 was provided for those residents whose projects had advanced to the data-gathering and analysis phase (Table 1). Residents were then encouraged to submit their findings to local, regional, and national scholarly conferences.
Mock RCA
Beginning in 2013, a mock RCA session was introduced to the residency program. This inaugural curriculum helped address EM-specific milestones for quality and patient safety that had been introduced by the ACGME at around the same time. The RCA session consisted of a four-hour conference day devoted to the demonstration of a medical case review from multiple stakeholder perspectives. It was meant to address points of view from nursing, EM providers/physicians, consulting services, laboratory, and radiology. The mock RCA session continues to supplement the QI curriculum.
During this mock RCA, residents, rotating students, and other learners are divided into groups, each with a faculty mentor. Each group spends time reviewing the mock medical record, creating a timeline of events related to the stakeholder point of view, and developing a list of areas of concern and corrective actions for those concerns.
For each small group, other mentors such as quality leadership for nursing, pharmacy, etc., may also participate. These mentors provide the stakeholder perspective when it is not easily identifiable from the medical record. They also provide further information on what the standard of practice is for that role. Each group nominates a spokesperson to participate in the mock RCA, which is moderated by quality and patient safety leaders.
The mock RCA portion lasts approximately one hour with a culture-only focus on system issues rather than on individual provider or clinician issues. After the system issues have been discussed, the group works to develop a corrective action plan to improve the system. All learners are asked to observe this part of the conference day, even when they are not the spokesperson for their small group.
A debrief at the end of the session asks learners to provide an educational takeaway that they will use moving forward in clinical care. The corrective action plans are then used to develop QI projects with resident involvement. An example case can be found here: https://www.cordem.org/globalassets/files/curricular-toolkit/root.cause/rca.instructors.guide.pdf .
Grading
There is no formal grading component to this curriculum, however, it is mandatory that all EM residents participate in some quality improvement education to meet ACGME requirements and successfully graduate from the residency program.
Assessment
We obtained a Weill Cornell Medical Center Institutional Review Board exemption from formal review (45 CFR 46.104 (d)(2)) based on the fact that our human subjects research was survey-based and anonymous.
Before implementing our curriculum, we administered an anonymous written questionnaire to all interested residents. This survey was used to assess any prior QI training and residents’ attitudes toward QI fundamentals. Residents were asked whether they had ever participated in a formal QI curriculum, if they had completed the Institute for Healthcare Improvement (IHI) online Open School quality improvement modules, and if they had ever participated in a QI project.
Residents were asked to rate their comfort with implementing basic QI methodology, including networking, constructing process maps and fishbone diagrams, writing problem statements, and developing structured plans to make change. They were also asked to rate their comfort regarding applying the plan-do-study-act (PDSA) cycle, choosing outcome measures, and analyzing data.
As an adjunct to the above survey, the Quality Improvement Knowledge Application Tool Revised (QIKAT-R) was administered to assess residents’ ability to apply QI processes to clinical scenarios relevant to EM.(26) The QIKAT-R is a modified version of the QIKAT tool, an instrument developed in 2003 to provide a rudimentary measure of QI skill.(26) The QIKAT, however, was shown to provide inconsistent reliability, and in 2014, the QIKAT-R was published. The revised scoring system was more user-friendly, with improved inter-rater reliability, and has since been validated as a tool to differentiate between excellent and poor responses, and therefore the ability to discriminate skill capability.(26)
The QIKAT-R gives survey-takers three clinical scenarios, each of which offers a pertinent quality problem. For our purposes, three pre-written EM-relevant topics were chosen: Scenario 2 “Emergency Department,” Scenario 5 “Admissions,” and Scenario 6 “Orthopedic Surgery.” For each scenario, residents were asked to develop a hypothetical program to investigate and improve each scenario problem. They were then given three questions: What would be the aim? What would you measure to assess the situation? And finally, can you identify one change that might be worth testing? Each case is complex, allowing for multiple possible full-credit responses.
The QIKAT-R includes a standard grading rubric meant to determine pre-post assessment, rather than a pass/fail metric. A potential of zero to three points is awarded for each response. A “poor” response to a question generates only one point. If the response fails to adequately address the question, zero points are awarded. A maximum of three points (corresponding to an “excellent” response) may be awarded for each answer. There were nine questions in total, yielding a maximum total of 27 possible points (nine points possible for each scenario).
The post-curriculum survey and QIKAT-R were administered to each resident within a minimum of six weeks after completing the QI curriculum, thus ensuring retention of the subject material. Pre-curriculum survey results were compared to post-curriculum survey results to measure improved understanding and skill in applying QI concepts. The same QIKAT-R scenarios were presented in both surveys, which ensured consistency throughout the learning process.
Statistical Analysis
Eighteen residents volunteered to participate in the study and complete the QI training. The QIKAT-R was distributed to all 18 residents, both before and after the curriculum. Questions concerning resident year and experience with QI were reported as frequencies. Differences between pre- and post-intervention surveys among these responses were found using Fisher’s exact test.
Likert scales were used to gauge resident attitudes toward QI processes and their comfort level applying them (1 = Very Uncomfortable, 2 = Somewhat Uncomfortable, 3 = Neutral, 4 = Somewhat Comfortable, and 5 = Very Comfortable). Responses were reported as means and standard deviations. A maximum of nine points were awarded for developing three “excellent” aim statements, nine points for three “excellent” measures statements, and nine points for three “excellent” tests of change.
These results were aggregated and averaged for all residents and were reported as means, standard deviations, and average score change after intervention (with 95% confidence intervals). Differences between pre- and post-intervention surveys among these responses were found using t-tests. Results are reported at an α = 0.05 significance level. Analysis was performed using Rv4.1.1.
Results
Eighteen out of 48 active emergency medicine residents (18/48, 38%) volunteered to participate in the study and survey. Two residents who volunteered to participate in the study and complete the QI training were in the Post-Graduate Year (PGY) 1 class, two residents were in the PGY2 class, seven residents were in the PGY3 class, and the remaining seven were in PGY4 (Table 3).
Before this curriculum, two (11%) of these residents had prior QI training. None (0%) had completed part or all of the IHI online modules (Table 3). One person (6%) had previously participated in a QI project (Table 3). Seventeen (94%) of these residents believed it was important to be able to make measurable improvements in their professional workplace, while 100% agreed after participating in the QI curriculum (Table 3).
Responses concerning resident attitudes and comfort level toward QI processes increased between pre- and post-curriculum assessments (p = 0.012 for networking and team building; p < 0.001 for all other responses) (Table 3).
Before receiving the QI curriculum, residents scored on average 2.2/9.0 (min 0, max 5) points for all three aim statements; 5.4/9.0 (1, 9) points when attempting to determine an appropriate measure; and 4.2/9.0 (0, 8) points for deciding on a test of change (Figure 1, Table 4). Out of a possible 27 points, residents taking the pre-curriculum QIKAT-R scored on average 11.8 (4, 20) points for three scenarios combined. After receiving the QI curriculum, residents scored on average 8.6/9.0 (min 7, max 9) points for all three aim statements, 8.1/9.0 (4, 9) points when attempting to determine an appropriate measure, and 8.1/9.0 (6, 9) points for deciding on a test of change (Figure 1, Table 4).
Figure 1. Average QIKAT-R Scores of EM Residents Pre- and Post-Intervention: Using the QIKAT-R tool, residents were assessed on their ability to describe the three major elements of the Model for Improvement — Aim, Measure, and Change — for three clinical scenarios. For each of the major elements, the maximum score is nine (three points for each scenario). QIKAT-R scores were measured before residents participated in our QI curriculum (Pre) and after completing the curriculum (Post). Error bars represent one standard deviation. (QIKAT-R - Quality Improvement Knowledge Application Tool Revised, QI = quality improvement)
Out of a possible 27 points, residents taking the post-curriculum QIKAT-R scored on average 24.8 (19, 27) points for all three scenarios for an average improvement of 13 points overall (Table 4). Significant increases were seen between pre- and post-curriculum measures for all response categories, as well as for all three responses combined (p < 0.001 for all) (Table 4).
Through this one-year curriculum, all participating EM residents were involved in nearly a dozen published departmental and enterprise-wide projects with varying levels of participation. For all projects, one resident was assigned the designation of “resident lead.” As many as three additional residents were involved in each project, with some residents involved in multiple projects at once.
Responsibilities of the resident lead included maintaining regular communication with all members of the project to adhere to timeline objectives, formulating PDSA cycles for implementation, and disseminating initiative goals to the residency. Resident leads worked closely with faculty process owners in all stages of initiative development to gain experience navigating administrative and cultural challenges. For each project, involved residents applied their understanding of QI fundamentals by developing fishbone diagrams, creating process maps, establishing SMART goals and aim statements, and analyzing data.
72-Hour ED Return Visits with Admission (RVA) Initiative
The initiative created a monthly case review program in which providers review patients who have returned within 72 hours of discharge and are subsequently admitted at the return visit. Reviews use a standard template for easy data abstraction, allowing for rapid identification of potential quality issues, trends in returning patients, and opportunities for improved discharge planning.
Catheter-Associated Urinary Tract Infection (CAUTI) Workgroup
The workgroup made improvements in inpatient indwelling urethral catheter (IUC) placement by developing and implementing best practices, including revision of indication and insertion guidelines, reinforcement of catheter care (improving IUC process of securement, placement, and labeling), standardization of maintenance and removal, as well as urine culture and antibiotic stewardship.
Super High Utilizer (SHU) Initiative
A SHU care plan initiative bundled with IT alert notifications to frontline teams has promoted interdisciplinary collaboration and established tailored actionable interventions for SHUs based upon their individual modifiable factors (behavioral issues, absence of longitudinal care, etc.).
Type and Screen / Transfusion Reaction Risk Reduction
This group created and implemented provider and nursing education tools, adjustments in electronic medical record (EMR) ordering sets, and hard stops in specimen labeling to reduce risk of fatal blood transfusion reactions.
Resident Charting Improvement Program (ChIP)
Established by the ChIP initiative, a HIPAA-compliant survey tool used by residents to critically assess the appropriateness of ED provider documentation from the perspective of admitting physicians and consultants, the legal defensibility of the medical encounter based upon the documented reasoning for treatment (or lack thereof), ED coding best practices by considering the necessary elements of meaningful and thorough medical decision making while maximizing reimbursement. Monthly online documentation training and take-home points are included in the initiative.
Geriatric Trauma Protocol
A novel geriatric trauma protocol for a level 1 trauma center with a unique focus on stabilization and initial assessment established a checklist that ensures point-of-care laboratory studies and procurement of emergent electrocardiogram are performed before imaging, thereby reducing the risk of missed/prolonged critical diagnoses.
OB-GYN Protocol
A novel ED treatment protocol for patients with a positive pregnancy test and no signs of a definitive intrauterine pregnancy or potential ectopic pregnancy on ultrasound, the OB-GYN protocol used factors such as clinical symptoms, stability, laboratory b-HCG levels, and imaging results to divide patients into cohorts requiring emergent gynecology consult, urgent gynecology consult, or placement on a Beta HCG list with expedited secured outpatient follow up.
Antibiotic Stewardship Initiative
This initiative developed ED EMR antibiotic order sets compliant with national and internal guidelines to improve ED provider compliance with prescribing practices based on local antimicrobial patterns. Compliance is monitored by on-site ED pharmacists with real-time individualized feedback to reduce adverse events, treatment failure, and antimicrobial resistance.
Opioid Stewardship Initiative
Opioid prescribing protocols and treatment pathways were created to increase ED provider compliance with guideline-based opioid prescription practices and to reduce opioid orders and prescriptions at ED discharge.
Guidelines include risk assessment tools for targeted disease states, review of state prescription drug monitoring programs, instruction in how to use naloxone (Narcan) and provision of a kit, and talking points for adverse events with respect to opioid misuse. Treatment pathways included non-opioid and multi-modal therapies, discharge prescription recommendations, and empathetic talking points with expectation setting.
Discussion
The resident-focused curriculum has been an overall success as shown by improved EM resident knowledge, attitude, and practice surrounding quality and patient safety. The curriculum framework successfully engaged residents in active QI projects and produced many scholarly projects. We believe this curriculum is distinctly appropriate for EM residents in that it provides personal and succinct, yet comprehensive initial didactic sessions followed by immediate resident involvement in QI projects with staggered timelines that fit the labile schedule inherent to EM residency programs. Furthermore, because this curriculum is resident-led, it offers opportunities for project ownership, leadership, and interpersonal skills development consistent with values shared by all post-graduate training programs.
Several primary characteristics added to the feasibility of this curriculum that may not be generalizable to all programs. First, the recruitment effort to attract interested residents was without incentivization beyond the intrinsic value of personal and professional development; therefore, we were fortunate to find as many highly motivated residents to undergo this level of QI training and project involvement.
Second, we are fortunate to have a strong administrative QI leadership team with years of experience in process improvement who were comfortable guiding a resident-led QIPS Council and who could uphold and maintain resident-led projects. Third, residency program and departmental goals were aligned in this instance, allowing for a durable foundation upon which this curriculum was created and operated.
We recognize that there may be several limitations to our educational intervention. First, this was a single-center study with a curriculum that was implemented in one residency program with considerable QI resources and faculty. It may be more difficult to implement in other EM residencies of shorter duration or those with fewer resources or specialized staff.
Second, our residents volunteered to participate in this curriculum and expressed a sincere desire to become involved in projects, indicating that our cohort may have been biased toward those interested in QI. This may not be representative of all EM residents, and therefore it may produce different educational and productivity outcomes if implemented elsewhere.
Third, there was no control group against which we compared survey outcomes. Rather, it must be assumed that a control group of residents who had undergone no formal QI curriculum would have no improvement in understanding of QI or ability to apply its methodology.
The implementation of this pilot curriculum helped nearly half of the residency program develop foundational skills in quality improvement. The QI curriculum teaches foundational skills in quality improvement and project management, both of which are immediately applicable to all fields in medicine and essential for career development during all stages of training and practice.
The QI curriculum is also easily adaptable to the medical student level and fits with the national education trend toward moving quality improvement into earlier phases of physician training. Various other medical departments within our enterprise have since reached out to the project team to learn about developing a similar curriculum for their trainees as well.
The residents were able to translate their initial didactic learning into practical projects that spanned multiple disciplines. These projects continue to have a meaningful impact on the care delivered to patients in our emergency departments and across the hospital enterprise. The experience of combining fundamental project management competencies with practical QI projects in the emergency department provided these residents with a toolkit that will serve them well as future leaders in the field of emergency medicine.
The program also fostered an excitement among other trainees who were not initially involved in this curriculum; as a result, there has been a substantial interest among remaining residents in participating in operational, quality, safety, and other department initiatives.
While this was piloted with a core group of residents, there are future opportunities to make this a standard component of the residency curriculum at NewYork-Presbyterian Hospital. Junior faculty, particularly those with operational and other leadership aspirations, would also be well served to participate in this curriculum. We believe the skills our residents honed are fundamental to the practice of medicine and are core leadership competencies that fit with our mission to train tomorrow’s leaders in emergency medicine.
Conclusion
This study reports the successful pilot of a comprehensive QI curriculum for a group of emergency medicine residents that resulted in several successful QI projects with measurable results, demonstrating the feasibility of this approach in developing fundamental core competencies that ultimately translate into impactful clinical change.
Acknowledgments: We thank the following people for their significant support and contributions to this manuscript: Maryam Zaeem, PharmD, BCPS; Peter A.D. Steel, MA, MBBS; Christopher Hennessy, MD; Neil Bhavsar, MD; Dubem Okeke, MD; Emily Benton, MD; Kessiena Gbenedio, MD; Zachary Freedman, MD; Paula N. Marin-Acevedo, MD; Bill Zhang, MD.
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