Not so basic training

Quality improvement has become a key part of residency training

By: April Lacey

As a medical student, San Chang, M.D., attended lectures on medical errors, quality improvement and patient safety. But it wasn’t until he started his residency in psychiatry at UF Health and was assigned to tackle a quality improvement project that he began to grasp what the term truly meant.

“Coming into residency, you think if you know your science and make the right medical decisions, that is all you have to do,” said Chang, now in his last year of residency and serving as a chief resident in the College of Medicine department of psychiatry. “Over time, you realize there is a lot more to it. There are a lot of things that affect the patient every day — how you communicate, your computer systems … There is an additional layer of complexity and things you need to be aware of to take good care of people.”

San Chang, M.D.

San Chang, M.D.

For residents, entry into residency means not only learning the ins and outs of their chosen specialty, but also becoming a crucial part of a health care team. Ensuring residents understand the myriad things within a health care system that can affect a patient’s care — and that they can effect the change needed to make improvements — is vital, which is why UF Health leaders have increased the focus on it in recent years.

Not only are individual residency programs focused on quality — typically involving residents in quality improvement projects and holding annual events centered around quality and patient safety education — the College of Medicine Graduate Medical Education Office has launched several measures to ensure that quality improvement and patient safety are integral parts of residency training across the board.

“Improvement of the quality of patient care has always been an integral part of the practice of medicine, but it is only relatively recently that we have recognized the need for a structured, disciplined approach to the evaluation of quality measures,” said Lisa Dixon, M.D., who was recently appointed associate dean of graduate medical education in the College of Medicine. “It isn’t until we pause, reflect and investigate that we identify the changes that can positively impact the care we deliver.” 

Most notable among these efforts is the Housestaff Quality and Patient Safety Committee, established two years ago as a way to bring more residents into the quality and patient safety fold. Currently led by Lee Titsworth, M.D., Ph.D., chief resident in the College of Medicine department of neurosurgery, the committee consists of residents representing nearly every UF Health residency program. The committee meets regularly to discuss systemwide quality and patient safety initiatives, information which they then share with the other residents in their programs.

Lisa Dixon, M.D.

Lisa Dixon, M.D.

“The committee communicates with the institutional quality group so that patient safety and quality goals are aligned across UF Health,” said Michael Mahla, M.D., former director of graduate medical education in the College of Medicine.

In addition, all residents are now required to complete modules from the national Institute for Healthcare Improvement as well as training to help them better teach other residents and medical students.

These focused efforts are making a notable difference in residents’ understanding of the role of quality improvement in health systems. This year, the Accreditation Council on Graduate Medical Education — the governing body for medical residency in the U.S. — released the results of a Clinical Learning Environment Review conducted at UF Health last fall. It was the first time ACGME has conducted such a review, and the findings were promising, said Cristin Owens, manager of housestaff affairs in the Graduate Medical Education Office.

“Overall, they were really impressed with the housestaff’s and nurses’ knowledge of what is going on [with quality and patient safety],” Owens said. “They were very happy with resident and fellow engagement. They are not disconnected from quality efforts.”

Given residents’ busy schedules, loaded with clinical and teaching obligations, taking the time to become involved in quality improvement efforts may seem like too much to take on, but the projects themselves actually can help improve processes and make them more efficient — ultimately saving time, said Andrew Pierce, M.D., a second-year resident in the College of Medicine department of psychiatry .

Pierce and Chang, who serves on the Housestaff Quality and Patient Safety Committee, are both part of a quality improvement project linked to improving patient handoffs within psychiatry. The project is part of a larger, systemwide initiative to make patient transitions through the hospital system smoother and more efficient.

“This is a chronic, nationally studied issue,” Pierce said. “During handoffs, a lot of information can get lost. That is something the hospital as a whole has recognized. We are focused on how to best implement change within our program. As you can imagine a surgeon sign-out is different from a psychiatrist’s sign-out. One of the benefits to having residents involved in this project is we really understand from the beginning how this will affect our daily workflow.”

And although time is a factor for residents, Chang feels residency training would not be complete without an emphasis on quality and patient safety.

“It is very important for residents to be exposed to quality improvement and patient safety, otherwise we would leave with an incomplete view on how to give the best care possible,” he said. “If you are working in the clinic and see a problem, we have to make sure we don’t make that mistake again. We have to decide what the problem is and follow up and implement changes. It’s not just ‘We won’t do that again.’”

There are still some opportunities for improvement, namely getting residents more involved in filing patient safety reports and getting experience participating in root-cause analyses, which try to ferret out the processes that need to be improved to solve a problem.

Jacqueline Hobbs, M.D., Ph.D.

Jacqueline Hobbs, M.D., Ph.D.

Jacqueline Hobbs, M.D., Ph.D., director of the psychiatry residency in the College of Medicine, has included quality and patient safety as a major part of her program for several years. And each year, the caliber of the residents’ quality improvement projects improves, she said. Across UF Health, residents have worked on various quality improvement projects such as creating electronic reminders for medication prior to surgery, improving hand hygiene and establishing a wellness protocol for psychiatric patients.

In addition to helping the health system as a whole, residents’ involvement in quality efforts can also help them in their careers, Hobbs said.

“If they put down on their CV that they have had experience in quality improvement and patient safety, that can catch the eye of an employer,” she said. “It puts them in a position to do something in their career and get them to a level they never imagined.”