Original Research

Teaching Quality Improvement to Internal Medicine Residents to Address Patient Care Gaps in Ambulatory Quality Metrics

Journal of Clinical Outcomes Management. 2023 January;30(1):3-8 | 10.12788/jcom.0119

Author(s):

Kinjalika Sathi, MD

Kristin T.L. Huang, MD

Daniel M. Chandler, MD

Stacy E. Schwartz, MD

Deborah Blazey-Martin, MD, MPH

Julie Tishler, MD

From General Internal Medicine, Tufts Medical Center, Boston, MA (Drs. Sathi, Huang, Chandler, Blazey-Martin, and Tishler), and Department of Medicine, University of Maryland Medical Center, Baltimore, MD (Dr. Schwartz).

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References

1. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). Approved June 13, 2021. Updated July 1, 2022. Accessed December 29, 2022. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf

2. Koh NJ, Wagner R, Newton RC, et al; on behalf of the CLER Evaluation Committee and the CLER Program. CLER National Report of Findings 2021. Accreditation Council for Graduate Medical Education; 2021. Accessed December 29, 2022. https://www.acgme.org/globalassets/pdfs/cler/2021clernationalreportoffindings.pdf

3. Liao JM, Co JP, Kachalia A. Providing educational content and context for training the next generation of physicians in quality improvement. Acad Med. 2015;90(9):1241-1245. doi:10.1097/ACM.0000000000000799

4. Johnson KM, Fiordellisi W, Kuperman E, et al. X + Y = time for QI: meaningful engagement of residents in quality improvement during the ambulatory block. J Grad Med Educ. 2018;10(3):316-324. doi:10.4300/JGME-D-17-00761.1

5. Kesari K, Ali S, Smith S. Integrating residents with institutional quality improvement teams. Med Educ. 2017;51(11):1173. doi:10.1111/medu.13431

6. Ogrinc G, Cohen ES, van Aalst R, et al. Clinical and educational outcomes of an integrated inpatient quality improvement curriculum for internal medicine residents. J Grad Med Educ. 2016;8(4):563-568. doi:10.4300/JGME-D-15-00412.1

7. Malayala SV, Qazi KJ, Samdani AJ, et al. A multidisciplinary performance improvement rotation in an internal medicine training program. Int J Med Educ. 2016;7:212-213. doi:10.5116/ijme.5765.0bda

8. Duello K, Louh I, Greig H, et al. Residents’ knowledge of quality improvement: the impact of using a group project curriculum. Postgrad Med J. 2015;91(1078):431-435. doi:10.1136/postgradmedj-2014-132886

9. Fok MC, Wong RY. Impact of a competency based curriculum on quality improvement among internal medicine residents. BMC Med Educ. 2014;14:252. doi:10.1186/s12909-014-0252-7

10. Wilper AP, Smith CS, Weppner W. Instituting systems-based practice and practice-based learning and improvement: a curriculum of inquiry. Med Educ Online. 2013;18:21612. doi:10.3402/meo.v18i0.21612

11. Weigel C, Suen W, Gupte G. Using lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013;28(5):392-399. doi:10.1177/1062860612474062

12. Tomolo AM, Lawrence RH, Watts B, et al. Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills. J Grad Med Educ. 2011;3(1):49-58. doi:10.4300/JGME-D-10-00104.1

13. Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: addressing core competency, improving systems. Acad Med. 2004;79(10 Suppl):S65-S67. doi:10.1097/00001888-200410001-00020

14. Essien UR, He W, Ray A, et al. Disparities in quality of primary care by resident and staff physicians: is there a conflict between training and equity? J Gen Intern Med. 2019;34(7):1184-1191. doi:10.1007/s11606-019-04960-5

15. Amat M, Norian E, Graham KL. Unmasking a vulnerable patient care process: a qualitative study describing the current state of resident continuity clinic in a nationwide cohort of internal medicine residency programs. Am J Med. 2022;135(6):783-786. doi:10.1016/j.amjmed.2022.02.007

16. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-1439. doi:10.1097/ACM.0b013e3181e2d0c6

17. Armstrong G, Headrick L, Madigosky W, et al. Designing education to improve care. Jt Comm J Qual Patient Saf. 2012;38:5-14. doi:10.1016/s1553-7250(12)38002-1

18. Hwang AS, Harding AS, Chang Y, et al. An audit and feedback intervention to improve internal medicine residents’ performance on ambulatory quality measures: a randomized controlled trial. Popul Health Manag. 2019;22(6):529-535. doi:10.1089/pop.2018.0217

19. Institute for Healthcare Improvement. Open school. The paper airplane factory. Accessed December 29, 2022. https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/PaperAirplaneFactory.aspx

ABSTRACT

Objective: To teach internal medicine residents quality improvement (QI) principles in an effort to improve resident knowledge and comfort with QI, as well as address quality care gaps in resident clinic primary care patient panels.

Design: A QI curriculum was implemented for all residents rotating through a primary care block over a 6-month period. Residents completed Institute for Healthcare Improvement (IHI) modules, participated in a QI workshop, and received panel data reports, ultimately completing a plan-do-study-act (PDSA) cycle to improve colorectal cancer screening and hypertension control.

Setting and participants: This project was undertaken at Tufts Medical Center Primary Care, Boston, Massachusetts, the primary care teaching practice for all 75 internal medicine residents at Tufts Medical Center. All internal medicine residents were included, with 55 (73%) of the 75 residents completing the presurvey, and 39 (52%) completing the postsurvey.

Measurements: We administered a 10-question pre- and postsurvey looking at resident attitudes toward and comfort with QI and familiarity with their panel data as well as measured rates of colorectal cancer screening and hypertension control in resident panels.

Results: There was an increase in the numbers of residents who performed a PDSA cycle (P = .002), completed outreach based on their panel data (P = .02), and felt comfortable in both creating aim statements and designing and implementing PDSA cycles (P < .0001). The residents’ knowledge of their panel data significantly increased. There was no significant improvement in hypertension control, but there was an increase in colorectal cancer screening rates (P < .0001).

Conclusion: Providing panel data and performing targeted QI interventions can improve resident comfort with QI, translating to improvement in patient outcomes.

Keywords: quality improvement, resident education, medical education, care gaps, quality metrics.

As quality improvement (QI) has become an integral part of clinical practice, residency training programs have continued to evolve in how best to teach QI. The Accreditation Council for Graduate Medical Education (ACGME) Common Program requirements mandate that core competencies in residency programs include practice-based learning and improvement and systems-based practice.¹ Residents should receive education in QI, receive data on quality metrics and benchmarks related to their patient population, and participate in QI activities. The Clinical Learning Environment Review (CLER) program was established to provide feedback to institutions on 6 focused areas, including patient safety and health care quality. In visits to institutions across the United States, the CLER committees found that many residents had limited knowledge of QI concepts and limited access to data on quality metrics and benchmarks.²

There are many barriers to implementing a QI curriculum in residency programs, and creating and maintaining successful strategies has proven challenging.³ Many QI curricula for internal medicine residents have been described in the literature, but the results of many of these studies focus on resident self-assessment of QI knowledge and numbers of projects rather than on patient outcomes.^4-13 As there is some evidence suggesting that patients treated by residents have worse outcomes on ambulatory quality measures when compared with patients treated by staff physicians,^14,15 it is important to also look at patient outcomes when evaluating a QI curriculum. Experts in education recommend the following to optimize learning: exposure to both didactic and experiential opportunities, connection to health system improvement efforts, and assessment of patient outcomes in addition to learner feedback.^16,17 A study also found that providing panel data to residents could improve quality metrics.¹⁸

In this study, we sought to investigate the effects of a resident QI intervention during an ambulatory block on both residents’ self-assessments of QI knowledge and attitudes as well as on patient quality metrics.

References

5. Kesari K, Ali S, Smith S. Integrating residents with institutional quality improvement teams. Med Educ. 2017;51(11):1173. doi:10.1111/medu.13431

7. Malayala SV, Qazi KJ, Samdani AJ, et al. A multidisciplinary performance improvement rotation in an internal medicine training program. Int J Med Educ. 2016;7:212-213. doi:10.5116/ijme.5765.0bda

9. Fok MC, Wong RY. Impact of a competency based curriculum on quality improvement among internal medicine residents. BMC Med Educ. 2014;14:252. doi:10.1186/s12909-014-0252-7

16. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-1439. doi:10.1097/ACM.0b013e3181e2d0c6

17. Armstrong G, Headrick L, Madigosky W, et al. Designing education to improve care. Jt Comm J Qual Patient Saf. 2012;38:5-14. doi:10.1016/s1553-7250(12)38002-1

Teaching Quality Improvement to Internal Medicine Residents to Address Patient Care Gaps in Ambulatory Quality Metrics

References

ABSTRACT

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