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

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

Results

Respondents

Of the 75 residents, 55 (73%) completed the survey prior to the intervention, and 39 (52%) completed the survey after the intervention.

Panel Knowledge and Intervention

Prior to the intervention, 45% of residents had performed a PDSA cycle, compared with 77% post intervention, which was a significant increase (P = .002) (Table 1). Sixty-two percent of residents had performed outreach or an intervention based on their patient panel reports prior to the intervention, compared with 85% of residents post intervention, which was also a significant increase (P = .02). The increase post intervention was not 100%, as there were residents who either missed the initial workshop or who did not follow through with their planned intervention. Common interventions included the residents giving their coordinators a list of patients to call to schedule appointments, utilizing fellow team members (eg, pharmacists, social workers) for targeted patient outreach, or calling patients themselves to reestablish a connection.

In terms of knowledge of their patient panels, prior to the intervention, 55%, 62%, and 62% of residents knew the rates of patients in their panel with diabetes, HTN, and colorectal cancer screening, respectively. After the intervention, the residents’ knowledge of these rates increased significantly, to 85% for diabetes (P = .002), 97% for HTN (P < .0001), and 97% for colorectal cancer screening (P < .0001).

Comfort With QI Approaches

Prior to the intervention, 82% of residents were comfortable managing their primary care panel, which did not change significantly post intervention (Table 2). The residents’ comfort with designing an aim statement did significantly increase, from 55% to 95% (P < .0001). The residents also had a significant increase in comfort with both designing and implementing a PDSA cycle. Prior to the intervention, 22% felt comfortable designing a PDSA cycle, which increased to 79% (P < .0001) post intervention, and 24% felt comfortable implementing a PDSA cycle, which increased to 77% (P < .0001) post intervention.

Patient Outcome Measures

The rate of HTN control in the residents' patient panels did not change significantly pre and post intervention (Table 3). The rate of resident patients who were up to date with colorectal cancer screening increased by 6.5% post intervention (P < .0001).

Interest in QI as a Career

As part of the survey, residents were asked how interested they were in making QI a part of their career. Fifty percent of residents indicated an interest in QI pre intervention, and 54% indicated an interest post intervention, which was not a significant difference (P = .72).

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

Results

Respondents

Panel Knowledge and Intervention

Comfort With QI Approaches

Patient Outcome Measures

Interest in QI as a Career

Pages

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