Published in the October 2004 issue of Today’s Hospitalist
When educators at Boston’s Beth Israel Deaconess Medical Center wanted to create a quality improvement elective for internal medicine residents, they were sure that it was an area of concern for housestaff. The challenge was showing residents how quality improvement processes could help them change the systems in which they work day in and day out.
“Residents talk about quality problems all the time,” says Saul N. Weingart, MD, PhD, an internist at the medical center. “It’s just that no one ever frames these issues in terms of patient safety. They have never been given a tool kit to address these issues.”
One issue: Housestaff are often too busy to think about broad issues of quality. “Residents are at the forefront of health care and doing a lot of service work around the hospital,” explains Anjala Tess, MD, director of education for the hospital medicine program, “but they don’t necessarily see themselves in the bigger picture.”
To balance residents’ interest in quality issues with their lack of time, Kenneth Sands, MD, vice president for health care quality, joined clinicians in creating a three-week elective that combines didactic content with hands-on projects. The goal is to give residents a detailed understanding of quality improvement processes, and to let them get to work improving the hospital’s systems.
The hospital’s quality improvement elective, which is now in its fourth year, consists of four basic segments designed to give residents a broad mix of activities.
1. Didactic content. Residents meet one-on-one with the hospital’s educators and leaders to discuss topics like medical errors, root cause analysis, systems failure mode analysis, and techniques to investigate errors.
“They have a one-on-one session where their mentor will come and meet with them and teach them about a given topic,” Dr. Tess says. “We have a core curriculum that we cover with each individual person.”
2. Hands-on experience. Educators help residents identify a quality improvement project during the elective. Dr. Tess says that many of the topics come from residents’ own experience at the hospital.
One project, for example, focused on systems to make sure that patients don’t receive too much contrast dye during their stay at the hospital. A resident proposed the idea after a hospitalized patient received dye on several occasions during a single admission. At that time, the hospital had no system in place to track how much dye patients had received during hospitalization.
Dr. Tess said that during his elective, the resident researched how intravenous dye is given at the medical center and which departments administer it. The resident also learned some valuable lessons about how those departments operate independently of each other and don’t always communicate regarding dye use. His solution was to create a system that puts a check into the hospital’s computer order entry system, allowing the person ordering the test to flag patients in whom intravenous dye may be contraindicated.
In another project, a resident helped reduce the inappropriate use of telemetry services in the medical center. After surveying the hospital’s units, he calculated that a certain percentage of patients didn’t meet the criteria for telemetry services. He estimated that the inappropriate use of telemetry services equaled the salaries of two full-time nurses.
The resident then held an educational intervention with his colleagues. Through those efforts, he was able to reduce the inappropriate use of telemetry in the hospital.
3. Investigating errors. Educators help residents identify a case that is going to be presented at the QI committee and have the resident look at the charts. Dr. Tess says near misses tend to provide the best educational experience, because residents can identify systems to prevent the mistake from being made again.
“The elective gives residents a chance to talk with people involved in the case and get a better understanding of how there can be different perspectives in a case,” she explains. “They can then come up with the root cause and identify solutions to try to make sure that it doesn’t happen again.”
In one case, for example, the hospital’s computerized order entry system allowed physicians ordering heparin to make a dosing error by asking for weight in kilograms and pounds.
As part of the elective, the resident identified the problem and changed the order entry system to prevent it from happening again.
While residents in the elective focus much of their time on identifying and correcting errors, Dr. Tess says they also learn how to talk to their colleagues in a way that doesn’t put them off.
“We coach them on how to speak to their peers in a nonthreatening way,” she explains. “It’s a great learning experience because they learn that nobody documents as well as they could, that the chart never contains all the information.”
4. Committee meetings. Finally, residents in the elective attend committee meetings that address quality improvement. The goal, Dr. Tess says, is to give them a first-hand view of how changes are made to the hospital’s processes.
“They get a sense as to why it’s not so easy to change things quickly,” she explains. “They also see how a small change can affect the rest of the institution. They get a sense of the process.”
Dr. Tess says that residents have access to such high-level meetings because the elective has the direction and support of Dr. Sands. “Recognizing that the institutional leaders value resident input is a terrific lesson for housestaff to learn,” she says. “Dr. Sands’ investment of time in creating the elective, mentoring projects and didactic teaching has been essential to residents becoming integrated into our local systems of quality improvement.”
While the elective exposes individual residents to the principles of quality improvement, educators have been able to use residents’ projects to expose a much larger group of residents to the process and its benefits.
Once a year, for example, residents who have already completed the elective present their projects to new residents. Those presentations help promote not only quality improvement initiatives in general, but the elective itself.
“There are two ways that residents learn to care about this type of thing,” Dr. Tess says. “They watch people they respect get involved, whether it’s the chairs of departments or teachers they respect for their knowledge. The also learn from their peers, who tell them, ‘This is the way we practice medicine around here.’ ”
Dr. Tess says the elective continues to grow in popularity among residents. This year, the hospital has doubled the number of slots in the elective so that two residents can now participate every three weeks, allowing significantly more residents to rotate through the elective this year. (While the program is also open to nurses, relatively few have participated to date.)
Even more importantly, Dr. Tess says, the elective has also generated interest in general quality improvement principles. “I have lots of residents coming up to me and saying, ‘This happened, what should I do?’ ” she says.
“They know that we need to figure out ways to not let it happen again,” she adds. “They recognize that they close the loop when a change has gone into effect that changes the way we practice. The knowledge that they can report something and a change will happen empowers them.”
Dr. Weingart says that residents’ attitudes reflect an overall culture change in health care. “The language has changed in the last few years,” he explains. “Residents are becoming familiar with the vocabulary of patient safety, even if they are still figuring out the key concepts.”
And while educators face some pressure from the ACGME to teach residents about systems and performance improvement, residents also accept that it’s going to be a part of their future. “People are realizing that they may be asked about this on the Boards,” Dr. Tess says. “It could easily be part of what you’re expected to do for recertification in the future, so getting experience in it now is going to be helpful.”