Practicing proper handwashing. Obtaining informed consent before a procedure. Disposing of needles and other “sharps” appropriately. Understanding how implicit biases can influence treatment. These are among a new set of competencies from the AAMC that detail what every trainee and physician needs to know to boost patient safety and promote high-quality care.
For decades, the medical community has worked hard to spread quality improvement and patient safety (QIPS) — but with no consensus-based, across-the-board document to guide it. Now, experts say, the AAMC competencies mark a significant step forward.
“For the first time, we have a road map that medical schools and teaching hospitals can use to develop curricula, assess learners, promote lifelong learning, and improve systems,” says Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships and QIPS Project lead. “Competencies give us a common, standard language we haven’t had before, and they provide goal posts to aim for as we work to improve quality and patient safety.”
“Instead of simply saying that if you pass your classes, you get to be a doctor, we want to have clearly defined skills you need to be acquiring and that we can confirm. To support that, we need acknowledged competencies.”
Nathan Spell III, MD, Emory University School of Medicine
Although some QIPS guidance already exists — milestones from the Accreditation Council for Graduate Medical Education, for example — this is the first umbrella document that suits all medical specialties and addresses each level of training. From ensuring timely specialty consults to reporting medical near misses, the competencies outline what newly minted physicians, recent residency graduates, and experienced providers all need to know.
The QIPS document supports a broader effort to fuel competency-based medical education, explains Nathan Spell III, MD, associate dean for education and professional development at Emory University School of Medicine and a member of the AAMC Expert Working Group that drafted the competencies. In fact, this release is the first in a series, New and Emerging Areas in Medicine, that next tackles two other major topics: telehealth and equity, diversity, and inclusion. Those are expected in 2020 and 2021, respectively.
“Instead of simply saying that if you pass your classes, you get to be a doctor, we want to have clearly defined skills you need to be acquiring and that we can confirm. To support that, we need acknowledged competencies,” Spell says. “Now we have them for QIPS.”
Trainees also are looking forward to the QIPS guideposts. “There has been a sea change in the amount of information QIPS trainees are taught,” says Byron Crowe, a third-year University of Colorado internal medicine resident. “These new across-the-board competencies will enhance that effort and help improve collaboration. Having trainees across the health care system equipped in these competencies provides the foundation for meaningful conversations between physicians and others in medicine about how to improve systems, deal with medical errors, and keep our patients safe.”
What do the competencies cover?
Agreeing on patient-care basics was no simple matter.
The AAMC Expert Working Group mulled options for months, gathering insights from hundreds of stakeholders in education, quality improvement, and hospital administration. Members also reviewed existing guidelines and frameworks, and then invited more than 60 organizations to review their draft. Throughout, they worked to whittle down the vast array of worthwhile items to what emerged as truly essential.
“It wasn’t always easy,” says Nancy Davis, PhD, a working group member and associate dean for continuing professional development at the University of Kansas School of Medicine. “For example, we thought perhaps health equity should be threaded throughout, but we ultimately decided it should be its own domain, partly because it’s so challenging to teach and partly because it’s so important. Certainly, throughout the process everyone was respectful of each other’s perspectives.”
Here are highlights and examples from each of the five QIPS competencies:
1) Patient safety: This category focuses on reducing preventable errors through such basics as hand hygiene, reporting errors, and using patient safety checklists. But it also includes practicing self-care and reaching out when feeling overwhelmed since clinician well-being plays a crucial role in patient safety.
2) Quality improvement: This domain covers efforts to improve health care services and patient outcomes. Competency in this area means knowing how to test the effects of small changes and recognizing when health care delivery is fragmented or fundamentally wasteful.
3) Health equity in QIPS: Achieving “the highest level of health for all people” is the goal of this domain. To do that, a student needs to identify local services for at-risk patients, for example, and a resident needs to be able to explain the effects of social determinants of health. A faculty member should be able to interpret and apply data to groups that are suffering from health disparities.
4) Patients and families as QIPS partners: Engaging with patients and their families respectfully and collaboratively lies at the heart of this competency. Among the necessary skills are obtaining informed consent, keeping patient concerns about costs in mind, and knowing how to discuss an adverse safety event.
5) Teamwork, collaboration, and coordination: This interprofessional competency involves communicating and coordinating effectively. Skills here include requesting a consult in a clear and timely fashion as well as melding recommendations from different providers to maximize patient care. And for faculty members, there is the need to model communication that shows that input from all members of the health care team is valued.
How competencies help
For Howley, patient safety is deeply personal. Thirteen years ago she spent more than 70 days in a high-risk maternity unit before the harrowingly complicated birth of her daughter.
“I experienced numerous diagnostic and system-related errors, but I also experienced incredibly caring providers and benefited from scientific advancements,” she recalls. “The experience gave me new insights into how we need to think about safety more expansively, making sure we look at the entire system while also always keeping the patient at the center of care.”
Those involved with the QIPS competencies predict they’ll do just that.
Michelle Ogunwole, MD, a hospitalist fellow at Johns Hopkins Medicine and a working group member, is most excited about highlighting how implicit bias can impact patient safety.
Ogunwole recalls a moment during her residency when preconceived notions cast a shadow over quality care. A somewhat disheveled-looking Hispanic man was stuck in the intensive care unit with a high fever, she explains. Assuming the cause was the patient’s IV drug use, providers initially overlooked a dangerously infected bile duct. “It was a very profound experience for me as I knew this patient almost died,” she notes. “That’s why I am so glad these competencies are helping ensure that concepts of equity and bias will be rigorously taught and modeled.”
For his part, Brennan Kruszewski, MD, a second-year resident at University Hospitals in Cleveland, Ohio, looks forward to having more quality improvement tools for efforts like the one he helped run in a local VA medical center.
“I am so glad these competencies are helping ensure that concepts of equity and bias will be rigorously taught and modeled.”
Michelle Ogunwole, MD, Johns Hopkins Medicine
“We were distributing gun locks to keep patients safe, but the effort began to fall apart,” Kruszewski explains. “So we used a lot of fundamental QI tools to figure out what was going wrong. We made a process map and investigated the logistics involved, for example. One key problem we found was that once the team that started the project moved on, no one was sustaining it. So we worked to hardwire steps into the system to ensure the distribution efforts were more permanent.”
“There’s always the temptation to think things can’t improve,” Kruszewski says. “But once you are equipped with tools, you feel empowered to improve patient outcomes. And seeing improvements helps fight burnout and restores your joy in your work.”
The road forward
Howley notes that the competencies will be a living document, adapting as research reveals new information and stakeholders provide additional feedback. “I expect that this effort will really take the field further along in supporting trainees and physicians in their desired mission of providing high-quality, safer care,” she says.
Looking ahead, Kruszewski hopes the document will help spur a fundamental shift in patient safety.
“Once you are equipped with tools, you feel empowered to improve patient outcomes. And seeing improvements helps fight burnout and restores your joy in your work.”
Brennan Kruszewski, MD, University Hospitals
“I would be thrilled if when we talk about errors people understand that they aren’t unavoidable,” Kruszewski says. “I want us to be coming up with a culture that supports discussion of errors but also of evidence-based solutions to improve patient outcomes. If we can do that, then I think we will see advances in safety on a remarkable level. I believe these competencies can be a key step toward that.”