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Association of American Medical Colleges Tomorrow's Doctors, Tomorrow's Cures®

Residents Help Drive Quality Improvement

—By Scott Harris

Peter Fleischut, M.D., has some advice for those looking to entice residents into attending a meeting.

“Get some food in the room.”

Fleischut should know. A resident physician himself at New York-Presbyterian Hospital, he recently co-founded one of the nation’s first programs aimed exclusively at helping resident physicians directly improve the quality of patient care.

Residents and medical students usually are not thought of as partners in quality improvement, or QI, which generally involves seeking and testing new ways to streamline processes or systems. In the December 2009 issue of the journal Academic Medicine, Carol Patow, M.D., M.P.H., executive director of the HealthPartners Institute for Medical Education and associate dean for faculty affairs at Regions Hospital, University of Minnesota Medical School, stated after reviewing published literature on resident involvement in QI that “hospital quality initiatives rarely include residents, and resident quality improvement projects often are not aligned with organizational priorities.”

There is evidence, however, that this is changing. Medical students and resident physicians are now looking not only to learn more about the tenets of the burgeoning QI movement, but to play an active role in QI efforts at their own institutions.

“We had not had a big medical school presence, but we’re trying to reach out more,” said Maureen Murphy-Ryan, a third-year medical student at Mayo Medical School and president of the student and resident group at the American College of Medical Quality (AMCQ). “I’ve met a lot of students who didn’t have a ton of quality experience but sought me out. There is real excitement, and real potential for change.”

Interest in QI appears to be on the rise in many segments of the health care workforce, as lawmakers, accrediting bodies, and individual institutions gather more evidence about QI’s potential to improve health outcomes and cut costs. For example, the National Board of Medical Examiners (NBME), which administers the United States Medical Licensing Examination that doctors must pass to practice medicine, is working to better evaluate quality and safety knowledge. Peter Katsufrakis, M.D., M.B.A., NBME’s vice president of assessment programs, said the board is considering new testing modalities such as video clips, in which students watch doctors interact with patients and then identify problems or issues related to quality and patient safety. These new test components could be unveiled by 2012, Katsufrakis said.

“We’re looking at how content within the exam could be changed, and how we might assess competencies that were not previously assessed as robustly as others,” he said.

This should only heighten the attention students pay to QI and its underpinnings, which in turn could drive interest in new avenues of QI instruction. Several resources are available, perhaps most notably the free online courses in QI offered by the Institute for Healthcare Improvement’s Open School for Health Professions. An increasing number of other medical schools have already integrated quality into their curricula. Jefferson Medical College of Thomas Jefferson University in Philadelphia has woven QI into each year of its curriculum, while the Jefferson School of Population Health and some other schools offer a master of science degree in health care quality and safety.

According to David Nash, M.D., M.B.A., dean of the school of population health, Jefferson first exposes students to QI basics in first- and second-year classroom lectures. In year three, special speakers address the entire class on quality issues and concepts such as communication and “going against the authority gradient when patient safety is at stake,” Nash said. In year four, students hold small-group discussions around quality and safety issues.

Of course, hospitals often differ in the way they work and in the challenges they face, which can make it difficult to generalize certain aspects of QI during medical school, long before students know where they will conduct their residencies. Nash counters that presumption by noting that QI instruction can instill a “deeper understanding of the health care system’s nature of care, and the ability to improve any system.” Nash said there are “a large number of skills that are readily transferrable” to any institution, such as familiarity with flow diagrams and system theory.

Armed with QI’s tools of the trade, Nash said, newly minted residents can make a difference from day one.“

"Students are natural catalysts once they have exposure to the tenets and get into the hospital,” Nash said. “They are a fresh set of eyes that can recognize the variation in what we do and where we make mistakes. Then they can start to connect the dots.”

Although the grounding in QI can begin in medical school, most of the real, hands-on training and actual quality improvement work indisputably happens during graduate medical education. Fleischut and Adam Evans, M.D., M.B.A., both residents at New York-Presbyterian, founded the Housestaff Quality Council© to “improve patient care and safety…by creating a culture that promotes greater house staff participation.” Fleischut called it a natural fit, in part because residents, nurses, pharmacists, and other house staff are the ones doing the actual work involved with any QI initiative.

“I definitely think QI is driven by house staff,” he said. “The integration of patient safety and quality has become much more prevalent, and that’s guiding a trend. When you engage the house staff and ask them for their input, you produce a solution that people are more likely to adopt.”

Fleischut said the council meets regularly to discuss areas for improvement and map out strategies to effect change. The council is now working with hospital leadership to improve procedures around communications, infection prevention, surgical and prescription safety, and other areas.

“We started small with medication reconciliation,” he said. “In just a couple of months, we changed compliance from 40 percent to over 95 percent.”

Fleischut, only half-joking when he spoke about enticing residents with food, outlined several common-sense objectives for emulating the house staff council at New York-Presbyterian.

“Start small with one initiative, one meeting,” he said. “Get people away from their clinical duties. A lot of people want to be leaders in this area now, so it’s just a matter of finding them.”

In 2007, the Alliance of Independent Academic Medical Centers organized approximately 20 of its member teaching hospitals into a national initiative called “Improving Patient Care through Graduate Medical Education.” Atlantic Health in New Jersey, one of the participating institutions, enlisted residents and faculty from eight of its 10 residency training programs for a six-month effort to improve medication reconciliation, or the process of accurately identifying and supplying patient medications. Each residency program developed detailed implementation and measurement plans using the Plan-Do-Study-Act method—a well-known process within QI circles that helps document the test of a proposed change. Each program achieved substantial increases in compliance with medication reconciliation documentation, and as a whole led to permanent changes in the hospital’s overall reconciliation processes.

Even as more efforts like this one get off the ground and drive institutional change, however, new regulations mandated by the Affordable Care Act may ultimately determine whether hospitals are reimbursed by Medicare for the QI efforts its residents undertake. The health care reform law stipulated that hospitals may be reimbursed for the didactic activities they provide, but not for resident research projects. The question is whether QI work is considered didactic or research-oriented.

“Under Medicare regulations, it is currently unclear whether quality improvement activities are reimbursable,” said Lori K. Mihalich-Levin, J.D., a senior policy analyst for the AAMC.

Students at some medical schools do not have to wait for residency to make a tangible difference in actual care delivery. Marcus Dahlstrom, a third-year medical student at the University of Chicago’s Pritzker School of Medicine, said the school’s Summer Research Project allowed him and other students to take part in a two-year effort to reduce bed sores among patients at University of Chicago Medical Center. The center instituted new documentation and point-of-care reminders as a result of the effort. Dahlstrom said institutional leadership was committed to hearing and considering recommendations arising from the students’ research.

“Here, everyone from the top down is humble about patient safety and quality,” Dahlstrom said. “When a medical student can go to the highest levels of leadership to give a presentation on a quality or safety issue, that means there’s a willingness to listen. It shows that in some places, times are really changing.”