In 2005, Dr. Roger Nelson, then dean of Mayo School of Graduate Medical Education (MSGME), decided to implement a systematic method for training MSGME residents and fellows in quality improvement (QI) and safety — all 1,500+ of them, at all three campuses (Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida). He had learned about the quality improvement curriculum at Mayo Medical School (MMS) and wanted the graduate students to have a similar experience. Dr. Prathibha Varkey, MD, MPH, MHPE, director of the MMS QI curriculum at the time, agreed to accept the challenge and was appointed the director of the MSGME QI curriculum. As the Program Director for the Preventive Medicine Fellowship, she had already been working on integrating these competencies into her fellowship, and was excited to expand her efforts to a broader scale.

At the time, the Accreditation Council on Graduate Medical Education (ACGME), which accredits all residency programs in the United States, had just mandated education in the areas of systems-based practice and practice-based learning and improvement. Many program directors across the country have found training residents and fellows in these competencies challenging, especially since many of them were not taught these skills themselves. 

MSGME took this challenge as an opportunity to create a “win-win” for the program directors at Mayo. By implementing a QI program, program directors (PDs) would also be able to address the ACGME mandate. The Dean’s Office sent an email to all program directors, introducing the new program and its director.  Everyone involved recognized early on that in order to be successful, the QI education effort would need to be developed and run locally with facilitation and assistance from MSGME. 

In addition, an essential step would be for the MSGME QI program director to meet with each program director one on one, to help facilitate the design and implementation of the QI curriculum and experience for each program. Brainstorming during these meetings included practical methods to teach and integrate the curriculum into the existing curriculum, QI projects that were relevant to the specialty, and orientation to the centralized website that had resources that would be helpful for the curriculum. She also connected the program directors to QI experts in their specialty area, as well as to information resources that would be relevant to their area. Finally, the MSGME QI program ran an interactive workshop in Rochester (videocast to Jacksonville and Scottsdale) for program directors on quality improvement techniques and teaching methodologies.

Since the fall of 2005, all 115 accredited residency and fellowship programs at MSGME now have QI curricula. While a QI curriculum website offers centralized resources, the curricula vary as they have been tailored to meet the needs of each program. Some have group projects, while others may rely upon individual learner efforts. In some cases projects are only a week, while others may span months. 

Several projects are interprofessional in nature, such as the medicine reconciliation effort. This project, organized by Dr. Varkey, involved two preventive medicine fellows, one internal medicine resident, two family medicine residents, and two master’s level nursing students, resulted in an 18 percent increase in the number of medication lists appropriately dictated by health care providers. This three-week project — the first outpatient medication reconciliation project in the institution — identified many reasons why there might not be a complete list for a patient, ranging from lack of patient knowledge to time pressures on residents.

In another QI project, endocrinology fellows in the bone clinic noted that patients recall less than half the amount of information provided to them; they used QI techniques to enhance patient understanding of diagnosis, management, and follow up at the end of the office visit. At the end of the three-week project, which included several interventions introduced using Plan-Do-Study-Act (PDSA) cycles, patients’ understanding of the reasons for testing, management plans, and follow-up plans improved from 64 percent to 80 percent, from 61 percent to 86 percent, and from 64 percent to 86 percent respectively.

Within 18 months of the MSGME QI program, 70 percent of responding program directors reported in a survey that their residents and fellows were participating in a QI project. Thus, almost 1,500 residents and fellows are now learning about quality improvement every year in a variety of settings, and making a difference as they do so. Recent projects have included efforts to increase patients’ access to care in the clinic, and to improve patients’ understanding of their diagnosis and management plans.

At the individual learner level, MSGME has seen some remarkable outcomes. One of the recent graduates is pursuing further QI and leadership training at the University of Minnesota, and another is now the director of a hospital’s QI programs. A third is pursing a Six Sigma “Black Belt.” At least two other Preventive Medicine fellows have made QI the focus for their academic careers.

Cindy Kermott, MD, MPH, was one of the fellows involved in the medicine reconciliation project as a preventive medicine fellow. The group’s first step was to work through “what was wrong” with the current process through process mapping and root cause analysis. Their next effort was to design an intervention to improve outcomes. Dr. Kermott quickly realized how challenging it was to work in an interprofessional group, each with their own additional obligations. The nursing students still had clinical time to attend, and the residents had their continuity clinics. The group had to be flexible about finding time to work together and became aware that each profession had its own culture and its own jargon. Members also learned to give effective feedback to each other and better understand the scope of each other’s practice. Like many effective teams, they developed revolving leadership roles within the team.

Participating in the project had a lasting effect on Dr. Kermott. After graduation, she obtained further training in quality and leadership from the Carlson School of Business at the University of Minnesota. She notes that she “likes to think that [she is] always trying to improve my little corner.”

Although this effort has already had remarkable success, Mayo Clinic is not resting on its laurels. Mayo intends to focus on practicing clinician next. If their past accomplishments are a predictor of their future endeavors, the practitioners are in for a career-changing experience.

Learning Points:

• When implementing a quality improvement curriculum on a broad scale, it is important to find a “win-win” with educators, so that the initiative is seen as a help rather than a hindrance.
• Just as QI initiatives may need to be implemented differently depending upon the local culture, QI curricula may need to vary from specialty to specialty.
• Involving residents and fellows in meaningful QI work can impact their career decisions.

More information on Mayo’s quality improvement curricula can be found at: “Teaching Quality Improvement and Patient Safety Skills Gets High Priority at the Mayo Clinic,” by Amy Schonfeld, Academic Physician and Scientist, March 2008, pages 2-7.