For Kristin Cox, MD, an internist and a program director at Newton-Wellesley Hospital in Massachusetts, the real value comes from the fresh eyes.
“Residents are in a perfect position to evaluate the systems we’re using,” she says. “They see best practices, what works, and what doesn’t work. They see every department on days, nights, and weekends. They see every aspect of the hospital.”
And seeing those things can lead to improvements — improvements in systems within the hospital, improvements within care teams, and, most importantly, improvements for patients. Those improvements are central to a unique QI-themed training program for residents at Newton-Wellesley.
“Improvement and safety are the two most important skills they are going to learn in their year here because the skills will apply to all of them, no matter where they end up in medicine,” Cox says about the program at Newton-Wellesley. “We want them to evaluate how the hospital works and improve the processes.”
To get these residents started on their quality and safety journeys, Cox uses the IHI Open School courses, which include more than 30 self-paced online courses that teach the basics of quality, safety, leadership, and population health. For 10 years, the IHI Open School has provided students, residents, and health care professionals with the basic skills and knowledge to improve health and health care around the world.
“Everyone who focuses quality and safety in the front lines should have this body of knowledge,” Cox says.
How does Cox structure her program? She oversees a four-week elective three times each year. The Open School courses serve as one of the foundations of the education, which is augmented by ongoing quality and safety meetings within the hospital. She sets aside a couple hours within training for the residents to complete an online module or two and then leads a discussion or exercise.
Cox practices what she preaches and has taken the modules herself — a few times. In fact, Cox re-takes the courses every other year to refresh her learning and note the improvements to the courses, which have recently included a new interface, more video content, and more interactive questions. The content covers the essential information about the quality and safety movement — concepts like the Swiss Cheese Model and the Institute of Medicine quality aims.
“The courses are a good way to teach fundamentals and provide a launching board,” she says. “We use them to reflect on our own initiatives in our hospital. A lot of the examples in the modules relate to things many hospitals, including our own, deal with.”
For example, when Cox taught PS 105: Responding to Adverse Events, she wrote up a case study about an adverse event that happened at the hospital to show residents how to apply their learning about root cause analysis. She’s also led exercises like the Myers-Briggs Type Indicator to teach team dynamics and asked residents to write aim statements as part of projects. Cox doesn’t want trainees to understand the material only on a conceptual level; she also wants them to apply the learning to things they see in the hospital every day.
Cox admits that residents faced with 20 hours of online learning are often skeptical at first. But attitudes shift as they see it’s much more engaging and practical than reading a textbook.
“The residents feel like they are learning a new skill and have a new way of looking at the world,” Cox says. “It can be very eye-opening to understand the complexity of the system. They say, “I don’t feel like a cog in the wheel anymore. I feel like I know how to make fixes within a system.’”
For now, Cox just uses the courses with her residents. Stricter ACGME requirements make learning about quality and safety an imperative, and residents, who are just learning the ropes at a hospital, make a captive audience. She’d like to expand the training to include other faculty and professionals at Newton-Wellesley in the future.
“I hope we go in that direction, maybe an interdisciplinary course — nurses and physicians doing something together,” she says. “Right now, it’s a bandwidth issue. But in the long run, it would make sense to invest time and effort in faculty that are going to stay here.”
Bandwidth and the lack of it is something that Cox points to as one of the main reasons for using the Open School courses.
“The alternative, for me, would be very time-consuming,” she says. “And the courses are better and more engaging than any lectures I could give. It really is an excellent resource that will save faculty time and create a better learning experience for faculty and residents. Plus, we [as educators] should be focusing on practicing and application. Learners can get the fundamentals on their own time, when it's convenient.”
Cox has been in her role for four years and is passionate about the role quality and safety will play in the future of health care. Her sister, 10 years her junior, is now in medical school and, according to Cox, has a much better awareness of patient safety than she did. Over the last couple years, she adds, there seems to be a stronger emphasis on quality and safety in residency programs and medical school.
“For the next generation of health care, we need physicians to be fully engaged in these learning processes,” Cox says. “And they are in an ideal position to do that. They have the fresh eyes.”