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Calling for Systems-based Training in Graduate Medical Education

By IHI Open School | Wednesday, September 25, 2013
By Don Goldmann, MD, Chief Medical and Scientific Officer, IHI, Katharine Luther, RN, MPM, Vice President, Hospital Portfolio Planning and Administration, IHI, and Kedar Mate, MD, Vice President, IHI

If you’re involved in teaching residents, are the quality and safety goals of your Graduate Medical Education (GME) program directly aligned with those of your sponsor organizations? Do you know? If you’re a quality officer, are the faculty and residents in your organization making a significant contribution toward improving the safety and care for your patients on a daily basis? If you can answer “Yes, absolutely” to these questions, you’re well on your way to preparing the next generation of physicians to step into leadership roles, whatever their chosen specialty.

If you need to think about these questions, you may not be a prepared as you think. The Next Accreditation System of the Accreditation Council for Graduate Medical Education (ACGME) calls upon academic medical centers to provide trainees greater competency in systems-based practice. Through its Clinical Learning Environment Review (CLER) program, ACGME will visit GME programs to assess resident participation in six areas—including patient safety and quality improvement—and generate national data on GME program and institutional attributes that help improve quality and safety.

Many teaching hospitals will face challenges in meeting ACGME’s new accreditation standards because their quality and safety work is not well integrated with educational objectives for trainees. Furthermore, many trainees view quality and safety skills as either difficult to obtain or tangential to their clinical training; academic medical centers may consider trainees obstacles rather than assets to institutional improvement. Few see how these entities can work together in meaningful ways.

Nonetheless, institutions can deliver training that fulfills the new standards and ensures trainees become tomorrows innovators and quality leaders engaging in work that supports these four principles:
  1. Embrace the idea that residents are critical to quality and safety. Residents are at the front lines of clinical care and therefore influence patient experience and the institution’s reputation. Without guidance, they can create waste and inefficiency, make errors, increase risk, and erode value. But with guidance they can be an “army” of quality improvers.

  2. Build an engaged, capable faculty. These are exciting times in the quality journey and there’s room for academic physicians at all levels to innovate and make real improvements to the quality of services patients receive. Tiered didactic courses, protected time to do quality and safety work, and a promotion track that recognizes quality and safety work enable faculty to increase their depth of knowledge. Results oriented projects with publishable outcomes not only directly benefit patient care, but also build knowledge in the field.

  3. Align quality and safety training projects with institutional goals. Teaching hospitals and GME program leaders must share a common vision of the core elements of quality and safety work in the institution and work together to align training with those goals. When aligned, improvement projects undertaken by trainees improve patient outcomes and ensure efficient and safe care while supporting institutional objectives. In addition, trainees become an integral part of existing organizational work and willing participants in improvement.

  4. Provide ongoing, experiential learning for deep practice. Training can take many forms but should reinforce the daily practice of improving quality and safety within a system. Examples of experiential quality and safety activities led by trainees might include integration of safety rounds into morning clinical rounds, active management of diabetes in inpatient wards, rotation-specific QI projects (15-30 days), routine adverse event and near miss reporting, and augmented discharge planning and medication reconciliation.

Integrating institutional quality and safety priorities into GME programs will help teaching hospitals meet ACGME’s Next Accreditation System. But it will do far more by improving care and the patient experience while creating the next generation of quality leaders.

On November 18-19, IHI will host an interactive forum "Focusing on Quality and Safety in a Clinical Learning Environment". This will be an opportunity to come together and help chart new directions for medical training and education.

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