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At Wake Forest, Fostering a Culture of Improvement from the Start

By IHI Open School | Tuesday, December 2, 2014

How can you foster a life-long passion for quality improvement (QI)?

Wake Forest University is betting on an early start.

Wake Forest University School of Medicine, located in Winston-Salem, North Carolina, is one of the latest academic medical centers to integrate the IHI Open School’s quality and safety courses into its curriculum. The school has long involved residents and fellows in QI work, and, this fall, they’ve begun teaching QI to first-year medical students — in their second week of class.

Wake Forest has adopted a “flipped classroom” model, in which students take the IHI Open School online courses as pre-work and then use class time for discussion. The school has also incorporated quality into learning communities, where students work together in a cohort for all four years of their medical education, studying basic concepts in years one and two, and applying them during clinical rotations in years three and four.

How did this change come about, and how is it going so far? The Open School inquired over email with leaders of the curriculum change — Kathryn E. Callahan, MD, MS, Assistant Professor of Internal Medicine; Simon A. Mahler, MD, MS, Associate Professor of Emergency Medicine; and Nandini Kumar, a medical student and IHI Open School Chapter Leader who worked with faculty to develop the new curriculum.

OS: Drs. Callahan and Mahler, why do you believe QI is an important component of medical education?

KC & SM: There are so many reasons! First, we believe that QI — meaning the systematic evaluation of performance, identification of areas to improve, and engaging colleagues from many disciplines to improve care — is the definition of what it means to be a professional. It’s also related to a critical component of being a doctor and medical decision-making — how do you know what you know? Does your performance match what you intend to do? What are the outcomes of your practice behaviors?

OS: Nandini, how about you?

NK: I first learned about IHI and quality improvement during my first week of orientation in medical school. The IHI Open School Chapter gave a terrific presentation on a QI project they’d completed the previous year at our student-run free clinic. The students improved the rate of recommended foot exams for diabetic patients from 40 to 75 percent, and these high rates have been sustained over the past year. It was inspiring to learn that we could have a real, measureable impact on patient care so early in our training. I think that is why many of us were initially drawn to QI.

One of the biggest lessons I’ve learned in the past year is that Qi is about more than just implementing interventions and measuring results — it’s about truly engaging others in a culture of safety and continuous improvement. Changing the culture of an entire profession is hard, especially when it requires changing attitudes and behaviors that may have developed early on [in the professional training]. I think it’s fantastic that Wake Forest and other medical schools have recognized this and are intentionally promoting safety, interprofessional collaboration, transparency, and continuous improvement as critical professional values we should internalize from the start.

OS: Drs. Callahan and Mahler, how were you able to incorporate this into the curriculum?

KC & SM: There’s really been great support for this at every level. As an institution, we have a strong focus on patient safety, and the faculty and staff have been trained in patient safety and safe leadership techniques. We have an active quality office and total support from our chief quality officer. Residents and fellows are being engaged in quality metrics. It’s time to include the students, too. The new [guidelines on] entrustable professional activities from the Association of American Medical Colleges (AAMC) require that medical students be competent in patient safety and systems improvement at graduation.

I think it’s really the perfect time to include students — the school is consciously focusing on the total development of the physician, and leadership recognizes its importance. Consensus was building over the past couple of years regarding the need to incorporate patient safety and QI into the medical school curriculum. A grant from the AAMC and Donaghue Foundation provided the final push needed to develop the curriculum.

OS: Nandini, what advice would you share with others who are working to make QI part of the undergraduate learning experience?

NK: I’d say go for it! There are many different ways to incorporate QI into the educational experience. Before we had a QI curriculum at Wake Forest, our IHI Chapter essentially operated like a student-run QI elective course. We’d meet once a month to discuss whichever Open School course or activity we’d selected for that day, and then we’d try to apply some of the concepts to our Chapter QI projects. For students working to integrate QI into their school’s curriculum, I have two suggestions: first, to find a way to document the existing interest in QI among the student body, since administrators are often very responsive to student interest; and, second, I’d recommend connecting with one or more faculty members who are passionate about QI and can champion your efforts. Experienced and committed faculty are a tremendous asset!

OS: Nandini, how was your experience representing students in the development of the curriculum?

NK: I was thrilled to have the opportunity to participate. It was wonderful to meet faculty from across the medical center who were experienced in QI and wanted to contribute to the medical student educational experience. I think the faculty already had a good pulse on the needs and interests of medical students, and hopefully I was able to provide some helpful perspective as well.

Some of the other IHI student leaders and I have also had the opportunity to co-facilitate some of the QI discussion sessions with the first-year medical students this fall. It’s been a great experience, and I think the curriculum has been very well-received. I’m interested to see the rest of the course unfold over the next several years — as well as to see whether the early exposure to QI has a noticeable impact on students’ attitudes and behaviors during the clinical years.

OS: Drs. Callahan and Mahler, how have the students reacted to learning QI in your experience?

KC & SM: Responses have been great — students seem engaged, excited, and talkative in their sessions. We opened the very first session (in the second week of med school!) with questions that helped bridge students’ life experience before medicine with QI concepts. We asked those who were comfortable to share stories of experiencing something in medicine that didn’t go right. This really helped them link their total selves — as people, as patients, as future physicians — to this overarching community commitment to safe, effective patient care.

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