IHI program building foundation for more quality-conscious providers

'Open School' med students are initiating their own QI programs

Quality experts have long bemoaned the fact that medical students are taught precious little about quality and patient safety, but that trend has been changing thanks to a program sponsored by the Institute for Healthcare Improvement (IHI). Called the Open School, it was launched in September 2008 and now has more than 22,000 students registered, according to Director Jill Duncan, RN, MSN, MPH.

The goal of the school, she says, is "to advance health care improvement and safety competencies in the next generation. It's an attempt to address the fact that many academic organizations were teaching improvement and safety in a very limited capacity — some not at all — so we wanted to bring it directly to students."

The school's offerings, she explains, "vary from what feel like formal courses to case studies, video clips on YouTube, discussion boards, and journal articles." Probably the development the IHI found most interesting, she continues, "is that while the program was initially targeted at students, we've also found a large number of faculty members showing interest. They view the content and integrate it with their course curriculum and share it with other faculty so the knowledge can be spread."

But the program's reach extends beyond pure academic pursuits; a number of the students have already initiated QI projects on their own. "Their numbers are growing," says Duncan. "We're excited because when we think about the Open School and online content, a big part of the culture is building experiential learning."

Student tackles diabetes care

One of the students who has put her knowledge to practical use is Saranya Kurapati, who initiated a program targeting diabetes care — and also developed an elective course on quality. She recently received the 2009 David Calkins Memorial Scholarship for her work, which gave her free entrance to the 21st Annual IHI National Forum and a $1,000 stipend to cover travel costs. Kurapati, a student at Loyola University of Chicago Stritch School of Medicine, will get her MD in June.

Although she had been involved with QI and the IHI for a while, "It was my third year when I was actually on the ground in the ward, seeing patients, working in teams, and began to see what I could do to change the system," she says. The Open School, she adds, "gave me more background tools and skills to do things in a much more professional manner."

At the beginning, she recalls, she took the online courses. "While I broadly understood the concepts of QI, I did not truly understand what it meant; nor could I articulate it to people I wanted to join me." So, she says, she gained "foundational knowledge" about QI — the history of how it came about, and how it can be applied to health care.

"I also learned about patient safety and how the two connect," she says. "I learned about the PDSA [Plan Do Study Act] cycle and how to take an idea to a QI intervention and do continuous and rapid cycling." In addition to being able to e-mail IHI experts, she says, "They had a number of white papers available for free, so if I was interested in a specific topic, I could read about it in greater depth."

Her intervention took place at a medical student-run free clinic. "I kept going to the clinic and asked myself if this was really the best way to do things," she recalls. "After the Open School, I realized there were a lot of interventions we could do to improve care in the clinic."

She used the framework of the PDSA cycle to implement her initiative. "It struck me while on the wards that diabetic foot disease was the No. 1 cause of traumatic foot amputation," she says. "So many of the patients we have at the clinic are diabetic — but how many times did I do a diabetic foot exam?"

So, Kurapati conducted a chart review, asking the secretary to pull three random weeks of patients. "During that period we saw 60 or so patients, and 20 were diabetic — of whom none had received a foot exam in the last year," she reports. "Unfortunately, I don't think we're alone."

She saw this as "A good way to demonstrate that a small and meaningful intervention could be done anywhere." She then created a little note: "If your patient is diabetic, please remember to perform and document a diabetic foot exam." Then, on a random Saturday, she had every chart reviewed. There were only 10 patients that day; of the 10, three were diabetic, and two of those three received proper foot exams.

"The intervention was not as robust as I would have liked, but it demonstrated to me, and to those who ran the clinic, that with very little effort we can improve basic care," says Kurapati. "After a small intervention we realized we could make a big change."

Student becomes educator

Kurapati is continuing to spread the word about QI. She has created an elective for fourth–year students in QI at Loyola. "I drew heavily on IHI and on Dr. Chad Whelan, director of the hospitalist program, who's been a tremendous resource and mentor," she says. "I told him I wanted others to learn about QI, and he took it head on, agreeing to teach the course."

Kurapati says she will be doing a knowledge-based assessment to see how much the students know about QI. Meanwhile, she says, there is hope that Loyola will incorporate the course into its curriculum.

In addition, using her diabetes initiative as a springboard, she is now creating a QI model for medical student-run clinics. "There is not one article in the literature on QI in medical students," she notes, adding that she discovered that fact after asking the school librarian to research the matter.

"The next step is not there, but in how it is applied," she emphasizes. "Students are so interested in this effort, and almost every single medical school has a student-run clinic."

A role for quality managers

Both Kurapati and Duncan say there is a definite role for quality managers as mentors of medical students. "I absolutely believe that; it's important to have them as mentors," says Kurapati. "At Loyola, you're given a three- or four-year rotation that takes you everywhere, and it may be hard to consistently engage in a QI initiative, but at Loyola the quality managers have been incredibly open to speaking with me and getting involved in whatever capacity I wanted them to."

She says that mentorships are "desperately needed among students," and that if it is not possible to do it in person it could be handled via e-mail. "Quality managers or patient safety officers could teach QI to students, as well as to the other health care professionals," she says.

"We have five hospitals where we are doing a small test with some local chapters; they are paired with a local hospital to see how they mentor these students who have expressed an interest," says Duncan. She adds that this program is "just getting started," and that interested quality managers can contact her at openschool@ihi.org or jduncan@ihi.org.

In addition, says Duncan, "We really hope hospitals will begin to see students as another partner in the community, so they can engage them while they're still students and can be influenced in an important way into thinking about quality of care and safety. It's a unique opportunity to do this while they're receptive to change, as opposed to them seeing it as something they just have to do as part of their jobs."

At present, she says, 25 chapters have been started in health systems, and "They are usually started in the quality department."

Kurapati adds that the school will "absolutely" impact quality and patient safety in U.S. hospitals. "There is a gap in education and training that students desperately need filled," she notes. "Also, students can feel incredibly empowered. As part of the hierarchy, you are at the bottom, but you're also not mired in the quagmire of the status quo; you can bring a fresh perspective. When students feel that there are small interventions which can do a lot to impact patient care, that's really empowering."

[For additional information, contact:

Jill Duncan, RN, MSN, MPH, director of IHI's Open School. Phone: (617) 301-4832.]