Grooming the next QI physician champion
Let them learn by doing
It can be very hard to find a physician champion for quality improvement projects. Docs are busy — there are more responsibilities, patients are sicker, days are longer, and resources are tight. But there is a way to make sure that you have a constant stream of physicians, not just to take a grudging lead on projects, but to be willing leaders of the quality brigade.
Increasingly, medical education includes some elements of quality education. However, what students learn and the quantity of time they spend on quality improvement education varies. But some of the best programs have good ideas on how to engage students at teaching hospitals in quality improvement in general.
Hiloni Bhavsar, MD, is proof of that. Currently a senior instructor in internal medicine at Case Western Reserve University's Medical School in Cleveland and the university hospital quality institute liaison, Bhavsar started out as a resident in search of a specialty like so many others.
"I did my residency and chief residency here, and until my third year was prepared to go into some sub-specialty fellowship. But as a second- and third-year student, I got involved in our quality improvement program. It got me interested."
In the end, she couldn't let go of it, and with the help of her advisor, who worked in the quality institute, she developed a hybrid position that is 40% clinical, 40% in the quality institute, and 20% working as department liaison for the electronic medical record program.
Case's quality education is in-depth. There is a four-week quality rotation for residents and medical students, as well as didactic instruction on quality improvement theory, metrics, measurement, and reporting.
Residents have to pick a quality improvement project, which they have to present to the appropriate committee just like any other project. For example, if it is a QI project related to medication errors, it would go to the patient safety committee.
That hands-on approach is why Bhavsar says she thinks so many of the students who have gone through quality education since it started in 2009 have stuck with quality after their rotations, after their projects, after they were done with school. "It isn't just a lecture. That's the least part of it," she says.
If you have a quality center or institute, it should be fairly easy to leverage students and residents into the quality infrastructure, she says. "Give them a chance to learn by doing. Let them sit in on meetings where QI projects are reported. Put them in the review meetings for morbidity and mortality so they can see how the system works and where there might be problems."
At Case, the students and residents do just that, and they are responsible for presenting cases before the quality assurance committee in the department of medicine during their course of study, and for answering quality-related questions in those meetings. If a problem is discovered, they are part of the process of determining if it was a system failure or something that relates to communication or education.
Once you get residents interested and working through the system by being a hands-on part of the QI process, you will find it's easier and easier to recruit new students and residents to the process. Bhavsar says that because she is so close in age to the students, they are willing to listen to her wisdom, come to her for help, and let her brainstorm with them for project ideas, ways forward when there is a problem, or proper design of a project. If possible, create a hybrid position for one of those freshly minted quality gurus. "I help create new converts," she says, so it's worth it.
You may have to argue for resident time to participate in quality projects and education, but there is increasing pressure to include this in education for all medical students and residents. If you start now, you can be on the leading edge and thus attract the best students and residents.
Getting buy-in from the leadership helps. You can educate them by pointing them to some of the training programs that make a big deal about quality — like Case (http://medicine.case.edu/residency-program/residents/education/quality-improvement), but also others, such as Stanford University (http://medicine.stanford.edu/education/quality_improvement.html).
Having a full-time quality guru isn't important, she says. You just need someone on the floor who they see working both with patients and with students. Just having that presence can help win over naysayers who don't think it's a good use of resident time to have them working on some quality project that a nurse or someone else could do. "The ones who express the most frustration with what you're doing are the least likely to step up and help you," Bhavsar notes. That makes creating your own team of go-to champions even more important in the future.
While it's true that quality improvement education done right can change the way a physician thinks for the better, Bhavsar says that having resident quality education has changed the culture of the institution as well. "Our residents can and do speak the language of quality — even more than some of the attendings," she says. "All of the didactic material is from presentations that are done for faculty and departments anyway — although possibly with less technical information. We are using the existing infrastructure and parlayed the resources we already have in nursing, risk management, and infection control to make this happen. These people give an hour of their time a month towards this."
It's paid off, too. "You have to expose students to this and increase their understanding of it in this healthcare world as it is now. You can't succeed with complete novices who don't understand this."
The program has gained such renown that other residency programs at Case are looking to adopt it. Neurology is particularly interested, says Bhavsar. "This is beyond just one sub-specialty. It can span them all."
For more information on this topic, contact Hiloni Bhavsar, MD, Senior Instructor, General Internal Medicine, Physician Informaticist, UH Care, UH Quality Institute Liaison. University Hospital, Case Western Reserve University, Cleveland, OH. Telephone: (216) 844-8199.