An exercise which examines some aspect of the resident or fellow’s practice to identify an area in need of improvement, and then implements a plan to bring about improvement in patient outcomes. Quality improvement projects do not generate new concepts or practices; instead they apply existing medical knowledge to improve outcomes for patients.
Some examples of quality improvement projects are summarized here:
A group of residents has decided to work on how growth in patients in the continuity clinic can be better tracked. First, they document their current tracking percentage; they look at 100 charts. Then they introduce a reminder system to improve such data. Several months after the change has been implemented, they check another 100 charts to see if the change has resulted in improved tracking.
A fellow has decided to work on reducing infection rates for a particular procedure. He thinks his rates exceed those of other fellows for the procedure. He decides to work on compliance with techniques known to reduce infections associated with the procedure. The fellow then introduces a new system of doing the procedure that increases the chance of completing the procedure in the expected way without infection. The fellow tracks the technique used and the rate of infection in the future related to the procedure.
A resident has studied her sign-outs on the inpatient service and noticed that the information she often provides has omissions and errors. At the urging of a faculty mentor, she decides to examine her own performance along with that of her colleagues. With the help of the Quality Improvement Department at the hospital, she gathers a sample of morning, evening, and weekend sign-outs. The sessions are analyzed for omissions and errors. An SBAR format is implemented, and the sign-out template is revised. Residents are trained to use the new format and omissions and errors are reviewed again two months later. The fellow documents improvement in her own performance, as well as reduced errors for all involved in the new approach. Data are used to further modify the sign-out template. This project can be seen as an example of a practice-based learning and improvement or a systems-based practice project. Since the project enhanced and improved individual practice, it was framed as a quality improvement project (practice-based learning and improvement), but since it also had a positive effect on the overall system within which the fellow works, it can also be seen and presented as an example of a systems-based practice project.
A fellow feels that her shift assignments in the Emergency Department (ED) are too long. She is convinced that after eight hours, she works slower and is more likely to make errors. She works with the faculty member in the ED to identify ways to track the patients seen by fellow providers. All medication errors are tracked through the electronic medical record (EMR). After obtaining IRB approval, the fellow and faculty member work to randomly assign fellows to either eight- or 10-hour shifts. The fellow reviews and compares her own performance relative to performance errors, and reports are generated across all fellows. Results are presented at the annual program evaluation and an action plan is determined. This example can also be seen from either a practice-based learning and improvement or systems-based practice perspective. Because this was conceived of and implemented by an individual fellow to improve her work, it is a practice-based learning and improvement example. However, because the project had an impact on the overall system, it is also an example of a systems-based practice project.
A practice-based learning and improvement quality improvement project involves residents/fellows looking at ways to improve their own individual practice outcomes.
A systems-based practice project is aimed at identifying systems issues within the program or institution that increase the occurrence of errors. The goal of a systems-based practice project is to create changes to improve all providers' work environment. However, a quality improvement project can be seen as both practice-based learning and improvement and systems-based practice, depending on how it is planned, implemented, and presented.
Two additional systems-based practice project examples are provided here:
Fellows notice that the wrong size bag and mask are at the bedside when they are called to provide care to an infant in respiratory distress. The fellows work with other health care team providers and those skilled in evaluating and addressing systems problems to analyze how often such errors occur. An intervention is implemented to reduce such errors. The fellows monitor error incidence rates after the intervention has been made.
A resident is concerned with the lack of proper patient monitoring after undergoing a procedure. Working with those skilled in evaluating and addressing systems problems, she determines the frequency and consequences of this problem, and tries to compare it to rates of occurrence elsewhere. She studies possible interventions and implements one. She then tracks the frequency of improper monitoring and/or its consequences as a result of the intervention.
Patient safety refers to freedom from accidental or preventable injuries produced by medical care. Thus, practices or interventions that improve patient safety are those that reduce the occurrence of preventable adverse events.
Data about personal practice habits is data provided to residents/fellows and faculty members on quality metrics and benchmarks related to their patient populations. Examples of metrics include, but are not limited to, those provided by the following: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Centers for Medicaid and Medicare Services (CMS), Press Gainey, and National Surgical Quality Improvement Program (NSQIP).
“Transition of care” is the process of relaying complete and accurate patient information between individuals or teams when transferring responsibility for patient care in the healthcare setting.
In the context of medical care and GME, work compression occurs when physicians are required to do the same amount of work in less time.
An interprofessional team is a team made up of physicians and other health professionals appropriate to delivery of care in the specialty. A team made up solely of physicians is not an interprofessional team. Teams may include residents, fellow, faculty, and other clinical support personnel such as nurses, pharmacists, case workers, and dieticians.
Residents are expected to be integrated into and actively participate in clinical quality improvement and patient safety initiatives within their program or sponsoring institution.