The Problem
While the ACGME has required EM residency curricula to incorporate quality improvement (QI), programs have faced the challenge of executing this in a meaningful way. How can EM residency programs effectively engage learners in an action-based curriculum for QI?
The Innovation: Action-based learning for initiating QI projects in the ED
A program focused on implementing resident-inspired and resident-driven QI and patient safety initiatives was developed as part of the the EM residency curriculum at Thomas Jefferson University in Philadelphia, PA. The goal was to seamlessly integrate QI into the curriculum while simultaneously motivating residents and faculty to contribute to cultural change and patient safety within the institution.
Learners Targeted
38 EM residents and 6 faculty coaches participated in the curriculum.
Group Size
The educational intervention was designed for the entire residency cohort, with participation from faculty members within the Department’s Education Division.
Materials
Access to Institute for Healthcare Improvement (IHI) modules.
ACGME Milestones
The ACGME Milestones require resident participation in quality-based performance improvement projects.
- Patient Safety (SBP1): “Participates in performance improvement to optimize patient safety”
- Systems-based Management (SBP2): “Participates in strategies to improve healthcare delivery and flow. Demonstrates an awareness of and responsiveness to the larger context and system of health care”
Detailed Description of the Activity
The project was introduced at conference during a two-hour slot. Prior to conference, residents were instructed to begin thinking about how they could make their workplace better.
The faculty coaches were instructed to go through several of the IHI models1:
- Why Engage Trainees in Quality and Safety
- The Faculty Role: Understanding and Modeling the Fundamentals of Quality and Safety
- A Roadmap for Facilitating Experiential Learning in Quality Improvement
- How to Improve with a Model for Improvement
- Testing and Measuring Changes with PDSA Cycles
- Leading Quality Improvement
The IHI theme ‘What ticks you off?’ was introduced to the residency during conference as a 1-hour didactic lecture, and it introduced general QI topics to inspire enthusiasm in resident learners.
After this first hour, the residency cohort was divided into 6 groups, composed of a proportionate amount of PGY-1, 2, and 3 residents. Each group was assigned to a faculty member who served as their QI coach. Most of the faculty involved were junior faculty members, within 5 years of graduation from residency. As described above, faculty coaches referenced tools and skills from the IHI modules they were assigned. Resident leaders were also established in each of the 6 groups; these individuals were either PGY-1 or 2 trainees.
The groups were asked to brainstorm quality and safety problems as vehicles for their projects during this first session. Groups were asked to focus on ideas that could be practically implemented throughout the academic year.
Six ideas and potential implementation plans were developed over the next week under the guidance of their respective faculty coaches and presented to the ED clinical operations leadership at their weekly steering committee meeting.
| Group | QI Project |
| 1 | Improving advance care planning documentation from the emergency room |
| 2 | Improving time to antibiotics and disposition times of patients who are potentially septic in the ED setting |
| 3 | Streamlining the discharge process while improving communications regarding discharge between the nurse and physician and between the patient and physician |
| 4 | Tracking time to consult response and time to consult arrival in order to improve disposition times in the emergency room |
| 5 | Obtaining point of care labs to improve disposition times and decrease rates of lab hemolysis |
| 6 | Participating in regular rounds to improve patient care and time to disposition |
Most projects involved a multidisciplinary, inter-professional approach. For example, the group that focused on streamlining the discharge process incorporated a working group that involved nursing staff interested in the topic.
These projects will continue through until the end of the academic year. Resident teams will be expected to submit, and hopefully present, their work and scholarship as poster presentations at local and national conferences.
Lessons Learned
Enthusiasm for implementing these projects was highest after the initial introduction of the program. Six smaller email groups were developed to keep communication going in between in-person meetings. The faculty leader was also tasked with keeping each group moving forward, and an hour of conference was devoted to allowing the small groups to meet. These aspects of the innovation helped maintain engagement.
Another identified obstacle was moving forward with projects while adapting to new changes within the institution and healthcare system. For example, our institution has been in the process of switching to the EPIC electronic medical record, which forced our individual groups to adapt their projects correspondingly. However, adapting to a changing landscape is a reality that any individual working on a QI project will face, regardless of institution. This aspect of the program has taught learners to be dynamic with ideas.
Theory Behind the Innovation/Closing Thoughts
The educational philosophy behind this curriculum-based QI initiative is rooted in action-based learning. Marquardt et al. describes how action-based learning has been implemented as a problem-solving tool at various large companies to develop strategic advantages successfully.2 They describe action-based learning as “a dynamic process that involves a small group of people solving real organizational problems, while focusing on how their learning can benefit individuals, groups, and the larger organization.”2
Action-based learning solves problems and develops leaders. This innovation aims to teach residents how to solve problems frequently faced in the ED while also developing leadership skills. Residents are developing the confidence to speak up and make changes in our department and hospital, and are developing iterative plans to carry out their projects. They are learning how to face challenges and become more dynamic in their approach to improving patient safety and clinical quality.
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