AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.
Chief Resident for Quality Improvement and Patient Safety: A Description
LeeAnn M. Cox, MD,a Laura C. Fanucchi, MD,b Noelle C. Sinex, MD,a Alexander M. Djuricich, MD,c Lia S. Logio, MDd a
Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Ind; bUniversity of Kentucky College of Medicine, Lexington; cIndiana University School of Medicine, Indianapolis; dWeill Cornell Medical College, Department of Medicine, New York, NY.
It has been approximately 15 years since the release of the Institute of Medicine report To Err Is Human: Building a Safer Health System.1 Although hospital systems devote considerable resources to quality improvement and patient safety, and residency programs incorporate experiential and didactic learning in quality improvement and patient safety, alignment and coordination of these 2 entities have not gained traction.2-7 The Accreditation Council for Graduate Medical Education has recognized that to fully prepare residents for practice in the current healthcare environment, a cultural shift toward learning and improving is required of training programs. These domains are explicitly included in the Next Accreditation System. However, resources, faculty time, and faculty expertise often limit the full development of these initiatives.7-9 Historically, the internal medicine chief resident served primarily as an educator, but the role has expanded Funding: Veterans Administration Graduate Medical Education Innovations Program for CRQPS in the Department of Medicine at Indiana University and Department of Medicine at Weill Cornell Medical College for CRQPS at New York Presbyterian Hospital/ Weill Cornell campus. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Lia S. Logio, MD, Weill Cornell Medical College, Department of Medicine, 525 East 68th St, M507, New York, NY 10065. E-mail address: [email protected]
and evolved to include administrative responsibilities and clinical assignments, as well as to serve as the middle manager for the program.10,11 As a natural liaison between the department, the hospital, and the training program, the chief resident can be uniquely positioned to champion quality improvement and patient safety, but given the numerous other duties, it may be challenging to add meaningful involvement in quality improvement and patient safety.12 The internal medicine residency programs at Indiana University School of Medicine (Indiana) and New York-Presbyterian Hospital/Weill Cornell Medical College (Cornell) created a new position: the chief resident for quality and safety (CRQS). To our knowledge, this article is the first to describe the CRQS.
CHIEF RESIDENT FOR QUALITY AND SAFETY DEVELOPMENT: ONE MODEL, TWO INSTITUTIONS The organizational structures of the teaching hospitals at Indiana and Cornell differ. At Indiana, 145 internal medicine residents rotate through 4 hospitals in downtown Indianapolis, including a Veterans Administration (VA) hospital, county hospital, tertiary care hospital, and community hospital. This system is home to the only allopathic medical school and is 1 of 3 internal medicine residency programs in the state. In contrast, 129 residents at Cornell spend approximately 90% of their time in the primary teaching hospital on the Upper
0002-9343/$ -see front matter Ó 2014 Alliance for Academic Internal Medicine. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.02.034
AAIM Perspectives
AAIM Perspectives
566
The American Journal of Medicine, Vol 127, No 6, June 2014
East Side of Manhattan. This urban setting includes a written quality improvement proposal. Quality im3 other teaching hospitals in Manhattan and more than provement 201 builds this foundation and introduces 30 internal medicine residency programs across the 5 residents to LEAN methodology during a week-long, boroughs of the city of New York. experiential learning process.14,15 The internal medicine residency at Indiana, with At Cornell, the CRQS partners with both an outpafunding from the VA Graduate Medical Education tient attending and hospitalist to deliver didactics and Enhancement program, initiated mentor resident projects during the CRQS in July 2009. The 2 distinct curricula. Over 6 to PERSPECTIVES VIEWPOINTS program at Cornell, through 12 months, postgraduate year funds from a vacant general As a natural liaison between the 2 residents learn and use the medicine departmental fellowdepartment, the hospital, and the model for improvement (planship fund, created a similar training program, the chief resident can do-study-act cycle) within the position in July 2011. One of context of their outpatient pracbe uniquely positioned to champion the authors (LSL) moved from tices, whereas postgraduate year quality improvement and patient safety, 3 residents revisit the concepts Indiana to Cornell and recrebut given the numerous other duties, it during a 2-week intensive asated the model in the new may be challenging to add meaningful signment applying quality imlocale. The original CRQS job involvement. description included 4 main provement methods to address components: clinical activities, The chief resident for quality and safety important predefined problems educational activities, scholarjob description includes 4 main com- within the inpatient units. ship production, and leadership ponents: clinical activities, educational development in quality improveactivities, scholarship production, and Supervising Patient Safety ment and patient safety. The poleadership development in quality im- Rotation sitions in the 2 programs have Another common CRQS role is provement and patient safety. diverged slightly to accommosupervision of the patient safety date the local needs of each resi Specific challenges in creating a chief rotation. Both programs sponsor dency program but continue to resident for quality and safety include a dedicated patient safety elechave a striking overlap. securing funding sources, providing tive in which residents gain adequate training, and integrating the experiential learning in patient new position among existing chief safety concepts. In addition to Clinical Activities participating in a variety of The clinical activities include residents. hospital and department quality attending on the general mediimprovement and patient safety cine inpatient teaching services committees, the patient safety residents perform safety and a half-day of outpatient medicine; at Indiana, they “consults,” investigating care that did not go as intenalso include supervising a half-day transitions clinic that ded to identify contributing factors, suggest ideas to serves patients in the vulnerable post-hospitalization mitigate similar events in the future, and provide period. By working on the frontlines of clinical care follow-up to the gap identifiers. The CRQS provides beside residents, the CRQS is able to both model good supervision and mentorship to the safety residents, stewardship in patient safety and translate realistic clinical shepherding them to key leaders and resources to aid context into quality improvement and patient safety opin their understanding of the complex system. An portunities. Clinical activities purposefully comprise less experienced faculty member serves as the course dithan 25% of the time, which allows the CRQS the flexirector. The safety consults provide a readily available bility to be immersed in the various ad hoc activities mechanism for busy residents involved in patient care related to quality improvement and patient safety. to raise issues and concerns. As a result, a wide variety of systems issues, lapses in care, and near misses are Educational Activities identified and addressed. Educational duties comprise the largest component of the CRQS position, with the primary responsibility to Facilitating Patient Safety Conferences coordinate curriculum delivery described in more detail. At both Indiana and Cornell, the residency programs reconfigured the traditional morbidity and mortality Curriculum Delivery conference into a monthly interprofessional, actionoriented Patient Safety Conference. The CRQS faciliAt Indiana, the CRQS delivers and oversees a 2-tier tates and coordinates with the safety elective resident quality improvement curricula. Quality improvement to present a case for discussion, inviting key stake101 consists of an introduction to the model for imholders (faculty, staff, and administration) to attend. provement5,13 and culminates in an attempt to implement
Cox et al
Chief Resident for Quality and Patient Safety
The conference promotes an open discussion about the safety issues to foster interprofessional collaboration and to develop realistic action items with stakeholder commitment. Invited disciplines have included other clinical departments, nursing, pharmacy, respiratory therapy, social work, informatics, and hospital administration. The CRQS tracks the follow-through on action items generated during the Patient Safety Conference discussions and identifies residents to participate.
Scholarship Production In addition to the clinical and educational activities, each CRQS is expected to choose one clearly defined project, identify a mentor, and produce a scholarly paper, poster, or presentation as the first author. The CRQS also may collaborate on other academic efforts with the residency program, department, and hospital. The CRQS at both Indiana and Cornell have had peerreviewed publications, presentations, workshops, and posters at local and national conferences.
Leadership Development Finally, an additional component of the CRQS position is leadership and career development. Each individual CRQS receives direct mentorship by the quality improvement and patient safety leaders to develop selfawareness and other leadership skills. The CRQS sits on several key departmental and institutional committees, representing the frequently overlooked learner perspective. Given the precarious position of sitting between the various stakeholders, the CRQS receives hands-on training in diplomacy, negotiation, and management of complex situations. It is important to note that all but one former CRQS (n ¼ 8) have obtained jobs that include dedicated time or effort devoted to quality improvement/patient safety.
567 quality improvement and patient safety; hands-on experience with the methodologies, tools, and curriculum; and personal introduction to the institutional stakeholders. The CRQS also learns techniques in facilitating difficult conversations.15 National programs offered annually also can be used to prepare the CRQS. Even with deliberate efforts to seamlessly hand off responsibilities from the outgoing CRQS to the incoming, a steep learning curve is required for each new CRQS. An overlap of the incoming and outgoing CRQS can provide important mentorship and has proven useful. Finally, integrating the CRQS position with that of previously established chief residents is best managed through ensuring transparency of roles, duties, and activities. There are important limitations to this description of the CRQS role. First, this model conforms to the tradition in internal medicine in which the chief resident serves an additional year. Smaller programs or disciplines with chief residents serving concurrently to the final year of training may choose to adopt only portions of the model. Further, we acknowledge that faculty time and other resources may be more limited in some settings. Each training program will have unique challenges in integrating quality improvement and patient safety education. Of note, the CRQS model has spread to other academic programs and departments across the VA system, including psychiatry and anesthesia. It cannot be understated that the success of this model at these 2 large academic institutions hinged on strong cooperation and alignment that promoted the efforts of the CRQS and reinforced its value across the organization. Direct integration with the existing infrastructure of risk management and patient safety management, and identification of mentors across the institution are key to early and continued success of the CRQS. One residency program leader should be tasked with directly supervising, mentoring, and monitoring the individual’s progress to ensure greater success.
CHALLENGES, LIMITATIONS, AND LESSONS LEARNED
CONCLUSIONS
Specific challenges in creating a CRQS position include securing funding sources, providing adequate training, and integrating the new position among existing chief residents. As previously noted, the initial funding mechanisms in these 2 institutions were different (VA vs departmental monies) and have been revisited at Cornell so that now the position is funded in the same model as the other chief resident position (hospital and department support). The hospital identified the value of CRQS and wanted to support and grow the role. Training and transitioning each individual CRQS year to year are key elements to anticipate in planning for training. A CRQS needs to quickly master new knowledge, skills, and tools within patient safety and improvement science. An intense CRQS orientation should include an overview of the key concepts of
A dedicated CRQS position yields tangible and sustained benefits for residency education and the larger hospital organization. The CRQS encourages resident involvement in institutional projects and promotes patient safety and quality improvement skill development necessary to thrive in our rapidly changing, complex healthcare delivery system.16 Individuals newly in the position as CRQS will encounter challenges of defining the role, fitting within the residency program structure, and leveraging the position within the organization. Each CRQS will have specific scholarly interests, but projects and initiatives should be defined as core to the role and should be prioritized and continued from one CRQS to the next for sustained improvements. Culture change toward accepting and integrating the CRQS can happen quickly if stakeholders realize the return on
568
The American Journal of Medicine, Vol 127, No 6, June 2014
investment. It swiftly results in increased demand for physician participation in quality improvement and patient safety activities and creates motivation for the hospital system to invest in CRQS positions. The leadership training and academic opportunity provided to individuals serving as CRQS provide real experience in navigating the complexities of the healthcare delivery system. Other excellent programs focus on training leaders in quality improvement and patient safety, but the CRQS role is unique in that it builds on an existing and trusted model for apprenticeship and learning. We anticipate that as the Accreditation Council for Graduate Medical Education moves into the Next Accreditation System and its Clinical Learning Environment Review, the CRQS model may be adopted broadly in teaching hospitals. The CRQS can facilitate deliverable and measurable value around 3 of the 6 areas of focus of Clinical Learning Environment Review: patient safety, quality improvement, and transitions. Finally, the position provides on-the-job-training for conflict management, influencing others, and viewing events through an interprofessional lens. It encourages respect and collaboration, and the recognition that expertise is found at all levels of the healthcare delivery system. As suggested by Pronovost,17 creating a pipeline for leaders in quality improvement and patient safety within medical schools and teaching hospitals is a necessary step to move healthcare improvements forward.
ACKNOWLEDGMENTS The authors thank the following for their support and dedication to the CRQS position: Indiana: Tyler Davis, MD, Liam Howley, MD, Anne Kitchens, MD, David Miller, MD, Heather Woodward-Hagg, MS, and Cheryl Stultz, RN, MSN, CPHQ. Cornell: Eugenia Siegler, MD, Joseph Cooke, MD, Jennifer Lee, MD, Cathy Jalali, PhD, and Brian Eiss, MD.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999. 2. Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency training. Acad Med. 2008;83:1080-1087.
3. Flanagan B, Nestel D, Joseph M. Making patient safety the focus: crisis resource management in the undergraduate curriculum. Med Educ. 2004;38:56-66. 4. Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ. 2005;39: 1195-1204. 5. Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: addressing core competency, improving systems. Acad Med. 2004;79(10 Suppl): S65-S67. 6. Canal DF, Torbeck L, Djuricich AM. Practice-based learning and improvement: a curriculum in continuous quality improvement for surgery residents. Arch Surg. 2007;142:479-483. 7. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85:1425-1439. 8. Cox LM, Logio LS. Patient safety stories: a project utilizing narratives in resident training. Acad Med. 2011;86:1473-1478. 9. Varkey P, Karlapudi S, Rose S, Swensen S. A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts. Am J Med Qual. 2009;24:214-221. 10. Steel K. The medical chief residency in university hospitals. Ann Intern Med. 1972;76:541-544. 11. Berg DN, Huot SJ. Middle manager role of the chief medical resident: an organizational psychologist’s perspective. J Gen Intern Med. 2007;22:1771-1774. 12. Eliastam M, Mizrahi T. Quality improvement, housestaff, and the role of chief residents. Acad Med. 1996;71:670-674. 13. Institute for Health Care Improvement. How to Improve. 2012; Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ default.aspx. Accessed February 28, 2014. 14. Hagg HW, Workman-Germann J, Flanagan M, et al. Implementation of systems redesign: approaches to spread and sustain adoption. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality; 2008. 15. Woodward H, Woodbridge PA. RPIW Participant Fieldbook: Guide to the Rapid Process Improvement Workshop. Available at: www.paloalto.va.gov/docs/va_rpiw_fieldbook_paloalto_adaptation. pdf. Accessed February 28, 2014. 16. Lucian Leape Institute at the National Patient Safety Foundation. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: National Patient Safety Foundation; 2010. 17. Pronovost PJ. Bridging the leadership development gap: recommendations for medical education. Acad Med. 2012;87: 550.
Chief Resident for Quality Improvement and Patient Safety: A Description
LeeAnn M. Cox, MD,a Laura C. Fanucchi, MD,b Noelle C. Sinex, MD,a Alexander M. Djuricich, MD,c Lia S. Logio, MDd a
Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Ind; bUniversity of Kentucky College of Medicine, Lexington; cIndiana University School of Medicine, Indianapolis; dWeill Cornell Medical College, Department of Medicine, New York, NY.
It has been approximately 15 years since the release of the Institute of Medicine report To Err Is Human: Building a Safer Health System.1 Although hospital systems devote considerable resources to quality improvement and patient safety, and residency programs incorporate experiential and didactic learning in quality improvement and patient safety, alignment and coordination of these 2 entities have not gained traction.2-7 The Accreditation Council for Graduate Medical Education has recognized that to fully prepare residents for practice in the current healthcare environment, a cultural shift toward learning and improving is required of training programs. These domains are explicitly included in the Next Accreditation System. However, resources, faculty time, and faculty expertise often limit the full development of these initiatives.7-9 Historically, the internal medicine chief resident served primarily as an educator, but the role has expanded Funding: Veterans Administration Graduate Medical Education Innovations Program for CRQPS in the Department of Medicine at Indiana University and Department of Medicine at Weill Cornell Medical College for CRQPS at New York Presbyterian Hospital/ Weill Cornell campus. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Lia S. Logio, MD, Weill Cornell Medical College, Department of Medicine, 525 East 68th St, M507, New York, NY 10065. E-mail address: [email protected]
and evolved to include administrative responsibilities and clinical assignments, as well as to serve as the middle manager for the program.10,11 As a natural liaison between the department, the hospital, and the training program, the chief resident can be uniquely positioned to champion quality improvement and patient safety, but given the numerous other duties, it may be challenging to add meaningful involvement in quality improvement and patient safety.12 The internal medicine residency programs at Indiana University School of Medicine (Indiana) and New York-Presbyterian Hospital/Weill Cornell Medical College (Cornell) created a new position: the chief resident for quality and safety (CRQS). To our knowledge, this article is the first to describe the CRQS.
CHIEF RESIDENT FOR QUALITY AND SAFETY DEVELOPMENT: ONE MODEL, TWO INSTITUTIONS The organizational structures of the teaching hospitals at Indiana and Cornell differ. At Indiana, 145 internal medicine residents rotate through 4 hospitals in downtown Indianapolis, including a Veterans Administration (VA) hospital, county hospital, tertiary care hospital, and community hospital. This system is home to the only allopathic medical school and is 1 of 3 internal medicine residency programs in the state. In contrast, 129 residents at Cornell spend approximately 90% of their time in the primary teaching hospital on the Upper
0002-9343/$ -see front matter Ó 2014 Alliance for Academic Internal Medicine. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.02.034
AAIM Perspectives
AAIM Perspectives
566
The American Journal of Medicine, Vol 127, No 6, June 2014
East Side of Manhattan. This urban setting includes a written quality improvement proposal. Quality im3 other teaching hospitals in Manhattan and more than provement 201 builds this foundation and introduces 30 internal medicine residency programs across the 5 residents to LEAN methodology during a week-long, boroughs of the city of New York. experiential learning process.14,15 The internal medicine residency at Indiana, with At Cornell, the CRQS partners with both an outpafunding from the VA Graduate Medical Education tient attending and hospitalist to deliver didactics and Enhancement program, initiated mentor resident projects during the CRQS in July 2009. The 2 distinct curricula. Over 6 to PERSPECTIVES VIEWPOINTS program at Cornell, through 12 months, postgraduate year funds from a vacant general As a natural liaison between the 2 residents learn and use the medicine departmental fellowdepartment, the hospital, and the model for improvement (planship fund, created a similar training program, the chief resident can do-study-act cycle) within the position in July 2011. One of context of their outpatient pracbe uniquely positioned to champion the authors (LSL) moved from tices, whereas postgraduate year quality improvement and patient safety, 3 residents revisit the concepts Indiana to Cornell and recrebut given the numerous other duties, it during a 2-week intensive asated the model in the new may be challenging to add meaningful signment applying quality imlocale. The original CRQS job involvement. description included 4 main provement methods to address components: clinical activities, The chief resident for quality and safety important predefined problems educational activities, scholarjob description includes 4 main com- within the inpatient units. ship production, and leadership ponents: clinical activities, educational development in quality improveactivities, scholarship production, and Supervising Patient Safety ment and patient safety. The poleadership development in quality im- Rotation sitions in the 2 programs have Another common CRQS role is provement and patient safety. diverged slightly to accommosupervision of the patient safety date the local needs of each resi Specific challenges in creating a chief rotation. Both programs sponsor dency program but continue to resident for quality and safety include a dedicated patient safety elechave a striking overlap. securing funding sources, providing tive in which residents gain adequate training, and integrating the experiential learning in patient new position among existing chief safety concepts. In addition to Clinical Activities participating in a variety of The clinical activities include residents. hospital and department quality attending on the general mediimprovement and patient safety cine inpatient teaching services committees, the patient safety residents perform safety and a half-day of outpatient medicine; at Indiana, they “consults,” investigating care that did not go as intenalso include supervising a half-day transitions clinic that ded to identify contributing factors, suggest ideas to serves patients in the vulnerable post-hospitalization mitigate similar events in the future, and provide period. By working on the frontlines of clinical care follow-up to the gap identifiers. The CRQS provides beside residents, the CRQS is able to both model good supervision and mentorship to the safety residents, stewardship in patient safety and translate realistic clinical shepherding them to key leaders and resources to aid context into quality improvement and patient safety opin their understanding of the complex system. An portunities. Clinical activities purposefully comprise less experienced faculty member serves as the course dithan 25% of the time, which allows the CRQS the flexirector. The safety consults provide a readily available bility to be immersed in the various ad hoc activities mechanism for busy residents involved in patient care related to quality improvement and patient safety. to raise issues and concerns. As a result, a wide variety of systems issues, lapses in care, and near misses are Educational Activities identified and addressed. Educational duties comprise the largest component of the CRQS position, with the primary responsibility to Facilitating Patient Safety Conferences coordinate curriculum delivery described in more detail. At both Indiana and Cornell, the residency programs reconfigured the traditional morbidity and mortality Curriculum Delivery conference into a monthly interprofessional, actionoriented Patient Safety Conference. The CRQS faciliAt Indiana, the CRQS delivers and oversees a 2-tier tates and coordinates with the safety elective resident quality improvement curricula. Quality improvement to present a case for discussion, inviting key stake101 consists of an introduction to the model for imholders (faculty, staff, and administration) to attend. provement5,13 and culminates in an attempt to implement
Cox et al
Chief Resident for Quality and Patient Safety
The conference promotes an open discussion about the safety issues to foster interprofessional collaboration and to develop realistic action items with stakeholder commitment. Invited disciplines have included other clinical departments, nursing, pharmacy, respiratory therapy, social work, informatics, and hospital administration. The CRQS tracks the follow-through on action items generated during the Patient Safety Conference discussions and identifies residents to participate.
Scholarship Production In addition to the clinical and educational activities, each CRQS is expected to choose one clearly defined project, identify a mentor, and produce a scholarly paper, poster, or presentation as the first author. The CRQS also may collaborate on other academic efforts with the residency program, department, and hospital. The CRQS at both Indiana and Cornell have had peerreviewed publications, presentations, workshops, and posters at local and national conferences.
Leadership Development Finally, an additional component of the CRQS position is leadership and career development. Each individual CRQS receives direct mentorship by the quality improvement and patient safety leaders to develop selfawareness and other leadership skills. The CRQS sits on several key departmental and institutional committees, representing the frequently overlooked learner perspective. Given the precarious position of sitting between the various stakeholders, the CRQS receives hands-on training in diplomacy, negotiation, and management of complex situations. It is important to note that all but one former CRQS (n ¼ 8) have obtained jobs that include dedicated time or effort devoted to quality improvement/patient safety.
567 quality improvement and patient safety; hands-on experience with the methodologies, tools, and curriculum; and personal introduction to the institutional stakeholders. The CRQS also learns techniques in facilitating difficult conversations.15 National programs offered annually also can be used to prepare the CRQS. Even with deliberate efforts to seamlessly hand off responsibilities from the outgoing CRQS to the incoming, a steep learning curve is required for each new CRQS. An overlap of the incoming and outgoing CRQS can provide important mentorship and has proven useful. Finally, integrating the CRQS position with that of previously established chief residents is best managed through ensuring transparency of roles, duties, and activities. There are important limitations to this description of the CRQS role. First, this model conforms to the tradition in internal medicine in which the chief resident serves an additional year. Smaller programs or disciplines with chief residents serving concurrently to the final year of training may choose to adopt only portions of the model. Further, we acknowledge that faculty time and other resources may be more limited in some settings. Each training program will have unique challenges in integrating quality improvement and patient safety education. Of note, the CRQS model has spread to other academic programs and departments across the VA system, including psychiatry and anesthesia. It cannot be understated that the success of this model at these 2 large academic institutions hinged on strong cooperation and alignment that promoted the efforts of the CRQS and reinforced its value across the organization. Direct integration with the existing infrastructure of risk management and patient safety management, and identification of mentors across the institution are key to early and continued success of the CRQS. One residency program leader should be tasked with directly supervising, mentoring, and monitoring the individual’s progress to ensure greater success.
CHALLENGES, LIMITATIONS, AND LESSONS LEARNED
CONCLUSIONS
Specific challenges in creating a CRQS position include securing funding sources, providing adequate training, and integrating the new position among existing chief residents. As previously noted, the initial funding mechanisms in these 2 institutions were different (VA vs departmental monies) and have been revisited at Cornell so that now the position is funded in the same model as the other chief resident position (hospital and department support). The hospital identified the value of CRQS and wanted to support and grow the role. Training and transitioning each individual CRQS year to year are key elements to anticipate in planning for training. A CRQS needs to quickly master new knowledge, skills, and tools within patient safety and improvement science. An intense CRQS orientation should include an overview of the key concepts of
A dedicated CRQS position yields tangible and sustained benefits for residency education and the larger hospital organization. The CRQS encourages resident involvement in institutional projects and promotes patient safety and quality improvement skill development necessary to thrive in our rapidly changing, complex healthcare delivery system.16 Individuals newly in the position as CRQS will encounter challenges of defining the role, fitting within the residency program structure, and leveraging the position within the organization. Each CRQS will have specific scholarly interests, but projects and initiatives should be defined as core to the role and should be prioritized and continued from one CRQS to the next for sustained improvements. Culture change toward accepting and integrating the CRQS can happen quickly if stakeholders realize the return on
568
The American Journal of Medicine, Vol 127, No 6, June 2014
investment. It swiftly results in increased demand for physician participation in quality improvement and patient safety activities and creates motivation for the hospital system to invest in CRQS positions. The leadership training and academic opportunity provided to individuals serving as CRQS provide real experience in navigating the complexities of the healthcare delivery system. Other excellent programs focus on training leaders in quality improvement and patient safety, but the CRQS role is unique in that it builds on an existing and trusted model for apprenticeship and learning. We anticipate that as the Accreditation Council for Graduate Medical Education moves into the Next Accreditation System and its Clinical Learning Environment Review, the CRQS model may be adopted broadly in teaching hospitals. The CRQS can facilitate deliverable and measurable value around 3 of the 6 areas of focus of Clinical Learning Environment Review: patient safety, quality improvement, and transitions. Finally, the position provides on-the-job-training for conflict management, influencing others, and viewing events through an interprofessional lens. It encourages respect and collaboration, and the recognition that expertise is found at all levels of the healthcare delivery system. As suggested by Pronovost,17 creating a pipeline for leaders in quality improvement and patient safety within medical schools and teaching hospitals is a necessary step to move healthcare improvements forward.
ACKNOWLEDGMENTS The authors thank the following for their support and dedication to the CRQS position: Indiana: Tyler Davis, MD, Liam Howley, MD, Anne Kitchens, MD, David Miller, MD, Heather Woodward-Hagg, MS, and Cheryl Stultz, RN, MSN, CPHQ. Cornell: Eugenia Siegler, MD, Joseph Cooke, MD, Jennifer Lee, MD, Cathy Jalali, PhD, and Brian Eiss, MD.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999. 2. Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency training. Acad Med. 2008;83:1080-1087.
3. Flanagan B, Nestel D, Joseph M. Making patient safety the focus: crisis resource management in the undergraduate curriculum. Med Educ. 2004;38:56-66. 4. Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ. 2005;39: 1195-1204. 5. Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: addressing core competency, improving systems. Acad Med. 2004;79(10 Suppl): S65-S67. 6. Canal DF, Torbeck L, Djuricich AM. Practice-based learning and improvement: a curriculum in continuous quality improvement for surgery residents. Arch Surg. 2007;142:479-483. 7. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85:1425-1439. 8. Cox LM, Logio LS. Patient safety stories: a project utilizing narratives in resident training. Acad Med. 2011;86:1473-1478. 9. Varkey P, Karlapudi S, Rose S, Swensen S. A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts. Am J Med Qual. 2009;24:214-221. 10. Steel K. The medical chief residency in university hospitals. Ann Intern Med. 1972;76:541-544. 11. Berg DN, Huot SJ. Middle manager role of the chief medical resident: an organizational psychologist’s perspective. J Gen Intern Med. 2007;22:1771-1774. 12. Eliastam M, Mizrahi T. Quality improvement, housestaff, and the role of chief residents. Acad Med. 1996;71:670-674. 13. Institute for Health Care Improvement. How to Improve. 2012; Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ default.aspx. Accessed February 28, 2014. 14. Hagg HW, Workman-Germann J, Flanagan M, et al. Implementation of systems redesign: approaches to spread and sustain adoption. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality; 2008. 15. Woodward H, Woodbridge PA. RPIW Participant Fieldbook: Guide to the Rapid Process Improvement Workshop. Available at: www.paloalto.va.gov/docs/va_rpiw_fieldbook_paloalto_adaptation. pdf. Accessed February 28, 2014. 16. Lucian Leape Institute at the National Patient Safety Foundation. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: National Patient Safety Foundation; 2010. 17. Pronovost PJ. Bridging the leadership development gap: recommendations for medical education. Acad Med. 2012;87: 550.
