549012
research-article2014
AJMXXX10.1177/1062860614549012American Journal of Medical QualityAbookire et al
Article
Creating a Fellowship Curriculum in Patient Safety and Quality
American Journal of Medical Quality 1–4 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614549012 ajmq.sagepub.com
Susan A. Abookire, MD, MPH1, Tejal K. Gandhi, MD, MPH2, Allen Kachalia, MD, JD3, Kenneth Sands, MD, MPH4, Elizabeth Mort, MD, MPH5, Grace Bommarito6, Jane Gagne7, Luke Sato, MD7, and Saul N. Weingart, MD, PhD8
Abstract The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School–affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article “Design and Implementation of the Harvard Fellowship in Patient Safety and Quality.” The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts. The process of curriculum development and the ultimate content are described in this article. Keywords patient safety, medical education, postgraduate training, quality Transforming and improving health care are national and international priorities. Efforts to reform health care; reduce cost; realign payment models; define, measure, and improve quality; and ensure patient safety are under way worldwide. However, few existing postgraduate training programs offer physicians the opportunity to acquire expertise in these domains.1 A lack of suitable training options is a barrier for physicians who wish to specialize in quality and patient safety and creates a challenge for organizations that seek to recruit professionals who can lead quality and patient safety initiatives. The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School (HMS)-affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article “Design and Implementation of the Harvard Fellowship in Patient Safety and Quality.” The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts.
Methods The HMS Fellowship curriculum development process was based on the 6-step approach to curriculum development outlined by Kern et al.2 Like quality improvement,
curriculum development begins with establishing clarity around needs or a problem to be solved and moving from there to establishing well-defined goals, a plan to achieve them, and a method to measure and evaluate success. This framework proved helpful in organizing a qualitative approach to setting the priorities for the content of the curriculum.
General Needs Assessment As described in the companion article, few graduate training programs exist for physicians to acquire expertise in quality and patient safety.1 This creates a mismatch between the rapidly developing priority for high-quality, low-cost health care and the availability of physician 1
Houston Methodist, Houston, TX National Patient Safety Foundation, Boston, MA 3 Brigham and Women’s Hospital, Boston, MA 4 Beth Israel Deaconess Medical Center, Boston, MA 5 Massachusetts General Hospital, Boston, MA 6 Partners HealthCare System, Boston, MA 7 Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO), Cambridge, MA 8 Tufts Medical Center, Boston, MA 2
Corresponding Author: Tejal K. Gandhi, MD, MPH, National Patient Safety Foundation, 268 Summer St, Boston, MA 02210. Email: [email protected]
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
2
American Journal of Medical Quality
leaders to contribute to realizing those goals.3,4 In addition, expanding physician interest in entering these fields creates a demand that must be met for health care organizations across the spectrum to align around the national goals of quality and reform.
Targeted Needs Assessment Physician leaders in quality and patient safety across HMS institutions achieved leadership roles through a variety of career paths, including public health, research, and systems engineering. Because their expertise had been gained through experience and ongoing learning as the field of quality and patient safety developed, a qualitative needs assessment process was undertaken to determine the fundamental knowledge and skills required for success in these roles. The proposed curriculum derives from the literature and leaders’ experiences in leading, teaching, and mentoring organizational quality and patient safety. Efforts were coordinated by the curriculum director, who had completed a fellowship in medical education.
Establishing Fellowship Objectives Using a consensus-building approach, the faculty leaders in quality and patient safety responded to the following questions: What did you wish you knew as you developed in your leadership role? Describe experiences in your training that were pivotal in shaping you as a successful leader. What roles should graduates of the fellowship program be competent to assume on completion? How would you characterize the essential qualities needed to succeed in your role? How important is it that, and to what extent should, fellows be trained to teach and mentor other physicians in quality and patient safety? Based on discussions that emanated from these questions, a set of core skills was established to prepare fellows to take on entry-level leadership roles in quality and patient safety, such as a medical director of quality in their clinical unit or associate medical director for quality and patient safety in an organization-wide role. Consistent with current practice in professional education, a competency-based approach was chosen to establish the goals. Competencies were broken down into the knowledge, skills, and attitudes required for success for physician leaders in this field.5 After the aforementioned questions had established overall goals, faculty leaders responded to a number of other consensus-building discussions. Leaders identified sentinel research articles, landmark cases, and fundamental texts that provided a lasting foundation for
their ongoing knowledge and success. In part, this was informed by responding to the following questions: What are the essential studies, cases, and literature that you feel every emerging leader must be familiar with? What core skills are necessary in these jobs? The curriculum, thus, built on a foundation of scholarly literature providing the science of patient safety, best practices in quality improvement, pivotal research about medical error, and sentinel cases in the development of the “movement” of patient safety. Next, emerging directions of quality and patient safety, such as principles of value-based health care, payment reform, and practice redesign were considered and incorporated. Finally, a consensus of the essential broad domains of learning in this field was established.
Recognition of Priority of Soft Skills The authors quickly recognized the priority of selecting and developing leaders with the soft skills required to lead change, using the question, “What do you look for when you are hiring someone?” Discussions with the advisory board (described in the companion article) reinforced the centrality of these skills. For example, education on change management commonly includes steps in project management such as workflow analysis and knowledge-based implementation. The faculty endeavored to articulate the personal skills required to be successful in leading the “people” side of change. The authors noted the need to include training in both leadership and management skills, being reflective of how one “shows up” in one’s work, conflict resolution, negotiation, inclusive and learning leadership styles, and the ability to establish clinical credibility and inspire confidence in others about achieving successful change.
Establishment of Broad Domains The resulting curriculum is modeled on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project.6 Learning objectives were built into a framework of 6 domains of quality and patient safety leadership competencies (Table 1).
Milestone Development Within each domain, specific knowledge, skills, and attitudes were identified along with milestones to provide a continuum from knowledge to skills and attitudes. For example, principles of a “just culture” and the methods of root cause analysis are taught (knowledge), followed by facilitated mentorship in leading a response to an adverse
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
3
Abookire et al Table 1. Six Core Domains for Quality and Patient Safety Training. Competency Domain
Examples
Clinical effectiveness
Biostatistics, population management Error, root cause analysis, teams Quality improvement, lean Principles of system design Leadership, self-awareness, conflict resolution Operations, contracts, health care reform, policy
Patient safety theory Quality improvement System design Leadership, self, and change management Clinical operations and national policy
CRICO (Risk Management Foundation of the Harvard Medical Institutions) to develop a more detailed understanding of malpractice claims and litigation and the potential patient safety implications for risk reduction. As fellows proceed in their training, they also report on research and improvement projects they have undertaken. In addition, fellows meet regularly with faculty mentors in the home institution. They are expected to participate in resident educational efforts and to develop teaching skills. The fellowship structure and curriculum were approved by the Partners HealthCare Graduate Medical Education Committee.
Evaluation and Feedback event in the operational component of the fellowship. A milestone approach signals the competencies that should be achieved by various points during the 2-year fellowship.7 A total of 77 milestones were included in the 2-year fellowship.
Course Development To convert the curriculum from a series of milestones to a work plan, the milestones were “rolled up” into courses. For example, “Introduction to Patient Safety,” the first course, encompassed the first 4 knowledge-based milestones about patient safety.
Educational Strategy The curriculum is highly focused on learning within an operational environment, with fellows actively engaged in, and eventually leading, improvement teams and patient safety programs. Additionally, 2 weekly sessions provided didactics in a highly participatory, small-group environment. Sessions are highly interactive and include workshops for analyzing cases, opportunities for leadership development, self-reflection, and feedback on institutional projects.
Implementation Fellows begin in the summer with the Program in Clinical Effectiveness at Harvard School of Public Health to obtain a core understanding of clinical epidemiology, biostatistics, health policy and management, and quality improvement. In addition, fellows may take additional coursework toward a master’s in public health degree. The second summer is dedicated to the Harvard School of Public Health. During the months of the academic year, fellows participate in 2 half-day didactic sessions, with presentations by program faculty as well as visiting scholars and practitioners. Fellows also spend significant time at
Assessment methods are tailored to learning objectives and include direct mentoring, didactic processes, workshops, and individual coaching. Fellow evaluation is elicited at each didactic session. Now in its second year, evaluations have been extremely positive, with a few exceptions. Modifications have been made based on the feedback, and the curriculum will continue to be reassessed in an ongoing way.
Conclusion Six domains of competence for physician leadership in quality and patient safety are identified. Within each domain, specific knowledge, skills, and attitudes are detailed. Assessment methods are tailored to learning objectives and include direct mentoring, didactic processes, workshops, and individual coaching. Opportunities for electives and interaction with other leading patient safety organizations are available to fellows. At the conclusion of the fellowship, fellows will have developed the requisite skills, knowledge, and perspective to succeed as clinical and operational leaders in academic quality and patient safety. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received the following financial support for the research, authorship, and/or publication of this article: Supported by a grant from Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO), Cambridge, MA.
References 1. The Lucian Leape Institute at the National Patient Safety Foundation. Unmet Needs: Teaching Physicians to Provide Safe Care. Boston, MA: Lucian Leape Institute and the National Patient Safety Foundation; 2009:1-38.
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
4
American Journal of Medical Quality
2. Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education: A Six-Step Approach. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 2009. 3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 4. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
5. Kraiger K, Ford JK, Salas E. Application of cognitive, skill-based, and affective theories of learning outcomes to new methods of training evaluation. J Appl Psychol. 1993;78:311-328. 6. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29:648-654. 7. Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1:5-20.
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
research-article2014
AJMXXX10.1177/1062860614549012American Journal of Medical QualityAbookire et al
Article
Creating a Fellowship Curriculum in Patient Safety and Quality
American Journal of Medical Quality 1–4 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614549012 ajmq.sagepub.com
Susan A. Abookire, MD, MPH1, Tejal K. Gandhi, MD, MPH2, Allen Kachalia, MD, JD3, Kenneth Sands, MD, MPH4, Elizabeth Mort, MD, MPH5, Grace Bommarito6, Jane Gagne7, Luke Sato, MD7, and Saul N. Weingart, MD, PhD8
Abstract The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School–affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article “Design and Implementation of the Harvard Fellowship in Patient Safety and Quality.” The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts. The process of curriculum development and the ultimate content are described in this article. Keywords patient safety, medical education, postgraduate training, quality Transforming and improving health care are national and international priorities. Efforts to reform health care; reduce cost; realign payment models; define, measure, and improve quality; and ensure patient safety are under way worldwide. However, few existing postgraduate training programs offer physicians the opportunity to acquire expertise in these domains.1 A lack of suitable training options is a barrier for physicians who wish to specialize in quality and patient safety and creates a challenge for organizations that seek to recruit professionals who can lead quality and patient safety initiatives. The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School (HMS)-affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article “Design and Implementation of the Harvard Fellowship in Patient Safety and Quality.” The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts.
Methods The HMS Fellowship curriculum development process was based on the 6-step approach to curriculum development outlined by Kern et al.2 Like quality improvement,
curriculum development begins with establishing clarity around needs or a problem to be solved and moving from there to establishing well-defined goals, a plan to achieve them, and a method to measure and evaluate success. This framework proved helpful in organizing a qualitative approach to setting the priorities for the content of the curriculum.
General Needs Assessment As described in the companion article, few graduate training programs exist for physicians to acquire expertise in quality and patient safety.1 This creates a mismatch between the rapidly developing priority for high-quality, low-cost health care and the availability of physician 1
Houston Methodist, Houston, TX National Patient Safety Foundation, Boston, MA 3 Brigham and Women’s Hospital, Boston, MA 4 Beth Israel Deaconess Medical Center, Boston, MA 5 Massachusetts General Hospital, Boston, MA 6 Partners HealthCare System, Boston, MA 7 Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO), Cambridge, MA 8 Tufts Medical Center, Boston, MA 2
Corresponding Author: Tejal K. Gandhi, MD, MPH, National Patient Safety Foundation, 268 Summer St, Boston, MA 02210. Email: [email protected]
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
2
American Journal of Medical Quality
leaders to contribute to realizing those goals.3,4 In addition, expanding physician interest in entering these fields creates a demand that must be met for health care organizations across the spectrum to align around the national goals of quality and reform.
Targeted Needs Assessment Physician leaders in quality and patient safety across HMS institutions achieved leadership roles through a variety of career paths, including public health, research, and systems engineering. Because their expertise had been gained through experience and ongoing learning as the field of quality and patient safety developed, a qualitative needs assessment process was undertaken to determine the fundamental knowledge and skills required for success in these roles. The proposed curriculum derives from the literature and leaders’ experiences in leading, teaching, and mentoring organizational quality and patient safety. Efforts were coordinated by the curriculum director, who had completed a fellowship in medical education.
Establishing Fellowship Objectives Using a consensus-building approach, the faculty leaders in quality and patient safety responded to the following questions: What did you wish you knew as you developed in your leadership role? Describe experiences in your training that were pivotal in shaping you as a successful leader. What roles should graduates of the fellowship program be competent to assume on completion? How would you characterize the essential qualities needed to succeed in your role? How important is it that, and to what extent should, fellows be trained to teach and mentor other physicians in quality and patient safety? Based on discussions that emanated from these questions, a set of core skills was established to prepare fellows to take on entry-level leadership roles in quality and patient safety, such as a medical director of quality in their clinical unit or associate medical director for quality and patient safety in an organization-wide role. Consistent with current practice in professional education, a competency-based approach was chosen to establish the goals. Competencies were broken down into the knowledge, skills, and attitudes required for success for physician leaders in this field.5 After the aforementioned questions had established overall goals, faculty leaders responded to a number of other consensus-building discussions. Leaders identified sentinel research articles, landmark cases, and fundamental texts that provided a lasting foundation for
their ongoing knowledge and success. In part, this was informed by responding to the following questions: What are the essential studies, cases, and literature that you feel every emerging leader must be familiar with? What core skills are necessary in these jobs? The curriculum, thus, built on a foundation of scholarly literature providing the science of patient safety, best practices in quality improvement, pivotal research about medical error, and sentinel cases in the development of the “movement” of patient safety. Next, emerging directions of quality and patient safety, such as principles of value-based health care, payment reform, and practice redesign were considered and incorporated. Finally, a consensus of the essential broad domains of learning in this field was established.
Recognition of Priority of Soft Skills The authors quickly recognized the priority of selecting and developing leaders with the soft skills required to lead change, using the question, “What do you look for when you are hiring someone?” Discussions with the advisory board (described in the companion article) reinforced the centrality of these skills. For example, education on change management commonly includes steps in project management such as workflow analysis and knowledge-based implementation. The faculty endeavored to articulate the personal skills required to be successful in leading the “people” side of change. The authors noted the need to include training in both leadership and management skills, being reflective of how one “shows up” in one’s work, conflict resolution, negotiation, inclusive and learning leadership styles, and the ability to establish clinical credibility and inspire confidence in others about achieving successful change.
Establishment of Broad Domains The resulting curriculum is modeled on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project.6 Learning objectives were built into a framework of 6 domains of quality and patient safety leadership competencies (Table 1).
Milestone Development Within each domain, specific knowledge, skills, and attitudes were identified along with milestones to provide a continuum from knowledge to skills and attitudes. For example, principles of a “just culture” and the methods of root cause analysis are taught (knowledge), followed by facilitated mentorship in leading a response to an adverse
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
3
Abookire et al Table 1. Six Core Domains for Quality and Patient Safety Training. Competency Domain
Examples
Clinical effectiveness
Biostatistics, population management Error, root cause analysis, teams Quality improvement, lean Principles of system design Leadership, self-awareness, conflict resolution Operations, contracts, health care reform, policy
Patient safety theory Quality improvement System design Leadership, self, and change management Clinical operations and national policy
CRICO (Risk Management Foundation of the Harvard Medical Institutions) to develop a more detailed understanding of malpractice claims and litigation and the potential patient safety implications for risk reduction. As fellows proceed in their training, they also report on research and improvement projects they have undertaken. In addition, fellows meet regularly with faculty mentors in the home institution. They are expected to participate in resident educational efforts and to develop teaching skills. The fellowship structure and curriculum were approved by the Partners HealthCare Graduate Medical Education Committee.
Evaluation and Feedback event in the operational component of the fellowship. A milestone approach signals the competencies that should be achieved by various points during the 2-year fellowship.7 A total of 77 milestones were included in the 2-year fellowship.
Course Development To convert the curriculum from a series of milestones to a work plan, the milestones were “rolled up” into courses. For example, “Introduction to Patient Safety,” the first course, encompassed the first 4 knowledge-based milestones about patient safety.
Educational Strategy The curriculum is highly focused on learning within an operational environment, with fellows actively engaged in, and eventually leading, improvement teams and patient safety programs. Additionally, 2 weekly sessions provided didactics in a highly participatory, small-group environment. Sessions are highly interactive and include workshops for analyzing cases, opportunities for leadership development, self-reflection, and feedback on institutional projects.
Implementation Fellows begin in the summer with the Program in Clinical Effectiveness at Harvard School of Public Health to obtain a core understanding of clinical epidemiology, biostatistics, health policy and management, and quality improvement. In addition, fellows may take additional coursework toward a master’s in public health degree. The second summer is dedicated to the Harvard School of Public Health. During the months of the academic year, fellows participate in 2 half-day didactic sessions, with presentations by program faculty as well as visiting scholars and practitioners. Fellows also spend significant time at
Assessment methods are tailored to learning objectives and include direct mentoring, didactic processes, workshops, and individual coaching. Fellow evaluation is elicited at each didactic session. Now in its second year, evaluations have been extremely positive, with a few exceptions. Modifications have been made based on the feedback, and the curriculum will continue to be reassessed in an ongoing way.
Conclusion Six domains of competence for physician leadership in quality and patient safety are identified. Within each domain, specific knowledge, skills, and attitudes are detailed. Assessment methods are tailored to learning objectives and include direct mentoring, didactic processes, workshops, and individual coaching. Opportunities for electives and interaction with other leading patient safety organizations are available to fellows. At the conclusion of the fellowship, fellows will have developed the requisite skills, knowledge, and perspective to succeed as clinical and operational leaders in academic quality and patient safety. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received the following financial support for the research, authorship, and/or publication of this article: Supported by a grant from Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO), Cambridge, MA.
References 1. The Lucian Leape Institute at the National Patient Safety Foundation. Unmet Needs: Teaching Physicians to Provide Safe Care. Boston, MA: Lucian Leape Institute and the National Patient Safety Foundation; 2009:1-38.
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
4
American Journal of Medical Quality
2. Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education: A Six-Step Approach. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 2009. 3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 4. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
5. Kraiger K, Ford JK, Salas E. Application of cognitive, skill-based, and affective theories of learning outcomes to new methods of training evaluation. J Appl Psychol. 1993;78:311-328. 6. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29:648-654. 7. Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1:5-20.
Downloaded from ajm.sagepub.com at University of Otago Library on December 26, 2014
