Below article originally appeared NEJM Catalyst. Click HERE to view the original article.
Contributors: Susan Pohl, MD, FAAFP, Sonja Van Hala, MD, MPH, FAAFP, Mari Ransco, MA & Jennifer Leiser, MD
The University of Utah Family Medicine Residency Program has designed a 3-year interprofessional experience in value improvement for the purpose of providing residents with transferable professional skills that will be immediately applicable following the completion of training. This effort, based on the Accreditation Council for Graduate Medical Education’s Practice-Based Learning and Improvement (PBLI) requirements, aims to create clinicians who will be ready, in their first year of practice, to lead value improvement efforts with their colleagues across professional lines. As part of this program, the task for each resident was to work with a team to improve a publicly reported quality metric. The power of this new training model is its dual emphasis on applying improvement science and leading a team.
To be ready to lead, residents must learn value improvement skills in the context of an interprofessional clinical practice.
Working on a publicly reported quality measure aligned institutional resources (available data, leadership support) to facilitate project completion.
The application of Utah’s improvement methodology helped residents develop critical leadership skills.
Physicians are increasingly expected to lead improvement teams, but little formal guidance exists on what skills are needed, let alone how to develop those skills during residency. The methods used to meet the practice-based learning requirement vary widely between residency programs.
The faculty of the University of Utah’s residency program observed that residents tend to focus on clinical skills and are less interested in building competency in value improvement if it is not integrated into the clinical experience. Additionally, the application of improvement science, including the development of the types of skills that are needed to collaborate with and lead an interprofessional team, is not traditionally included in residency training.
The Family Medicine Residency Program endeavored to go beyond basic PBLI requirements to prepare residents for the real work of improving clinical practice. University of Utah faculty wanted to prepare residents with transferable professional skills such as working on an interprofessional team, understanding and applying improvement skills, and improving publicly reported quality measures.
In 2011, the residency program created a curriculum on value improvement for its 24 residents. The program combined lectures with structured participation on a value improvement team. Topics covered in the classroom included improvement methodology, leadership, and team dynamics.
To apply learning, each resident joined an interprofessional value improvement team located in the clinic where they practiced. These teams included faculty, residents, medical assistants, physician assistants, pharmacists, nurses, and psychologists. Each resident’s role corresponded to his or her level of training; first-year and second-year residents performed delegated tasks, whereas third-year residents led teams with faculty supervision. During the year, the team met every month to follow the improvement methodology, review data, discuss progress, and assign tasks. The faculty physician advisors provided third-year residents with structured verbal feedback on leadership skills.
Working on an interprofessional team and following the value improvement methodology taught several important lessons to the residents. First, they learned to appreciate the critical importance of baseline analysis before diving into improvement design. Second, they learned that teams with diverse roles (e.g., a medical assistant, nurse, and clerical staff) design better solutions than a lone physician. Third, they learned leadership skills that are necessary to influence the practice of others, with an emphasis on effective communication and team activation. Most importantly, they learned the importance of maintaining clear focus on a strategic clinical goal.
Prescribed Improvement Project
Initially, the residents chose a value improvement topic based on personal interest, but in 2015 the Family Medicine Residency Program began assigning topics according to institutional priorities. Each value improvement team worked to improve a publicly reported quality measure, such as a disease-management metric, immunization rate, or screening-guideline adherence. Aligning the work of the improvement teams with institutional goals brought crucial success factors, including available data, resources, and leadership support.
The change in emphasis from personal interests to institutional goals was met with some resistance. However, residents soon realized that the skills that they learned while working on prescribed topics translated to reliable success in areas of personal interest.
For example, one resident led a team that focused on an institutional goal of improving chlamydia-screening rates in young women and also led his own project that focused on improving the safety of opioid prescriptions in the clinical practice. Working on both projects allowed the resident to apply skills that were learned in the first project (e.g., analyzing data, guiding an improvement team, implementing improvement strategies, and monitoring the changes) to the second project.
Other projects focused on adherence to asthma guidelines, control of diabetes mellitus, improving childhood immunization rates, documenting physical-activity counseling during adolescent patient visits, improving pneumococcal vaccination rates in elderly patients, increasing influenza vaccination rates during pregnancy care, increasing chlamydia screening in young women, and improving blood-pressure control in patients with hypertension.
The improvement curriculum planning team included the division chief, residency program director, the medical director of each clinic, the quality-improvement curriculum director, the clinic manager, and the clinic nursing supervisor.
The team was interested in understanding if the improvement curriculum would lead to sustained and relevant results. The Family Medicine Residency Program examined both formal educational outcomes to assess the efficacy of the curriculum as well as initial anecdotal reports from the residents as they sought employment. Specifically, the program evaluated the project-completion rate, resident competency in PBLI, and resident scholarship that resulted from the work of each value improvement team.
Between 2011 and 2015, the residents completed 33 projects and presented their work to the Division of Family Medicine, which includes all of the clinicians who practice with the residents. Each resident presented all components of his or her team’s work according to the University of Utah’s value improvement methodology (project definition, baseline investigation, analysis, improvement design, improvement implementation, and monitoring).
All third-year residents achieved a “competent” or “proficient” skill level in their PBLI Milestones assessment by the end of their residency.
Residents successfully presented the work of the value improvement teams in local, regional, and national venues. Upon completion of their residencies, two residents published peer-reviewed manuscripts that described their value improvement work.
Informally, the Family Medicine Residency Program found that its residents possessed leadership skills that were sought out by other health systems.
As the third-year residents interviewed for potential positions, they were asked to discuss their experience leading a value improvement effort, the methods that they used, and the lessons that they learned while working as part of an interprofessional team. The residents were surprised to discover that potential employers wanted to talk about their work organizing and leading improvement on a publicly-reported measure as much as they wanted to hear about their personal research interests and clinical expertise.
Where to Start
- All residency training programs must provide process-improvement training. To embed value improvement training into the clinical training environment, residency faculty first need to understand their resources in terms of time, expertise, staff, leadership support, and funding.
- If other residency programs at your institution have had success in improvement training, pursue interprofessional collaboration with them. Don’t silo yourself: learn from the experiences of others.
- It is important to focus on aligning resources while educating. Improvement work not only meets required educational needs, but it also engages clinical staff in improving care and gives faculty an opportunity for scholarship.
- Resident training in improvement methodology can be applied in the clinical learning environment from the first day of residency.
- Residents have told us that applying improvement principles in an interprofessional team feels clinically relevant to their experience as trainees.
- Learning to work with a team of professionals who do not report to the resident encourages the development of important leadership skills.
- Aligning the work of practice-based learning improvement training and value improvement teams with institutional goals helped the University of Utah Family Medicine Residency Program overcome barriers such as data acquisition and clinical administration support.
Susan Pohl, MD, FAAFP, is an assistant clinical professor with the Department of Family and Preventive Medicine who practices at the Madsen Health Center Clinic.
Sonja Van Hala, MD, MPH, FAAFP, is an assistant clinical professor with the Department of Family and Preventive Medicine who practices at the Sugar House Clinic.
Jennifer Leiser, MD, is the Division Chief of the Division of Family Medicine in the Department of Family and Preventive Medicine.
Mari Ransco, MA, is Director of Patient Experience and Value Engagement at the University of Utah.