Quality Improvement in Residency: A Way Forward

Over recent years, there has been a growing emphasis on resident involvement in quality improvement (QI) projects, a practice that has been proven beneficial despite its associated challenges. Resident participation in hospital QI projects provides a unique opportunity for training physicians to understand the intricacies of health care systems, foster critical thinking, embrace multidisciplinary teamwork, and acquire leadership skills that are invaluable for their future career goals. A letter in Annals of Internal Medicine (1) highlights how the Accreditation Council for Graduate Medical Education has promoted this initiative in the context of systems-based practice competency and can serve as a road map for QI incorporation into other aspects of medical practice, such as continuing medical education (1). I will elaborate further on the benefits in graduate medical education (GME) by exploring universal resident participation in QI projects and a way forward, as residents are at the forefront of patient care.

During internal medicine training, residents are expected to participate in research and QI as part of their curriculum, with programs having specific graduation requirements. Studies have also demonstrated that residents engaged in QI initiatives report increased confidence in analyzing data, identifying organizational-level challenges, and implementing evidence-based solutions (2, 3). Such involvement makes them change agents in a rapidly evolving health care landscape. Considering all this data and feedback from our past graduates and faculty, we implemented an initiative for universal resident participation in hospital QI projects at a 420-bed regional referral center. With more than 50 residents and a limited number of hospital QI projects, this initiative required multidisciplinary collaboration between hospital QI committees and the residency program.

Like any program development initiative, we designed a program to assign all residents to ongoing hospital QI projects after an initial needs assessment evaluation. After a program-wide survey, residents were assigned QI projects aligning with their future career goals as closely as possible to create a culture of ownership. Moving forward, our primary challenge was managing residents’ scheduling constraints and ensuring their participation. To mitigate this issue, multiple residents were assigned to each QI project, allowing residents to rotate based on availability while ensuring continuous participation. We also identified significant areas of opportunity to help with the process and improve future transitions. This initiative for residents was reintroduced during noon conferences to better understand the process, desired outcomes, and vision behind the initiative. Chief residents were also involved to take the lead on the initiative, as GME and the hospital QI teams worked together to make sure residents had a smooth transition on individual QI projects and to ensure better understanding of their role within the QI project.

In the past, we have seen that resident involvement in QI projects was a driving force in not only career development in hospital medicine or primary care but also pursuit of various fellowships. Residents who worked closely with the congestive heart failure QI committee ended up working on projects that benefited them in pursuing a cardiology fellowship; the same was true for other fellowships. We also saw residents come up with initiatives to improve process outcomes pertaining to their individual arena, like the implementation of specific order sets for their QI projects. Such initiatives by residents will be critical in the future to evaluate and analyze data for QI and advance patient care. It was also evident that continuing an approach integrating QI training into residency curricula with mentorship and faculty support is highly beneficial. Recognizing residents’ contributions to QI efforts through recognition and/or highlighting any publications that may result can also motivate further participation.

Looking forward from the junction of resident education and QI, this relationship benefits resident training and hospital outcomes. It enhances systems-based practice competency and offers an ideal framework for residents to grow, improve health system operations, and contribute sustainably to process improvement. In our experience, this provides a unique opportunity for multidisciplinary collaboration, comprising teamwork and communication, along with ideas for research and QI projects, while delivering high-value patient care. Giving residents a sense of ownership in QI projects promotes professional fulfillment and abates burnout while fostering a more profound commitment to their training and becoming future health care leaders. Promoting resident involvement in QI should be a priority for residency programs and health care institutions committed to advancing education and academic excellence.

References

1. Djuricich AM. Continuing medical education and quality improvement: a match made in heaven? [Letter]. Ann Intern Med. 2012;157:77-8. [PMID: 22751772] doi:10.7326/0003-4819-157-1-201207030-00021 
2. Schroll R, Paramesh A, Guidry C, et al. A structured quality improvement educational curriculum increases surgical resident involvement in QI processes. J Surg Educ. 2020;77:e183-e186. [PMID: 32571691] doi:10.1016/j.jsurg.2020.05.025
3. Haggerty T, Lewis W, Plaugher C, et al. Residents' views on research and quality improvement training can guide practice-based research network collaboration. W V Med J. 2018;2018. [PMID: 32483393] doi:10.21885/wvmj.2018.14

Syed S. Fatmi, MD, MPH

Syed is the Associate Program Director and Director of Research for the Southeast Health Internal Medicine residency program and a clinical preceptor for the Alabama College of Osteopathic Medicine. He is also the President of the Society of Hospital Medicine Wiregrass Chapter. His passions are medical education and promoting the quality of clinical care by integrating evidence-based medicine into clinical practice.