Quality Improvement Training Need Not Wait for Residency

By Scott Harris

When you think of quality improvement in a medical education context, usually that means residency and other phases of graduate medical education (GME). Though there are programs rooted in medical school, usually they are introductory in nature, providing essentially a first brush with the language of quality and process improvement.

But this is not so at the University of Missouri School of Medicine, one of a handful of medical schools in America for which quality is a central tenet of the curriculum, more or less from day one. Students gain hands-on familiarity with key concepts, learn alongside students in other professions, and carry quality improvement knowledge and commitment with them into their first day as a resident.

“We’re teaching them to think about patients on a one-by-one basis, but also in terms of how the system is providing care for all, and what they can contribute to the system,” said Linda Headrick, MD, senior associate dean for education at the school. “They learn how to problem-solve the system. They think about data and about the care pattern as a process that can be analyzed and improved.”

It all begins in the first year, when key goals and concepts are introduced. Students who witness the white coat graduation ceremony also hear a big emphasis on quality and safety during the proceedings.

The second year, there is an increased focus on quality and safety from an interprofessional perspective. School leaders see interprofessional education as an equally important and overlapping goal with quality improvement.

“In order to have our graduates finish school collaboration-ready, they need to be learning about and with other professions,” Headrick said. “They need to be learning alongside those who are about to become nurses, pharmacists, physical therapists, and all the other important professionals.”

One of the second year’s key quality and safety activities takes place in a mock patient room in the school’s simulation center. The room is intentionally strewn with potential hazards, from a cigarette in the patient’s hand to misplaced allergy bracelets and medication lists. Medical and nursing students complete the exercise separately and then together, identifying all the hazards they recognize.

“It quickly becomes quite evident how different each profession is in its contributions,” Headrick said. “It’s an Aha! moment, because it shows how much we really need each other.”

During third-year clerkships, medical and nursing students select a real patient (usually one with whom they have interacted previously) and discuss the risk of falling with that patient, with the goal of assessing the patient’s risk for falling and identifying potential prevention methods. The students then debrief on how the patient responded both to the questions and the students themselves. Procedural components of care that are sometimes overlooked, such as patient hand-offs, also are covered and discussed.

In the fourth year, many medical students identify a specific care question or improvement area in a given care environment, and work with other students to formulate a plan to address the issue.

After medical school, University of Missouri graduates are ready to improve quality at their GME institution. So much so, Headrick joked, that residents who come to the Missouri system after graduating from another medical school often face an adjustment period.

“Our grads get frustrated with residents from other places,” Headrick said. “Other residents don’t have a sense of what they can do to improve quality.”

The program was developed in part through support from the Retooling for Quality and Safety initiative, jointly created by the Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement.

0 thoughts on “Quality Improvement Training Need Not Wait for Residency

  1. In fact, I don’t think the University of Missouri is being ambitious enough. As an undergraduate pre-med interested in quality improvement, I had to search out my own opportunities to learn about patient safety, convince registrar’s to enroll me in graduate level public health courses, and began interning to help with patient safety policy. Today, I’m taking a lot of the lessons learned and implementing them in hospitals.

    Hardworking undergraduates arguably have more time to learn about quality improvement. These are not just students that get in the way either. My fellow classmates have convinced schools like my institution to give $10,000 fellowships to pursue patient safety and global health initiatives in China, work with the World Health Organization on checklists, and measure patient safety culture in Pakistan. A few have even published in high impact journals as first or co-authors. I’m just one of many undergraduates who have an interest in patient safety though. I know of countless others that are interested but don’t have the resources to support them to accomplish this. Dr. Peter Pronovost and other safety thought leaders give yearly lectures in classes about this but I still believe this isn’t ambitious enough. There’s also a strong lack in MD/PhD programs or MD/MPH programs that specialize specifically in human factors engineering, or patient safety. As a current medical school applicant, I eagerly looked for them but the dearth of programs in few but the most elite of institutions was thoroughly disappointing.

    By understand the context of quality improvement while learning about the healthcare system, and using opportunities throughout their college career to conduct research, we can train the next generation in healthcare leaders. These students will have a strong foundation when going to medical school and can hit the ground running. Peter Pronovost, Maureen Miller, Robert Wachter, and Gregg Meyer have emphasized physician leadership in quality and safety, but taking that time even throughout residency would take far too long for the level of direction the field needs. If we are serious about patient safety and quality, it needs to be introduced alongside other premedical requirements like biology, organic chemistry, and physics. A fundamental understanding of health systems and quality improvement will help us in our careers and our nation’s health over the long haul just as much as understanding biochemical mechanisms or cell biology.