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- Hospital medicine
- Quality improvement methodologies
- Quality improvement
- Lean management
- Medical education
My pager goes off. It’s the nurse worried about my sick patient in room 143 who spiked another fever overnight and is becoming more tachycardic. I ask my intern to evaluate and consider broadening the antibiotic coverage. Looking over our list, I notice there are still 12 patients to see: 4 potential discharges, 3 overnight admissions and 5 others. My pager beeps again and it's the emergency department (ED) calling for another admission. I look at the clock and notice its 8:05. Attending rounds begin in 55 min. Just under 11 h left in the call day.
I run to the ED to triage the new admission, passing by our quality improvement board for inpatient medicine. It's packed with information: charts and graphs depicting length of stay, hand washing, patient satisfaction and infection control. Our progress interests me greatly, but I seldom have a moment to look at the board given the time pressures of my daily work. Downstairs in the ED, I interview and examine the patient, diagnosing decompensated heart failure. I enter admission orders quickly, starting a diuretic so we don’t waste time. It has been the new standard work to place orders for an inpatient admission within 1 h of an ED call in an effort to improve the patient experience and expedite movement from the ED to the medicine ward. I know this target well because I was the resident representative during our recent quality improvement workshop on decreasing patient wait times in the ED.
During this activity, we were educated in the use of Lean, one of many powerful tools for process improvement.1 Lean starts with understanding the ‘current state’ of a system and outlining an ideal ‘future state’ followed by transitioning towards that ideal through a series of stepwise experiments using the scientific method. Lean has been used in a variety of healthcare systems to increase productivity, improve safety and efficiency, decrease length of stay, improve morale, and enhance fiscal stewardship through decreasing waste and promoting the use of standards to drive continuous improvement.2–5 A core principle of Lean is to conceptualise an ideal future state that maximises value for a ‘customer.’ In the healthcare setting, that customer is typically assumed to be the patient. This core principle is invoked during quality improvement initiatives for many major healthcare systems around USA, including the tertiary academic medical centres where I work.
However, few papers in the literature have discussed the challenges inherent in using Lean methodology in an academic medical centre. In contrast to other healthcare organisations, teaching hospitals must balance care of highly specialised populations, medical education and research. It follows that, in academic medicine, there are actually quite a few ‘customers’ with highly complex needs. Determining what type of change constitutes true improvement is a challenge when elements of this multifaceted mission compete for priority. For example, involving residents in improvement work can also compete for time with other critical activities core to their development. The customer is of central importance, but have we been careful in identifying all critical customers and including their perspectives? A failure to do so would come at the expense of other, important objectives within the broader mission.
As a resident interested in hospital quality improvement, this becomes most apparent when suggestions are made during improvement activities that add value to the patient at the expense of educational development. Many components of a resident's work do not directly, or at least immediately, benefit patients. Activities such as sequential patient interviews, procedures performed by novices under supervision, morning and noon educational conferences do not immediately add value to the patient's experience and in some instances may actually worsen it. When a patient comes through the ED and is admitted to the medicine ward, he or she will likely be interviewed by upwards of nine healthcare providers: the ED triage nurse, the ED nurse, the ED resident, the ED attending physician, the floor nurse, the medical student, the medicine intern, the medicine resident and the medicine attending physician. Many of the same questions are asked repeatedly, and while there may be some added value to the patient in this workflow by uncovering new symptoms or pertinent pieces of history, diminishing (or even negative) returns quickly evolve. However, the value to the medical team is tremendous as one cannot learn medicine except by seeing patients with increasing levels of independence, honing history-taking and physical examination skills, slowly refining the differential diagnosis, and developing a reasonable assessment and plan. Morning educational conference is another example of an activity with immense value to the resident, but only indirect value to the patient. It would be tempting to skip the hour-long dissection of a complicated case for the sake of an earlier discharge, which could potentially translate to decreasing length of stay or freeing up an extra bed for a new admission, but missing this teaching deprives the resident of a valuable learning experience at the expense of an immediate benefit to the patient. In short, there is an inherent dilemma in academic centres between favouring the short-term, centre-specific benefits to today’s patient for the long-term, societal benefits of the future patient.
So what is the best response?
First, residents must be engaged with the quality improvement process. A 1993 article by Asthon argues that academic medical centres benefit from the involvement of residents in quality improvement programmes as they often have valuable insight and expertise on the day-to-day workings of the hospital,6 though this reality is still in its infant stages over 20 years later. While this vision on the scope of resident engagement with quality improvement is narrow, it is a critical start and perhaps a critical necessity. Internationally, UK doctors in training have a desire to improve healthcare quality, but feel that their working environment is not receptive to their skills.7 Neither in USA nor in the UK is the concept of healthcare quality improvement taught to trainees in necessary volume.8 As frontline workers, residents have insight into work processes that other hospital employees lack and without leverage of this knowledge, any effort to improve care is at best inefficient. Operationally, residents could be included on quality improvement projects which are meaningful to workflow, such as streamlining the admission and discharge processes, or meaningful to patient safety, such as decreasing rates of inpatient venous thromboembolism. Quality improvement could also be brought into clinical rounds where hospital-wide priorities such as adverse events or hospital-acquired infections are discussed and evaluated daily. Furthermore, the incorporation of resident input into quality improvement initiatives is an important goal of the Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review (CLER), a programme which intends to align medical centres and training programmes around developing excellent physicians and high quality patient care.9
Second, those who are involved with quality improvement in academic centres must recognise that the mission of an academic hospital is multifactorial, with multiple customers. Therefore, quality improvement solutions require a strategic negotiation between adding value to patient care and adding value to other important objectives such as resident education and novel investigation. Residents, chief residents and their programme director advocates need to be involved in improvement as clinical experts in the ‘current state’, and as partners in strategically selecting targets or aims that represent true organisational improvement with the whole of the institutional mission in mind. With reluctance to participate in planning and negotiation of improvement targets, training programmes risk finding themselves in an environment where residents’ first exposure to the improvement process is something done ‘to’ them, rather than with them. Similarly, institutionally selected aims for process improvement may risk being ineffective or short-sighted when executed without residency input into the frontline workings of the hospital. Therefore, quality improvement goals must be jointly determined in a collaborative setting to address and prioritise this multifactorial mission in an academic centre.
Third, training programmes and their leaders must role model engagement with quality improvement. Programme directors, chief residents, core faculty and other educators should emphasise how ‘quality work’ permeates the gamut of healthcare settings from the outpatient clinic to the operating room to the hospital wards. To the extent that respected clinicians are observed reducing Foley catheter-days, mindfully reflecting on barriers to adherence for central line insertion bundles, or discussing how to decrease unnecessary blood transfusions, these behaviours become part of the image of a skilled clinician of the future to which trainees aspire. Another complimentary approach is to consider using the tools of quality improvement to support improvement of programmatic educational objectives. Would residents find it easier to participate in problem solving hospital initiatives if they used the same Lean principles to improve performance on work hours adherence or delivery of core educational content?10
Finally, perhaps the easiest way to align agendas between the trainee and the patient is to seek out and prioritise process improvement opportunities where the patient and the resident benefit from a single intervention. For example, one of our medical centres recently added a pharmacist to each of the medicine teams. This intervention provides value to residents through education and offloading work, allowing residents to allocate their time in other ways. At the same time, pharmacists provide value to patients by overseeing medicine reconciliation during the admission and discharge process. Therefore, the outcome of this quality improvement project benefits the educational mission of the hospital while also improving patient care. After our hospital’s workshop on decreasing patient wait times in the ED, the medicine teams began to do daily management huddles, a 15 min check-in to receive feedback on the 1 h requirement between an ED call and admission orders. These huddles also allow an opportunity for the residents to identify problems that impede their daily work, to recruit faculty champions who can address these issues, and to escalate problems to senior leadership when necessary. Through these huddles, several important quality improvement projects have been developed and implemented. For instance, it was discovered that a delay in placing admission orders often occurred because residents were waiting for a follow-up lab result to determine the appropriate level of care. ED nurses then became in charge of drawing this lab and following up the result to notify the resident, allowing patients to get admitted quickly and safely.
As a resident who has had the privilege and opportunity to participate in many successful quality improvement projects, I believe we have dual roles as clinicians and learners. While we provide important expertise in the clinical delivery process, we must also recognise our second but equally important role as trainee, slowly building our own foundation of clinical experience for the future. This joint responsibility reflects the multifaceted mission of the academic medical centre and emphasises the overarching need to develop strategies which consider all customer perspectives together. Through the successful integration of these perspectives, academic medical centres can provide high quality medical care and outstanding training for future physicians.
Contributors All authors were involved with the conception, planning, drafting and revision of this work.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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