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.