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An Approach to Enhancing Health Care Quality

In the last decade, quality improvement and patient safety have risen very high among the priorities facing caregivers in the United States – and at Penn Medicine itself. The problem, as articulated in a recent article in Academic Medicine, is that even after national reports have noted the critical need for improvements in these fields, the matter remains extremely complex. According to the article, written by current Penn physicians as well as two who have moved to other institutions: “Physician leadership is critical to the success of these initiatives, yet many organizations struggle to engage physicians in health care improvement efforts, and some even encounter resistance from medical doctors.”

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Recent HLQ residents and instructors

The approach Penn Medicine took, as described in “Building the Pipeline: The Creation of a Residency Training Pathway for Future Physician Leaders in Health Care Quality,” was to focus on the residency training years as a time to identify, train, and develop the next physician leaders in the field. Since its beginning in 2010, 66 residents have matriculated in the Healthcare Leadership in Quality (HLQ) track. At this early stage, the article reports, the track has demonstrated its feasibility and efficacy. The track “allows those who show early interest in quality and safety to develop a unique skill set while effecting local system changes and experimenting with a career focused on QI/PS.”

The article lists 27 quality improvement projects that HLQ residents worked on between 2010 and 2014. Among them: improving the review and accuracy of medication lists at discharge; increasing rates of screening colonoscopy in the ambulatory setting; creating an innovative system to improve and track outpatient medication adherence; and investigating what clinical factors predict readmission for persistent hypertensive disease in women with preeclampsia.

The HLQ track was sponsored and financially supported by the Office of the Chief Medical Officer of Penn’s Health System and the Department of Medicine. (P. J. Brennan, MD, the Chief Medical Officer, and Richard P. Shannon, MD, former chair of Medicine, are among the authors of the article.) Originally, the track was open only to residents in the Department of Medicine; in 2012, the cohort included residents from emergency medicine, obstetrics-gynecology, radiology, and general surgery. A year later, the track was again broadened, accepting trainees from all Penn residency programs. The application form for the HLQ track puts it bluntly: “We believe that this program, along with other hospital and residency program strategies, will move residents from their current role of passive followers to active leaders in institutional QI and PS initiatives.”

As described, the track is a two-year longitudinal training pathway embedded within a standard residency program. Each resident who enters the track must devote a minimum of seven weeks of elective time to the curriculum and also participate in longitudinal HLQ track experiences. The major components are the core curriculum; integration into a Quality Improvement leadership team; a capstone QI project; and mentorship. Instruction is provided by the track directors, Neha Patel, MD, MS, lead author of the Academic Medicine article and assistant professor of clinical medicine in the department of Medicine; and Jennifer S. Myers, MD, associate professor of clinical medicine in the department of Medicine and Patient Safety Officer for the Hospital of the University of Pennsylvania. They are also directors of the Center for Healthcare Improvement and Patient Safety, founded in 2009. The center has been essential in the creation of the HLQ track. In addition, Myers is a former Macy Faculty Scholar by the Josiah Macy Jr. Foundation, and she used the award toward expanding the track.

Patel and Myers are assisted by a wide array of colleagues, including the Health System’s quality and safety leaders, nurse leaders, the chief medical information officer, the vice president for quality and safety, performance improvement experts, and select chairs of departments. Of note is the deliberately interprofessional nature of the instruction. Other professionals are “co-learners”: nurses, pharmacists, and social workers. Indeed, as the article notes, identifying faculty mentors for the residents’ capstone QI projects can be challenging, which is why the program seeks to draw upon quality improvement experts who are not physicians.

The HLQ track, of course, did not spring into existence from nothing. For several years, Penn’s Health System has employed the “Blueprint for Quality and Patient Safety,” which has led to several advances, such as significant reductions in blood-stream infections. One notable development through the Blueprint was the creation of unit-based clinical leadership (UBCL) teams. These multidisciplinary teams, composed of a physician leader, a nurse manager, and a quality and safety project manager, have had system-wide success in improving safety and quality. These are the teams that HLQ residents join, aligned with their particular clinical interests. In addition, the UBCL teams support the completion of each resident’s capstone QI project.

The authors of the article concede that one limitation of the HLQ track is that, at present, it reaches a minority of trainees. Some residents already in the track report challenges in staying connected with their UBCL teams because of the requirements of their clinical rotations. And the authors note that they must continue to measure the impact of the track. Still, in its first few years, the track has drawn interested residents and may attract more as it proceeds. The track, the authors conclude, “is beneficial to institutional QI and physician engagement efforts and logically feasible in an academic medical center.” It makes sense that centers like Penn’s continue a program to produce active leaders in health care quality.

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