Quality Improvement Curriculum - Division of Pulmonary & Critical Care Medicine

A Quality Improvement Curriculum for Critical Care Fellowships at Henry Ford Health System

Division of Pulmonary and Critical Care,

Henry Ford Hospital

Prepared by: Namita Jayaprakash, MB BcH BAO, MRCEM

Reviewed by: Pulmonary and Critical Care Fellowship Program Director/Associate Program Directors; Chair, Division of Pulmonary and Critical Care

Background:

The Institute of Health promotes a culture of safety in healthcare. The publication of its report in 2000, ‘To err is human’ emphasized that the majority of medical errors do not occur as a result of a failure because of individual recklessness but rather because of a failure of systems, processes, and conditions that lead people to make mistakes or fail to prevent them.[1]

Quality improvement (QI) can be defined as a set of principles that involve knowledge, skills, and methods used to evaluate and implement change in a health care system using a systems based approach.[2] This often involves groups of people and not just an individual to identify the shortcomings that can be attributed to dysfunctional systems and realize that not all changes are improvements but all improvements involve change.[3]

Recognition of the importance of quality improvement and system improvement in enhancing the delivery of health care includes optimizing the skill set available to health-care professionals. A system that is effective in promoting safety and implementing change requires leaders with the skill in quality improvement and patient safety. Programs such as the VA National Quality Scholars have recognized the importance of this through inter-professional education.[4] Raising medicine’s level of performance related to quality improvement includes a process of experiential learning or a cycle of experience, observations, conceptualization and retrying. It is best accomplished through groups of people and not just an individual.

The Accreditation Council for Graduate Medical Education (ACGME) also emphasizes the importance of quality improvement education for trainees specifying a common requirement for programs to:

‘Systematically analyze practice using quality improvements methods and implement changes with the goal of practice improvement’.[5]

ACGME promotes a cohesive model that includes providing goals, tools, and techniques essential for health care professionals to achieve quality improvement goals. The common program requirements specify that:

‘Experiential learning is essential to developing the ability to identify and institute sustainable systems-based changes to improve patient care.’[5]

Boonyasai et al reviewed the effectiveness of teaching quality improvement to clinicians. QI knowledge in this systematic review was classified using the Institute of Healthcare Improvement (IHI) framework: health care a system; variation and measurement leading, following and making change; collaboration; developing new, locally useful knowledge; social context and accountability; and professional knowledge.[2] Curricula of the studies included were assessed by the following 9 characteristics: (1) enabling learners to be active participants, (2) providing content relating to learners’ current experiences, (3) assessing learners’ needs and tailoring teaching to their past experiences, (4) allowing learners to identify and pursue their own learning goals, (5) allowing learners to practice their learning, (6) supporting learners during self-directed learning, (7) providing feedback to learners, (8) facilitating learner self-reflection, and (9) role-modeling behaviors.[2] The results suggest that a variety of QI teaching strategies including collaborative skills, experiential learning, incremental change from trial and error, and providing learners with opportunities to work closely with colleagues from other disciplines, improves QI related knowledge as well as attitudes toward heath care system participation in QI activities.[2]

Implementation of a formalized quality improvement curriculum as a required component of critical care fellowships is feasible. The Mayo Clinic Combined critical care fellowship program implemented a pilot QI educational program that improved learner satisfaction and led to graduates feeling that the training had improved their QI skills and enhanced their employment and career advancement opportunities. The pilot has been successfully adopted and continues as part of the curriculum.[6]

Curriculum

Purpose:

To introduce a formalized quality improvement curriculum for the pulmonary and critical care fellowships within the Henry Ford Health System (HFHS) that uses experiential learning in combination with adult learning principles to enhance QI knowledge and application within our health care system.

Goals

The goal of the quality improvement curriculum is to translate knowledge and lead change by teaching key principles of QI, enhancing QI skills, providing QI tools for application in processes that evaluate and implement change in healthcare systems and to promote a culture of safety and quality amongst trainees. This program aims to develop and cultivate future leaders in healthcare quality and innovation by providing them with the skills to improve health care systems and reduce waste and inefficiency while focusing on enhancing patient safety and outcomes.

Objectives
Define quality improvement and understand principles of quality improvement
Discuss change management and how it relates to success in quality improvement projects
Describe models of quality improvement
Illustrate the use of QI models in healthcare system improvement
Design and complete a quality improvement project

Methods of implementation

Pulmonary and Critical Care fellows are adult learners. In order to optimize their learning of QI principles and applications through experiential learning, a 12-month longitudinal curriculum will be utilized. This will include a combination of didactic lessons, active learning through development of a quality improvement project and direct senior faculty feedback sessions for opportunities for improvement.

Didactic sessions: 30-minutes to 1-hour sessions using a combination of IHI open school modules, traditional classroom teaching, interactive sessions, flipped classroom approaches.
- At the end of the didactic curriculum learners will be able to:
  - Distinguish quality improvement from quality assurance
  - Determine how to organize a QI team
  - Generate a flow chart for QI of a clinical process
  - Develop a QI charter
  - Analyze data collected using QI tools
Active learning: Project teams will include approximately 4 fellows each. Projects will be developed by individual teams and selected using an impact-effort prioritization matrix. Fellow teams will be required to include multi-disciplinary team members to encourage a team based multi-disciplinary approach to QI.
- Learners will apply QI skills to identify, design, develop, complete and report results of their self-selected QI project for a clinical process
Faculty feedback sessions: A core group of volunteer faculty interested in QI will provide feedback to fellow teams with regards to progress in the development of projects. Faculty will also serve QI faculty advisers. The purpose of these sessions will primarily be to ensure progress and reinforce QI skills as teams develop their projects.

Content
- Didactic sessions (delivered over first 3-6 months)
  - Assigned IHI modules for self-directed learning:
    - QI 101: Introduction to Health Care Improvement
    - QI 102: How to improve with the model for improvement
    - QI 103: Testing and measuring changes with PDSA cycles
    - QI 104: Interpreting Data: Run charts, control charts, and other measurement tools
    - QI 105: Leading quality improvement
    - QI 201: Planning for spread: From local improvements to system-wide change
    - QI 202: Achieving breakthrough quality, access, and affordability
  - Defining quality improvement and differentiating from quality assurance and research (30 minutes)
  - Defining the problem, developing a project charter (30 minutes)
  - Models of QI and change management principles (60 minutes)
    - Change management principles (Preparing for change, managing the change, reinforcing the change)
    - Defining models of QI: Care model; Lean model; Model for improvement; FADE; Six-sigma
    - Design for Six-Sigma and approaches
      - DMAIC
      - IDDOV
  - Analyzing and displaying data (30 minutes)
    - Control charts
    - Cause and effect matrix
    - FMEA
    - Lean tools: Spaghetti diagrams, circle of work
  - Essential elements of a control plan (30 minutes)
- Active participation in projects
  - Form the team
  - Identify projects
  - Write project charters
  - Flow chart process
  - Collect data
  - Develop plan for change
  - Communicate plan to stakeholders
  - Implement plan
  - Collect data to evaluate implementation of plan
  - Disseminate results including control plan during months 13 – 14
- Feedback sessions
  - Timing: Once a month to monitor progress in first quarter and then quarterly with an aim to provide direct feedback to teams regarding progress
  - Quarter 1
    - Month 1: Forming teams
    - Month 2: Identify and select projects using impact-effort prioritization matrix
    - Month 3: Develop and write project charters
  - Quarter 2: Review flow chart of processes and identify data collection processes with development of plan for change
  - Quarter 3: Implementation of change
  - Quarter 4: Post change data collection and analysis. Evaluation of projects by faculty using balanced scorecards.

Timeline

The longitudinal curriculum in Quality Improvement will span a total of 12 months. Dissemination of results and final evaluation of projects will occur in the 5^th quarter after completion of the program. As the majority of critical care fellows are enrolled in multi-year the programs we will take into account a period of acclimatization to fellowship and/or the hospital system. Thus, the curriculum will begin 6 months after the start of the fellowship. For example, fellows who commence their fellowship in July 2018, will begin the curriculum in January 2019 with an expected completion in January 2020.

Month	Didactic curriculum	Active learning	Feedback sessions
January	Defining quality improvement and differentiating from quality assurance and research (30 minutes) Defining the problem, developing a project charter (30 minutes)	Forming groups/teams (7 first year fellows split into 2 – 3 teams)
February		Identifying projects and additional team members (multi-disciplinary team members)	Flipped classroom: interactive games for concepts of design/measure/PDSA/variation/leadership (45 minutes) Selection of projects using Impact-effort matrix (45 minutes)
March	Models of QI and change management principles (60 minutes) Change management principles (Preparing for change, managing the change, reinforcing the change) Defining models of QI: Care model; Lean model; Model for improvement; FADE; Six-sigmaDesign for Six-Sigma and approaches (DMAIC, IDDOV)	Writing a project charter	Feedback on project charter and aims (60 minutes)
April		Developing a flow chart of processes Identifying data collection processes	Feedback on flow chart of processes (Define, measure) – 60 minutes
May	Analyzing and displaying data (30 minutes) Essential elements of a control plan (30 minutes)	Analyzing results of data collection
June		Developing a plan for change	Feedback on plan for change (Define, measure, analyze) – 60 minutes
July		Implementing change
August		Implementing change	Feedback on implementation of change (Define, measure, analyze, improve) – 60 minutes
September		Implementing change
October		Identifying processes of post change data collection
November		Collection of post change data
December		Analysis of post change data and development of control plan	Feedback on project prior to final presentations – 60 minutes

Faculty involvement

A core group of faculty interested in quality improvement principles is required for the successful implementation of this longitudinal quality improvement program. The Division will support faculty development and continued professional development using the IHI open school. All core faculty will be asked to obtain the Basic certificate in Quality and Safety through IHI in addition to completing GME modules through IHI. Intra-professional development is also encouraged with those within the division who either have formal training or experience in QI principles sharing and developing QI knowledge amongst colleagues. Faculty mentors will be identified for each of the project teams and core faculty (2-3 persons) will in addition be available for feedback sessions. All volunteer faculty involved in the quality improvement curriculum in addition to the Program Directors and Associate Program Directors will provide final scoring of projects to teams.

Feedback

Ongoing project feedback will be provided to the fellow teams as part of the longitudinal curriculum. Fellows will also be surveyed at the start and end of the curriculum to provide the opportunity for feedback regarding the program.

Evaluation
Self-assessment program for QI competencies
How comfortable are you in your current skill with the following aspects of quality improvement? Please circle the most appropriate option (whole numbers only) for each item

Defining a clear problem statement (goal, aim)	1 2 3 4 5
Developing and writing a quality improvement project charter	1 2 3 4 5
Change management principles including managing individual change	1 2 3 4 5
Models of quality improvement and application of different models	1 2 3 4 5
Identifying waste using LEAN principles	1 2 3 4 5
Analyzing data through a failure modes effects analysis	1 2 3 4 5

Quality improvement Knowledge Application Tool (QIKAT) and Quality improvement knowledge application tool revised (QIKAT-R) will be used for faculty evaluation.[7, 8]
ICU/clinic scenarios will be provided. Each of these will represent system level quality problems. The respondents will be asked to read the scenarios and respond with an aim, a measure and one focused change that addresses a system level issue raised in the scenario. Scorers will use the QIKAT or QIKAT-R standardize scoring systems to evaluate the aim, measure and intervention/change.
Scoring of final fellow project presentations using a balance score card as outlined below:

	Balanced Score Card This tool is to be used after completion of the QI project.
	Title of project: Team members:
	Rating system: 0 = no 1 = some attempt was made but does not meet the requirements 2 = met some requirements but substantial improvement is required 3 = good (can use some improvement) 4 = very good (only minimal improvement is required) 5 = excellent (no improvement needed)
	Please circle appropriate number for each question
1. Have the fellows worked effectively as a team?	0	1	2	3	4	5
2. Do the project findings indicate a patient focus?	0	1	2	3	4	5
3. Do the project findings indicate knowledge of process?	0	1	2	3	4	5
4. Do the project findings incorporate tests of change?	0	1	2	3	4	5
5. How would you rate the aim statement (including use of appropriate methodology to identify causes of the problem)?	0	1	2	3	4	5
6. How would you rate the measurement/ collection/use of data? (0 = no actual data)	0	1	2	3	4	5
7. Has the team engaged stakeholders in planning, executing and evaluating the change?	0	1	2	3	4	5
8. How would you rate the change suggested/ achieved? (0 = no change suggested)	0	1	2	3	4	5
9. Do the three elements (aim, measure, change) bear some relationship to each other?	0	1	2	3	4	5
	Comments:
	Total Score /45

References

1. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000.

2. Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB: Effectiveness of teaching quality improvement to clinicians: a systematic review. JAMA 2007, 298(9):1023-1037.

3. Batalden P, Davidoff F: Teaching quality improvement: the devil is in the details. JAMA 2007, 298(9):1059-1061.

4. Estrada CA, Dolansky MA, Singh MK, Oliver BJ, Callaway-Lane C, Splaine M, Gilman S, Patrician PA: Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program. J Eval Clin Pract 2012, 18(2):508-514.

5. Accreditation Council of Graduate Medical Education: Common Program Requirements. In.; 2017.

6. Kashani KB, Ramar K, Farmer JC, Lim KG, Moreno-Franco P, Morgenthaler TI, Dankbar GC, Hale CW: Quality improvement education incorporated as an integral part of critical care fellows training at the Mayo Clinic. Acad Med 2014, 89(10):1362-1365.

7. Singh MK, Ogrinc G, Cox KR, Dolansky M, Brandt J, Morrison LJ, Harwood B, Petroski G, West A, Headrick LA: The Quality Improvement Knowledge Application Tool Revised (QIKAT-R). Acad Med 2014, 89(10):1386-1391.

8. Ogrinc G, Headrick LA, Morrison LJ, Foster T: Teaching and assessing resident competence in practice-based learning and improvement. J Gen Intern Med 2004, 19(5 Pt 2):496-500.