As medical students, we've heard the phrase “medical quality” thrown around quite a bit—in the clinic, in class, on the news. It's reasonable to wonder what all the fuss is about, and how it applies at this stage in a physician's career.
There is a growing interest across medical specialties in quality improvement initiatives and the emerging field of medical quality management. This interest has been intensified by recent discussions surrounding national health care reform. The ultimate goal of medical quality measures is to improve outcomes and reduce health care cost for patients and the system overall. The evolving principles of medical quality assurance and quality improvement can be applied to any patient care setting, including the hospital.
From residency, physicians are expected to be competent in applying the principles of medical quality to practice. Beginning in 1999, the Accreditation Council for Graduate Medical Education (ACGME) incorporated the tenets of quality and safety as two non-traditional core competencies.
One competency is “practice-based learning and improvement,” which expects residents to “systemically analyze practice using quality improvement methods and implement changes with the goal of practice improvement,” according to the ACGME. The second is “systems-based practice,” which calls on residents to “advocate for quality patient care and optimal patient care systems, work in inter-professional teams to enhance patient safety and improve patient care quality, and participate in identifying system errors and implementing potential systems solutions.”
Since 2006, residency programs have been required to show that these two competencies are integrated into their curriculum, in order to be accredited. Yet, specific information is scarce as to how the programs should modify existing curricula to meet the requirements. Even scarcer are resources for medical schools that are interested in creating curricula on quality; many schools lack concrete instruction on the topic entirely. Given these challenges, how can students gain experience with medical quality?
Advocate at your school
Advocate for integrating quality curricula at your school. The curricula might include safety training, skills performance assessments and elective courses that emphasize quality improvement in the health care system. Due to the ACGME requirements, internal medicine residency programs have generally had more experience in medical quality than many medical schools; an interested advocate can use their work for guidance.
Several IM residency programs, like the University of Virginia's, have published their experiences developing patient safety and quality improvement (QI) curricula. Medical schools that have implemented quality improvement curricula have reported that active learning through practical experience, simulation and exercises, in the context of meaningful clinical work, was most effective in helping students develop quality improvement knowledge and skills. And they have found that medical students can make meaningful contributions to quality improvement projects that result in measurable improvement of patient care. The American College of Medical Quality has an annotated bibliography of resources for teaching quality and safety to medical trainees that may be a useful tool for creating or modifying medical school quality curricula.
Get involved with groups
The American College of Medical Quality (ACMQ) was founded in 1973 with the mission to provide leadership and education in health care quality management. In 2007, the ACMQ opened its doors to medical students through the creation of a Student & Resident Section. Since then, the ACMQ has provided generous support for students to attend its annual national conference through the Quality Scholars Program.
We were recently given the opportunity to attend the 2010 ACMQ annual meeting through this program, and were surprised by how many of the lessons we learned at this conference could be applied to our daily lives as medical students in the hospital. The Institute for Healthcare Improvement (ihi.org) is another excellent resource with online educational programs, and the IHI Open School is an online educational quality curriculum with many lessons at a level appropriate for medical student learners.
Stay informed, active about reform
Be an advocate for health care reform by volunteering to serve at your state's Senate hearings and/or calling your state representative. The following resources provide current information about the ongoing health care reform debate: the Mayo Clinic Health Policy Center, the Commonwealth Fund, and the Kaiser Family Foundation.
Talk to your patients
Medical students can play an important role in facilitating transitions of care by talking with hospitalized patients before discharge about their continuing health care management. Appropriate questions assess patients' comprehension; focus on patient-relevant outcomes; and facilitate active involvement. A few sample questions include:
- What are your goals for this hospitalization?
- How does your treatment plan fit into these goals?
- Can you tell me what each of your medications is for, and how you are going to take them?
- What barriers can you think of that might prevent you from achieving your goals?
- What are some ways you could resolve these barriers?
In addition to assisting in the creation of an effective discharge plan, asking these questions helps make medical students aware of the impact of outside factors (social, economic, etc.) on a patient's ability to maintain his/her health.
Understand the “value equation”
Value = Quality/Cost. This key equation underlies many of the principles of medical quality. Research into understanding the inverse relationship between quality and cost and the regional variance of “value” across the United States is a current hot discussion topic. We can help maximize value for our patients and the health care system by developing an early awareness of “best practices” based on evidence-based medicine, and by keeping this knowledge grounded in cost realities.
Reflect on performance
Solicit feedback from peers and mentors about your clinical performance, and create concrete objectives for implementing their suggestions. Know the procedures for reporting errors at your medical institution and do so on behalf of yourself or others, whether or not a negative health outcome occurs. Accountability is key in quality improvement, and is effectively coupled with efforts to reduce or eliminate future errors, rather than create individual blame. Identify opportunities for systems quality improvement, and be familiar with the resources available at your institution to implement such QI changes.
We hope that by following these suggestions, we as medical students can begin a lifetime of active involvement in improving quality of care for patients.