Aug 1 2014

The Imperative to Engage Surgical Residents in Quality Improvement

Charles D. Scales Jr., MD, MSHS, an alumnus of the Robert Wood Johnson Foundation/VA Clinical Scholars program (UCLA 2011-2013), is a health services researcher at the Duke Clinical Research Institute and assistant professor in the division of urologic surgery at Duke University School of Medicine.  He is also assistant program director for quality improvement and patient safety for the urology residency training program at Duke University Hospital.  


Young doctors training to become surgeons, also called surgical residents, are increasingly caring for patients in an environment that links quality, safety, and value to patient outcomes. Over a decade ago, the Institute of Medicine highlighted the need for improving care delivery in the landmark report, Crossing the Quality Chasm, suggesting that high-quality care should be safe, effective, patient-centered, timely, efficient (e.g., high value), and equitable. Just this week, the Institute of Medicine followed with a clarion call for training new physicians to participate in and lead efforts to continually improve both care delivery and the health of the population, while simultaneously lowering costs of care.

To support this imperative, the Accreditation Council for Graduate Medical Education, which accredits all residency training programs in the United States, mandates that all doctors-in-training receive education in quality improvement. Despite this directive, a number of substantial barriers challenge delivery of educational programs around quality improvement.  Health care is increasing complex, driving residents to focus on learning the medical knowledge and surgical skills for their field.  Patient care demands time and attention, which can limit opportunities to learn about quality improvement within the context of 80-hour duty limits. This barrier particularly challenges surgeons-in-training, who often spend 12 or more hours daily learning surgical skills in the operating room, leaving little time for a traditional lecture-format session about quality improvement. Finally, many surgical training programs lack faculty with expertise in the skills required to systematically improve the quality, safety, and value of patient care, since these skills were simply not taught to prior generations of surgeons.

Overcoming these barriers to engaging surgeons-in-training in quality improvement is the focus of my work in resident education. I believe that just as they assume progressive responsibility for patient care during training, surgical residents should also assume progressive responsibility for improving the quality, safety, and value of their care. One model to facilitate progressive responsibility would include early didactic teaching, followed by subsequent integration of residents into the ongoing quality improvement processes of their department or hospital.  Ultimately, residents should have the opportunity to lead meaningful quality improvement projects in the final years of their training.

To create an innovative didactic experience, a team comprised of Jonathan Bergman, MD, (UCLA CSP 2011-13), Tannaz Moin, MBA, MD, (VA Health Services Research & Development fellow), and I have received a grant from the Society of Urologic Chairpersons and Program Directors. Key teaching points will be identified from a review of existing Quality Improvement (QI) curricula and validated as important to urologic surgeons by a stakeholder panel of urologists who have expertise in quality improvement, patient safety, or resident education. Once the key teaching points are identified, urology-specific cases will be developed. The cases and questions will be delivered using a state-of-the-art learning platform that can be accessed by any device with a web browser. Learning interactions are evidence-based and take only 2-3 minutes per day. We anticipate rolling the curriculum out to 40 residency training programs for testing and evaluation in 2015, and if successful may disseminate it nationwide through the American Urological Association.

This method of learning overcomes several barriers to teaching surgical residents about quality improvement. It provides content to training programs that may not have expert faculty in this area, and allows residents to learn in small spaces of time during the day, rather than hour-long lectures. It also averts the need for residents and faculty to gather in the same time and place to learn.

At the end of the program, residents should have improved knowledge of QI methods, and will be able to apply those methods in their local hospitals to improve care delivery and patient outcomes. Based on this foundation of knowledge, future educational research will identify ideal methods to engage surgical residents in ‘hands-on’ QI activities.

Surgeons are different – they work differently and think differently. Thus, innovative programs for engaging surgical residents are required and this grant represents a first step in that direction. Through progressively and meaningfully engaging surgical residents in the ongoing QI process of their institutions, we will help build a surgical workforce that is not only medically knowledgeable and technically skilled, but will also possess the ability to advance the quality of care they deliver.

Tags: Clinical Scholars, Health Care Quality, Health Leadership, Education, and Training, Voices from the Field