Simultaneous Improvement of Patient Care and Medical Student Training - Dartmouth Develops a New Model
Between December 2004 and June 2006, researchers from six medical centers, led by Dartmouth Medical School in Hanover, N.H., created a conceptual model on how to improve simultaneously patient care and student training. They developed the model as a result of lessons learned from pilot projects conducted in different clinical settings during that time.
- Researchers constructed a conceptual model of how to create multidisciplinary training opportunities for health care students in clinical settings and also improve patient care. In the model, they stressed the importance of:
- Collaboration between academic and clinical leadership at all levels within medical centers.
- Linking health care professionals, including physicians, nurses, students and support staff at academic and clinic settings, via shared information systems.
- The project director wrote a white paper in June 2006, Creating Something Special Where Exemplary Care and Learning Come Together, which summarized the project, pilots and conceptual model.
The Robert Wood Johnson Foundation (RWJF) provided a $75,000 grant to support the project.
The current structure of professional education for physicians, nurses and others in the health care field does not adequately address the evolving challenges of patient care. A 2001 report from the Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century, identified two issues:
- Students need to learn how to analyze clinical processes with an eye toward improving patient care.
- Students need hands-on experience working on multidisciplinary teams.
The Association of American Medical Colleges responded to the IOM report in 2001 with Report V: Contemporary Issues in Medicine: Quality of Care that suggested strategies to speed the process of change. The association recommended that academic medical centers create opportunities for students to learn through hands-on participation in quality-improvement activities at the point where care is delivered to patients.
The association's recommendations interested the nonprofit Institute for Healthcare Improvement, in Cambridge, Mass., which supports promising concepts for improving health care worldwide. In 2003, the institute created a collaborative of medical schools to create models for wide-scale change that would test projects aimed at teaching students to analyze and continually improve patient care as members of a team. After nursing and pharmacy schools joined the collaborative, it became the Health Professions Education Collaborative.
Under this grant, six members of the collaborative of academic medical centers created pilot projects to test ideas about how to combine exemplary education and patient care in a variety of clinical settings. Paul Batalden, M.D., investigator in the Dartmouth Institute for Health Policy and Clinical Practice at the Dartmouth Medical School, was the project director.
The project was an extension of the work of Batalden and others, also funded by RWJF, in which they described the characteristics of clinical microsystems (see Grant Results on ID# 036103). A clinical microsystem is a small group of people at the front line of clinical care, including patients and their families, who work together to minimize the burden of a patient's illness. Information technology also plays a role because it enables members of the microsystem to share information.
The six pilot programs developed under this project were:
- Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., launched collaborative rounding teams on an inpatient pediatric unit in which doctors, nurses and medical and nursing students participated with patients and their families in discussing patients' cases. Medical-school faculty members involved in patient care were linked one-to-one with students.
- Mayo Clinic, Rochester, Minn., planned for residents to work on patient-care quality-improvement projects during their rotation in the occupational medicine department. However, the pilot was not completed because the leadership opted instead to expand the project to all residencies.
- Penn State College of Medicine, Hershey, Pa., and Lehigh Valley Hospital and Health Network, Allentown, Pa., created collaborative rounding teams on an inpatient pediatric unit involving family practice and emergency medicine residents, third-year medical students, nurses and patients and their families.
- University of Minnesota Medical School, Minneapolis, planned to include patient-care quality-improvement education as part of an existing 36-week course in which third-year medical students practiced and lived in rural communities. Because of limited communication with the rural clinics, the project director is not sure of the site results. (See Lessons Learned.)
- At the University of Missouri Health Care network, Columbia, Mo., including the University of Missouri School of Medicine, family practice residents and third-year medical students rotated through medical practices, in which learning focused on teamwork among doctors and nurses. The students worked on a program to manage chronic illnesses in elderly patients proactively, reducing patients' visits to the emergency department.
- The University of Tennessee Health Science Center, Memphis, Tenn., created a course on multidisciplinary teamwork within clinical microsystems open to all students in the health professions.
Lehigh Valley Hospital and Health Network contributed $5,000 toward the project manager's salary for its project.
Batalden set up regular opportunities for project members to communicate via:
- Monthly virtual meetings through the Web, including audio and visual capabilities.
- Site visits to the University of Missouri in October 2005 and to Dartmouth in May 2006.
- Meetings of the Institute of Healthcare Improvement's Health Professions Education Collaborative.
- Researchers constructed a conceptual model on how to create training opportunities within clinical microsystems for health care students while also improving patient care. "We were trying to develop an idea. We weren't trying to test whether something worked. We were consciously trying to explore a variety of kinds of ways of bringing about this kind of situation. We were interested in knowing: what, when, where, how and why these things worked not did [they] work," Batalden explained.
- In the model, investigators stressed the importance of collaboration between the academic and clinical leadership within academic medical centers. Common information systems also are necessary to link people, including students, from academic and clinical realms. The model includes these steps:
- Select a site.
- Understand current practice and performance levels.
- Pick a focus of action.
- Try out new ideas and evaluate their impact.
- Track progress and share results.
- The project director wrote a 2006 white paper, Creating Something Special Where Exemplary Care and Learning Come Together, summarizing the project, pilots and conceptual model. The paper is not available online.
- Set up regular virtual meetings via the Web to keep geographically dispersed members working on a project up-to-date on colleagues' work. (Final Narrative Report to RWJF)
- Do not expect virtual meetings to replace face-to-face encounters. Site visits to Dartmouth and the University of Missouri enabled in-depth discussions about achievements and problems with the pilot projects. (Final Narrative Report)
- Recruit site managers who are present at the pilot test location. A coordinator of the University of Minnesota's rural medicine program was the key contact for the grant project, but the coordinator was in Minneapolis and did not have firsthand knowledge of what actually happened at the rural medical sites where students were working. (Project Director/Batalden)
AFTER THE GRANT
- Collaborative, multidisciplinary rounding, including participation from students, continues at Dartmouth-Hitchcock Medical Center and Lehigh Valley Hospital and Health Network.
- A working group of faculty from three U.S. medical schools (Dartmouth, University of Missouri and University of Minnesota) and one Swedish school continues to collaborate and will pilot lessons learned from this project in their respective care and teaching settings.
- A parallel evaluation plan will test the theories that were developed to underlie the initial work in this current project and in the new settings.
GRANT DETAILS & CONTACT INFORMATION
Developing a Blueprint for Exemplary Learning Sites in Clinical Academic Training
Dartmouth Medical School Center for the Evaluative Clinical Sciences (renamed the Dartmouth Institute for Health Policy and Clinical Practice) (Hanover, NH)
Dates: December 2004 to June 2006
Paul Batalden, M.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Batalden P. Creating Something Special Where Exemplary Care and Learning Come Together. Hanover, N.H.: Dartmouth Medical School, 2006.
Report prepared by: Linda Wilson
Reviewed by: Pamela Lister
Reviewed by: Molly McKaughan
Program Officer: Constance Pechura