Hospital taps residents to direct quality improvement program

A Boston hospital has found a solution to the persistent lack of involvement by residents in case reporting: Appoint a resident as director of quality improvement (QI) each year, according to an article in the April edition of Academic Radiology. The move has led to a culture change in how errors are reported at the institution.

Having one of their own in charge of QI has made the radiology residents at Beth Israel Deaconess Hospital far more willing to discuss their misses and their technical and interpretation failures, all while coming up with great ideas for new quality control projects.

"Where we were getting almost nothing before, suddenly the residents were willing to actually share their mistakes and complications, so we had this new catchment of great cases that we weren't getting before," said Dr. Jonathan Kruskal, PhD, who chairs the hospital's radiology department, in an interview with

The QI director is chosen each year from the fourth-year residents. This individual receives special training in professional development, didactic teaching, and other skills that will allow him or her to create a strong environment for quality improvement at the institution (Academic Radiology, April 2013, Vol. 20:4, pp. 500-505).

Avoiding discussion?

Before 2011, when QI was headed by a staff radiologist, residents seemed intent on avoiding discussions of irregularities, misses, and technical glitches. The hospital has maintained a sophisticated quality program for years, but traditionally it has received very little input from residents, wrote Kruskal and co-authors including Dr. Ammar Sarwar and Dr. Roland Eisenberg.

"The program was focused primarily on the radiologists, technologists, and staff nurses, but the residents were having very little involvement in it," Kruskal said. "When there were errors or mistakes, it was the radiologists who were doing the reporting, and the residents in a way were excluded from the whole performance improvement process."

QI is increasingly taking center stage for residents, however. Importantly, the Accreditation Council for Graduate Medical Education (ACGME) now requires that all residents be trained in quality improvement, which means designing and completing their own outcomes projects as a condition of completing resident training.

"The whole concept of QI is that the day they graduate they have to be doing performance improvement projects," Kruskal said.

Resident in charge

The resident QI director at Beth Israel receives dedicated training in QI methods, mentored opportunities to develop professional skills in QI, and didactic teaching in applications of QI to other residents, Kruskal said.

Resources assigned to the role include attendance of a national education meeting and the RSNA Quality Course, as well as an additional two weeks of mentored elective time during the year.

The QI director also serves as a full member of the departmental QI committee and is taught about the various QI initiatives in place, both in the department and in the hospital, the authors wrote.

Exposure to the programs in the facility represents an important educational and administrative learning opportunity about a wide range of topics, including knowledge of specific adverse events and personal involvement in root-cause analyses, process improvement, and issues involved in implementing successful QI measures.

Monthly QI meeting

"The resident QI director runs a monthly QI meeting that only residents attend, and it's mentored sort of from the outside," Kruskal said.

This means that faculty can join forces with the resident QI director outside of the meeting to work through some of the cases, show the director how to perform a root-cause analysis, and help analyze problems.

"The only thing we ask is that if there are cases that impact patient care, we get notified immediately so we can manage them," Kruskal said.

The resident QI director is responsible for selecting topics for these meetings, choosing adverse events for discussion, and teaching basic QI methods, according to the authors. Conference topics are derived from recommendations from the residents, from issues identified at the department QI meeting where quality assurance metrics are reviewed each month, and from topics selected by the QI director.

Past conferences have highlighted topics such as blind spots on head CT imaging, and difficult diagnoses of appendicitis, the group wrote.

"One of the several successful conference formats that have been used is a discussion of reported and peer-review errors related to specific modalities or diagnoses," the authors wrote.

The resident-led meeting serves two purposes, according to Kruskal and colleagues.

"First, encouraging residents to show their own mistakes and discuss personal QI is designed to change the culture of QI at an early stage in their careers," they wrote. "Errors are treated as opportunities for improvement, rather than as the subject of castigation by peers. Second, by introducing a given problem to a larger audience, the solution is effectively crowdsourced."

Other opportunities

The resident QI director attends monthly meetings of the hospital-wide clinical operations and medical executive committee, and discusses operational challenges, policies, and guidelines, with an emphasis on reviewing all reportable events. The resident director is also given the opportunity to attend hospital-sponsored workshops and educational seminars on QI, which are otherwise limited to staff members.

At one grand rounds every year, the resident QI director shares his or her experiences in the role, including the results of the project and insights learned with respect to QI activities, the authors wrote. Finally, the resident QI director is also required to author a paper on a completed QI project and submit it to a peer-reviewed radiology journal.

"The first QI director [study co-author Dr. Ammar Sarwar] was very involved in error reporting, dose reduction, and imaging appropriateness," Kruskal said. "He got very involved in trying to reduce the amount of unnecessary imaging."

The new resident QI director, Dr. Elizabeth Asch, who was appointed two months ago, is implementing a resident idea system to create a platform for generating quality improvement ideas.

"They've had, to date, 20 to 30 ideas coming in, and they actually respond to every one, trying to see how they can effect performance improvements," Kruskal said. "It's actually been very successful and we couldn't be happier."

The greatest accomplishment of the program so far may be the success of the position in destigmatizing mistakes; instead, they are brought out into the open so everyone can learn from them.

After all, the tendency to keep quiet about errors is only natural. Residents are staffing emergency rooms overnight, and they are expected to accomplish difficult tasks on their own -- and that leads to very real fears of coming up short. In addition, it's easy for attending physicians to see their mistakes when they review the reads, so residents feel they are constantly being evaluated.

In essence, the resident QI initiative is aiming for no less than a change in the culture that says all errors can be avoided, Kruskal told

"We're trying to ... teach them that errors are normal and we all make them, and that we should try to see every error as a learning opportunity -- to see how that person and everyone else can benefit from it," he said. "That sounds a bit flowery, but it's pretty much what it's all about."

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