We Are Great at Generating New Knowledge, but Bad at Implementation…Can We Do It Right In Graduate Medical Education?

“We are great at generating new knowledge, but bad at implementation.”

James B. Battles, PhD
Social Science Analyst for Patient Safety
Agency for Healthcare Research and Quality
Harvard IOM Conference presentation, June 18, 2010

I loved this quote when I first read it in an excellent white paper entitled, Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety”. It is a well-written review regarding many of the issues and challenges that lie ahead in graduate medical education (GME). Over the years I have heard many, including myself, express dismay at the ability of our profession to generate new ideas yet fail to see those practices turned into universal action across care sites–but never so simply put as Battles articulated. Having had the great pleasure of knowing Dr. Battles through the years, it didn’t surprise me that this eloquent quote came from him.

Over the past decade, research and outcomes studies have shown us what we need to do to improve the safety and quality of care for our patients. Be it misaligned financial incentives, lack of internal resources, competing time constraints, or a lack of strong leadership that fails to make safety and quality top priorities, we continue to struggle with the implementation of proven best-practices at the bedside…things we know work.

Can the same Jim Battles quote now be said for graduate medical education? As shared in my previous post, “Graduate Medical Education: Value Based Reimbursement…”, in December, 2008, the Institute of Medicine (IOM) issued a report entitled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”.  In 2010, the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors responded by approving new requirements for residency programs, including updated standards for resident duty hours, education, and supervision. These new standards were implemented on July 1, 2011. In line with many of the IOM’s recommendations, the new ACGME standards required residency programs to:

  1. Tailor supervision standards for different levels of training, particularly greater supervision for first-year residents
  2. Ensure competence in structured handover processes
  3. Incorporate clinical quality improvement and patient safety into resident learning
  4. Provide safe transportation and/or sleeping facilities for fatigued residents
  5. Adjust workload according to patient severity and resident training
  6. Improve oversight of compliance with duty hour limits

Following the release of the new standards, Dr. Nasca the current CEO for the ACGME, was quoted in a perspective piece published in the New England Journal of Medicine (September 30, 2010). In it, he highlighted “the important role of the IOM report in ‘solidifying the ground on which GME programs will move forward to adjust duty hours, provide closer supervision to residents, and improve the quality of care by making it safer.'” Program directors would now be held accountable in ensuring that their residents:

  • Participate in identifying system errors and implementing potential systems solutions.
  • Work in interprofessional teams to enhance patient safety and improve patient care quality.
  • Are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

Some say the ACGME requirements are not enough. The white paper cited above was the result of a conference entitled, “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” Twenty-six stakeholders participated in the invitation-only roundtable discussion, and included quality improvement experts, medical educators and hospital administrators, consumers, regulators, sleep scientists, policy makers, a resident physician, and a medical student. The group also included two members of the IOM committee that produced the “Sleep, supervision and safety” report. The conference was structured around the 10 major recommendations made by the IOM. The expert panel concluded:

Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference…it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require.

The new ACGME requirements are clearly a big step in the right direction. However, I have been continually surprised through my recent travel and speaking engagements across the country at the number of residency program directors, designated institutional officers (DIO’s), quality/safety directors and C-suite leaders who are still unaware of the new ACGME requirements, or the new CLER (Clinical Learning Environment Review) program that now uses unannounced site visits to assess the GME learning environment of each sponsoring institution and its participating sites. Many residency program directors who have heard of the new programs cite lack of institutional support needed to address the new requirements–they know what they need to do but don’t have the support or resources to implement what they need to do.

Here’s hoping Dr. Battle’s quote doesn’t also prove to be true in GME.

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Patient and Family Advisory Councils – The Importance of the Patient Voice in Our Safety and Quality Work

Patient and Family Advisory Councils are forming in many hospitals across the country. Some institutions, like the Dana Farber Cancer Institute and Cincinnati Children’s Hospital have had “Patient Partnership” Council’s in place for over a decade, inviting the patient into healthcare decision-making and strategic planning, setting examples for those just starting the process. Aurora Health in WI, who received AHRQ funding to look at best practices around the formation of a Patient Safety Advisory Council for outpatient medication safety has provided guidelines for all to follow if they so desire to set up their own Patient Advisory Council.

But with many now rushing to engage patients, a few leading patient advocates have become a bit skeptical. Engaging patients is more than just addressing the call from the Institute of Medicine in their September report. It’s more than gathering people in a boardroom, serving lunch and feeling good about ourselves. It’s more than just checking the patient council box when the Joint Commission comes visiting. And it’s more than just asking patients about hospital room colors. It’s about true partnerships that define, and then measure, patient safety and quality improvement outcomes from projects that directly result from the time invested in these types of meetings.  When done correctly, these partnerships become powerful and lead to positive changes in a number of areas. The culture of medicine is in transition, and like any industry, changing culture takes time, courage and the ability to take action outside our normal comfort zones.

This week, I had the great pleasure of spending time with a number of leading patient advocates – people who have devoted their careers to helping patients, caregivers and health systems better understand what is needed to lower risk and improve quality in patient care. Many are good friends and have been personal mentors to me through the years. People like Helen Haskell, Carole Hemmelgarn and Patty Skolnik, three remarkable women who continue to share their personal stories of loss so others can learn, and make care safer.  People like Rosemary Gibson, Michael Millenson, Sorrel King and Victoria Nahum who have touched us all through their writings, educational materials and collective call for change.  They have graciously agreed to help us at MedStar Health better understand and appreciate what terms like patient-partnership, shared decision-making, and transparency really mean to our patients. Their definitions and perspectives can be quite different at times from those I have thought were correct and published in the literature through the years. Many times I think I get it, only to realize that “I don’t know what I don’t know”. Tim McDonald, a good friend, mentor and patient safety leader, always likes to say we can be “unconsciously incompetent” when describing this phenomena.

We all met as a group last week, and the conversation took on a life of its own. With the advocates asking the tough questions, the conversation and discussions evolved organically and led to the open, honest discourse we all know is critical if real change has a chance to occur. Rosemary challenged the leadership in the room to measure our success by striving for the day when every healthcare provider working in our system was one that we as caregivers would refer a family member to – no hidden secrets on who we know is good, and who we would take our loved ones to for care. A second recommendation focused on outcomes data, and how to present it in a meaningful way–in a way that patients could truly understand, and then use it for decision-making. And more than one of our advocates implored us to create educational tools that patients could not only use to guide them through their hospital stay, but also make it clear they were a welcome and engaged part of the care team. Many health systems like MedStar already have different patient educational tools in place, but the group pushed us to think differently and be even more innovative in our approach to patient education.

The day ended with excitement around the different opportunities to create change right in front of us, and in fact, work has already begun on more than one consensus recommendation resulting from the meeting. We all look forward to the continued sharing of ideas with our council members, and graciously thank them for their insight and resolve to push us past our limits in the best interest of our patients.