Once a month, I precept a small group of residents in our internal medicine program to review elements of the core curriculum that are not encountered on clinical rotations. One of these topics is quality improvement, or “QI”. The Accreditation Council for Graduate Medical Education (ACGME), the same body that stipulated stricter rules for residency work hours this July, now requires that residents complete a QI project, from start to finish, each year of their training. In our small group session, QI specialists from the hospital’s Center for Clinical Effectiveness gave an hour-long presentation on the technical aspects of designing a QI project, everything from the PDSA cycle (plan-do-study-act), to control charts, to team-building exercises to achieve goals. After the presentation, when the residents were invited to ask questions, there were blank stares and furrowed brows. For most, there was no familiarity of how much work a QI project entails, what “quality” even means in health care, and why they have to concern themselves with it. The assignment of completing the QI project during their busy clinical training years seemed to be just an additional burden.
The time for educating physicians on health care quality has arrived, both for residents and established practitioners. Health care costs are rising uncontrollably without clear understanding of the effectiveness (as well as the harm) of much of the health care services that our trainees are learning to provide. Preventable medical errors, nosocomial infections, re-admissions, and high-cost, low-value care continue to plague hospitals and physician practices. With the new rule, the ACGME insists that doctors—not just hospital administration, public health officials, or nurse managers—have a duty to improve quality. In the newly re-named competency of “Professionalism, Personal Responsibility, and Patient Safety,” the ACGME declares that “residents and faculty members must demonstrate an understanding and acceptance of their personal role in the monitoring of their patient care performance improvement indicators.” In addition to quality, training on cost and value in health care may also become a standard for physicians: for example, the American College of Physicians has now proposed a 7th core competency for internal medicine: high-value, cost-conscious care.
The increased attention to quality and cost are understandable, but the question is, is there time? With the fast pace of growth in medical knowledge and technology and an aging patient population with more complex disease, the answer to this is not clear to residency program directors and physicians in practice. The ACGME is trying to make more time for didactic education with dramatic changes in duty hours, but only a small part is systems-based learning and health care quality.
Besides time, are there the institutional support, the academic motivation, and the physician practice climate to support this training? The institutional motivation has been clear for a while, as hospitals face steep cuts in insurance reimbursements based on quality indicators measured by private and public watchdogs, such as National Committee for Quality Assurance (NCQA), the University Hospitals Consortium, and, of course, the Center for Medicare and Medicaid Services (CMS). In fact, the representatives from the Clinical Effectiveness department spent much of their presentation detailing this scrutiny. The residents watched, however, mostly disconnected from these financial pressures.
The disconnect may lie more at the physician practice level, even in academic settings. The burden felt by the residents is parallel to that felt by practitioners who are increasingly asked to measure their own performance, report it, and adjust their practice to meet benchmarks. Quality measures in the form of pay-for-performance have been used by CMS for reimbursement previously, and these have been met with overwhelm, skepticism, and ire.
It’s no wonder. In a busy practice, there is little time to engage in quality improvement. More importantly, there are few positive financial incentives (as opposed to punitive threats) to do so. As it is, primary care providers spend a large amount of providing care that goes unreimbursed just to communicate with their patients, document well, and provide coordinated care—features of high quality primary care. In addition, many physicians rightly argue that sometimes quality standards and guidelines that derive from the available evidence are implemented too soon; the data are flawed, insufficient, or do not apply broadly to their patient population.
Understanding the evidence on quality is also not as straightforward as that for clinical medicine, where randomized controlled trials, often funded by pharmaceutical and device manufacturers, provide easy, if sometimes biased, conclusions. Bastions of basic science and clinical research like the NIH are well-known, while the Agency for Health care Research and Quality (AHRQ, pronounced “Arc” for those in-the-know) is not exactly a household name.
Neither is the Institute of Healthcare Improvement, founded by CMS director Don Berwick. However, the IHI is trying to provide the kind of training, in the form of online tutorials and tools and collaboration, for institutions to undertake quality measurement and improvement projects. Hundreds of institutions have benefited from this tutelage, and IHI has revolutionized quality-thinking in medicine.
Still, in order for health care quality to truly make inroads into individual trainees’ and physicians’ practice mentality, the whole health care community, including academic medicine, must embrace the quality culture. The health care industry has lagged far behind other industries, claiming that medicine as an art cannot be studied like widgets. This thinking remains, despite improvement in sectors like the airline industry that face similar challenges for ensuring safety and preventing fatal error. In academia, the prestige and money still do not accompany health systems research as readily as they do clinical research.
It may be entirely true that we do not have enough evidence about what constitutes health care quality to justify strict quality-based payment schemes for most of the care we provide. However, we do know about certain quality processes that succeed in preventing many nosocomial infections, wrong-site surgery, and pharmacy prescription errors. For that which remains unknown, academic centers must make larger commitments for quality research, and the knowledge base will evolve.
The need to focus on quality and cost in health care has been clear for a long time, and physicians as stakeholders and drivers of health care decisions need to be at the center of the quality improvement movement. But changing training requirements is not enough; the system that surrounds physicians’ practice must be also be supportive. Evidence-based medicine changed the thinking and language of physicians-in-training, so there is reason to be optimistic for another paradigm shift. When electronic medical record requirements arrive, for example, small practices will hopefully have cost-effective and tailored EMR solutions, paying off their large investments in the long run and keeping track of quality benchmarks more easily. The Affordable Care Act will demonstrate innovative payment models to support quality over quantity and fund a growing evidence base for clinical effectiveness. With a change in the financial climate and the intellectual support of academic mentors, the quality culture may soon characterize the next health care revolution.