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Choosing a High-Impact Resident or Student Quality Project and Getting it Published

John J. Kelly  DO, FACEP, FAAEM, FCPP

The current ACGME mandate for residents to "develop, implement, and assess a project to improve care in the ED, such as a clinical pathway, a patent satisfaction survey, or improvement of a recognized problem area.... each resident should be given the opportunity to monitor their own patient care performance improvement indicators" has led all academic faculty to search for new strategies for Quality Improvement and Patient Safety (QIPS) topics and studies.  Finding success with your residents’ and students’ pursuit of a Quality Project that leads to Abstract and Manuscript can be elusive and frustrating.  Above all, make it fun, make it easy, and make them proud of their accomplishments!

The Current Program Requirements:

IV.A.5.g). (4) Advocate for quality patient care and optimal patient care systems;

IV.A.5.g). (5) Work in inter professional teams to enhance patient safety and improve patient care quality;

IV.A.5.g). (6) Participate in identifying system errors and implementing potential systems solutions;

IV.A.5.g).(7) Participate in performance improvement to optimize self-learning, emergency department function, and patient safety;

VI.A.3. The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

VI.G.4.b).(2) It is essential for patient safety and resident education that effective transitions in care occur....

Institutional Site Visits will assess sponsoring institutions in the following  focus areas:

  • Patient Safety – including opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care.
  • Quality Improvement – including how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes.

There are many barriers to this quest.  QIPS topics can be boring to most, and not many ED Faculty have QIPS knowledge or QIPS research experience.  Furthermore, there may not be a Chairman’s “priority” for this:   no protected time, no budgeted money, no interest, no excitement.

Start with the usual Plan-Do-Study-Act (PDSA) Cycle strategy and stay organized!  What are we trying to accomplish and how will we know the change is really an improvement?

Ensure that there is department leadership and faculty “Buy-In”, as well as strong leadership in Clinical Quality and Patient Safety.  Create a “Culture of Research” in Quality Improvement and Patient Safety (QIPS).  Schedule a BRAINSTORM SESSION with your Chair, Quality Officer, Residency Program Director, Research Director and create basic this concept and framework, then share with ED Faculty and ED Chief Residents.  Codify this concept and framework, and post it for everyone to read and see!

Next, create a list of important “Hot QIPS Topics” to study, and have the Residents come up with a list, too!  Constantly have everyone asking “why” on shifts, and at every Resident Conference, and generate “why” in each lecture.  Review the IHI Quality Map, Joint Commission (NatPtSafetyGoals) and CMS (Inpt, Outpt, PQRS) sites for more ideas.  Always look for “High Cost” and “High Risk” topics.  Collect articles that recommend “next areas of study”.  Try to hold a faculty meeting over lunch to conduct a “Research Ideas Open Forum”.  Best of all, I like to use last year’s Annals and Academic EM Journal with the Annual Meeting’s Abstracts Summary; Look for all of the QIPS-related topics, and identify any follow-up studies or ideas from the abstracts. Also, scan the usual websites of TJC and IHI, the commercial payers (ie BCBS) P4P measures, and your Hospital QA Department for more ideas.  Create an “Idea Line” (call-in or Web) for possible study ideas, attend monthly ED RN meetings, and network with other specialists and medical staff for more possible ideas.

Now that you have ideas, you need to develop mentors for these resident projects.  Find “Project Partners” using Quality Leaders within every department.  Grow these leaders and build “Culture”. Creating “Outside” mentors from other medical centers also works.

All important study questions must face the “So What?” question.  Make sure that the idea is currently important, definable, and measurable.  A QI Intervention may not be a good study, as we may already know the answer!   Instead, carve out a smaller idea, for example, a new Quality Tool or Checklist!

Create a longitudinal plan with foundational project management strategy.  Start with Intern year (best model, yet a QIPS project may not need 3-4 years) and have them read the EM Quality and Safety Curriculum; then identify an area of study. There must be a timed plan with deadlines, and enforced by the Program Director. This is easily incorporated into “Scholarly Tracts”.  If a Resident tells colleagues it was a difficult task, this will not help you build the culture.  Study every step of the process and make it easy (get feedback from each resident on their obstacles). Get help from your Research Committee, especially in completion of the IRB paperwork, data collection, statistics analysis and abstract/manuscript Write up (or at least to help edit the work).  Use the Chairman’s Discretionary Budget to help fund all of the above and to find protected time for the mentor.  Research Associates can assist and should be included as authors if appropriate.

Every completed project must receive recognition, and the Chair must lead the celebration! Submit the resident’s work for awards like the ACEP QIPS Section Resident Quality Award. Have a “Recently Published” Bulletin Board, and even acknowledge successfully completed Quality Projects that may not be published.  Consider a “Bonus” for the Resident (Movie Tickets and “Thanks”) and use the energy of many to fuel the culture.

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