Building continuous quality and systems improvement into clinical practice is a key component of fostering a patient-centered approach to health care delivery. At Dartmouth Medical School in Hanover, N.H., which has incorporated elements of quality improvement, or QI, and systems knowledge into its medical curriculum for more than a decade, students start learning about these processes almost from the moment they set foot on campus. Now, those students have taken their educational experience several steps further, completing nine hands-on clinical improvement projects in the past four years.
The projects are described in the article(content.healthaffairs.org) (abstract) "Building Experiential Learning About Quality Improvement Into a Medical School Curriculum: The Dartmouth Experience," which was published in the April Health Affairs.
According to Greg Ogrinc, M.D., a co-author of the article and an associate professor of community and family medicine and of medicine at Dartmouth, more and more medical schools are seeing a need to pursue this training -- and to start it early.
"There was a recognition that there's a gap (between) where the system should be performing and where it is performing," Ogrinc told AAFP News Now. "And I mean the system at a very local level -- one family medicine practice in rural Vermont or rural New Hampshire is a system. There are standard methods to look at their small, local systems of care -- the microsystem of care delivery."
AAFP Vice President for Education Perry Pugno, M.D., M.P.H., said that introducing students early in their education to the concept of QI -- which is a principle of the patient-centered medical home -- is valuable because students can see how QI fits in with the whole idea of health care delivery.
Moreover, he told AAFP News Now, when oriented early in their medical education, students will be better prepared to think about QI topics when they start their clinical work.
At Dartmouth, first-year students are introduced to basic concepts of improvement, patient-centered care and outcomes. Second-year medical students learn the core skills needed to describe the people, structures and processes within a system and the principles of variation and measurement for improvement through various large-group sessions.
During their second year, students can choose to enroll in the Health Leadership Practicum, or HeLP, elective. Working in small groups with an on-campus faculty mentor and a faculty site coach, the students learn to apply knowledge from the core curriculum to improving the health of patients in a local setting.
Long a leader in the quality improvement, or QI, field, the Academy has produced or collected many resources to help members select and implement QI projects in their own practices.
In addition to these and other related resources and tools, various CME activities with a QI focus also are available.
Using the textbook Fundamentals of Healthcare Improvement, students learn the foundational elements of improvement, including finding evidence, focusing an aim, process analysis, measurement and making changes. They visit a clinical site, observe the site's process of care delivery and construct a model of that process.
"Improvement work is a skill-based activity," Ogrinc said. And, like any other skills learned by medical students, such as reading chest X-rays or electrocardiograms, "These are skills you have to practice -- analyzing these local systems and making recommendations about change."
During the past four years, 22 students enrolled in HeLP have completed nine improvement projects. Two notable success stories are:
Urine samples among pregnant women: Students recommended passive reminders to patients, such as posting a reminder at the intake window; active reminders, such as informing patients at check-in of the need to collect a sample; educating nurses about the importance of the test; and consolidating nurses' patient intake responsibilities to streamline the process.
As a result of these efforts, the clinical site went from completing the test on about 55 percent of patients to more than 80 percent, said the article. According to Ogrinc, the completion rate is even higher now.
"The site coach was really invested, she took the students' suggestions, and now their levels (have been) consistently above 95 percent for the past 12 months," he said. "The students generate some energy."
Colonoscopy follow-up: Students also examined ways to improve colonoscopy follow-up after positive fecal occult blood testing. Although they initially recommended that positive results be sent directly to the practice's gastroenterologist, this suggestion was not feasible. So the practice decided to place a green sticker on each printed colonoscopy referral for a positive screening test, which sped up the scheduling process.
"The students' work shined a light on areas for improvement, even if their specific recommendation was not adopted," the article noted.
"Students take time to understand the patient flow and the small system of care," Ogrinc explained. "And so the site gets to know the students. When they come back and say, 'These things might help,' they are taken seriously."
According to the article, students who complete the HeLP elective approach their clinical years with a new lens through which to view patient care.
"No longer are these students bound by the view of providing care to one patient at a time. The immersion in the HeLP elective allows them to 'see' broken systems and recognize how the system can be improved."
Ogrinc called it putting on "system-level glasses."
"We usually teach medical students to take care of one patient at a time," he said. "But they need to recognize that, in addition to diagnosing and treating one patient at a time, there is a way to look at the system that cares for many patients."