Criteria for Excellence | Chapter 8B: Quality improvement and patient safety

Programs of Excellence have a culture of continuous quality improvement (QI). They engage staff, residents, faculty, and patients in a shared culture. Residents are actively involved in quality initiatives with the expectation that they will be prepared to lead care teams and design/implement QI programs in their future practices. The importance of quality and safety processes in residency programs is underscored by their inclusion as critical components of accreditation in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements.

Common barriers to achieving excellence in the areas of quality and safety include lack of time for teams to meet to do this work and lack of resources needed to implement some team recommendations. Other barriers include electronic health record (EHR) systems that lack robust registry functionality and lack of staff support to manage and display data in ways that promote effective QI cycles. Confusing and conflicting external reporting expectations are also burdensome to many programs.

Some barriers can be addressed by embedding quality and safety in nearly all of the routine processes of patient care. Prioritizing resident participation on clinical teams and in other developmental work through innovative scheduling will reinforce the importance of these systematic improvement efforts.

Programs of Excellence participate in mandated quality activities such as those required by The Joint Commission and the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA). (See the Models of Care Delivery section for additional information.) They adapt to the local care environment by adopting best practices in their medical community, or they become thought and practice leaders in their health system.

Within the context of mandated options, a Program of Excellence identifies the most important areas of improvement based on its unique circumstances.

A resident must have a reasonable understanding of QI tools and participate as the leader or co-leader of at least one QI project through a complete Plan-Do-Study-Act (PDSA) cycle as required by ACGME Program Requirements. The curriculum must include adequate time for residents to fulfill this requirement.

QI Principles for Residency Programs

Critical QI principles for any residency program include the following:

1. The care improvement process is systematic and data driven.
   1. It includes the following:
      1. Regular review of evidence-based best practices for common and high-risk conditions
      2. A systematic process designed to improve and support adoption of best practices
      3. iii. Regular measurement of adherence to best practice standards of care
      4. iv. Data sharing on performance with team members through team-based performance improvement activities
   2. Example: The program has care process model (CPM) development teams that focus on achieving high performance for chronic conditions such as diabetes, chronic obstructive pulmonary disease (COPD)/asthma, congestive heart failure (CHF), depression, and preventive care.
2. The QI process focuses on outcomes that matter to patients.
   1. Patients are involved in determining meaningful outcomes.
      1. The practice shares performance measures, including individual patient metrics, with patients.
      2. Examples:
         1. The program convenes a patient advisory panel composed of a representative sample of patients served by the family medicine practice who can give meaningful feedback.
         2. The program posts QI results in the waiting room and/or on the practice website.
         3. The program provides patients with “report cards” on their own preventive and chronic care measures.
3. Quality of care is enhanced by collaborative interprofessional teams.
   1. Team members do the following:
      1. Share responsibility/accountability for patient care
      2. Practice at the top of their licensure and training, with ongoing, purposeful processes to enhance staff training and performance
      3. Function within the constraint of practice finances as a robust care team of health professionals to meet all of the primary care needs of patients, including physical, behavioral, and social health needs
      4. Engage in proactive, real-time communication with other team members
      5. Become involved in safety and QI activities as a team and take accountability for these activities
   2. Examples: Team “huddles” prior to clinic session; pre-visit planning; integrated behavioral health in primary care; clinical pharmacist review of high-risk medications; joint pharmacy practice; health coach or care navigator assigned to clinical team.
4. Patient engagement is a key element of care quality.
   1. The practice routinely communicates with patients between visits and facilitates communication between patients and their care team.
   2. Patient-driven care goals and preferences are systematically requested, documented, and followed.
   3. Social determinants of health are considered and incorporated into the care plan, as appropriate.
   4. Patients are provided a written care plan and visit summary at each visit and transition of care.
   5. Examples:
      1. Patients receive notification of all test results.
      2. Patients receive a meaningful printed or electronic summary of each visit.
      3. A patient reminder system is used routinely for important follow-up and preventative care.
      4. Patients can pose questions and receive prompt responses from their care team between visits (e.g., through a secure web portal).
5. Health outcome disparities are a key element of data collection, analysis, and process improvement.
   1. The program collects appropriate demographic data on all patients, which allows analysis of disparate patient access, process measures, and outcomes based on these demographic characteristics.
   2. The program considers both internal and external barriers to care when designing and carrying out process improvements.
   3. The program demonstrates commitment and outreach to vulnerable populations in its catchment area.
   4. Examples:
      1. Performance in multiple areas, including prevention, chronic care measures, and patient satisfaction, can be broken down by race/ethnicity, geographic area, payer type, etc.
      2. Apparent disparities in performance are addressed by including patients in the target population when identifying barriers to care.
      3. The curriculum includes self-reflection on inherent personal biases of clinicians and staff toward certain diseases, conditions, or types of patients.
      4. The program works closely with community-based organizations that employ community health workers who perform outreach to underserved or vulnerable populations.

Patient safety is a complex construct that requires robust process design and individual professional commitment. In the hospital environment, required safety practices are often embodied in facility licensing and The Joint Commission requirements. Residents need to be aware of these requirements and have time for instruction and participation in required safety activities.

Patient safety expectations are not always as explicit in the residency ambulatory practice environment. All communities have some facility requirements in areas such as fire safety and handicapped access. However, office procedures for dealing with incidents such as fires, medical emergencies, or disruptive or violent patients are equally important.

Storage of biologicals and vaccines; infection control; procedural safeguards including training, credentialing, and supervision; and compliance with laboratory regulations are also important in an ambulatory setting. As in the hospital, some type of Unusual Occurrence Reporting (UOR) system needs to be in place, and an environment conducive to UOR needs to be established and reinforced.

Principles of best practices for patient safety in both inpatient and ambulatory environments include the following:

1. Safe care depends on creating a culture of safety.
   1. Creation of this culture includes the following:
      1. Stressing personal/professional responsibility to recognize impairment
      2. Creating a no-blame environment without undermining the need for professional accountability
      3. Demonstrating institutional and individual desire to know about all errors and correct unsafe processes
      4. Examples: Training residents and staff to recognize and report when they are fatigued, stressed, or distracted; administering the Agency for Healthcare Research and Quality (AHRQ) patient safety culture survey​ annually to all staff to measure success in achieving a no-blame environment; rewarding staff for reporting near-miss events; involving all staff in process improvement activities.
2. Special attention is given to redesigning and monitoring high-risk steps in the care process.
   1. These steps include the following:
      1. Structured, supervised handoffs between care teams and clinicians
      2. Planned, closely monitored processes to facilitate transitions in care (e.g., hospital to home)
      3. High-risk medication prescribing and monitoring
      4. Management of patients with complex or potentially unstable medical conditions
   2. Examples: Formal checkout rounds between shifts supervised by senior clinicians; multidisciplinary team rounds at the bedside of patients being discharged, with direct communication with the outpatient care team; anticoagulation clinic; chronic pain multidisciplinary group visits; clinical pharmacist review of patients on multiple or complex drug regimens; in-room precepting of complex patients.
3. Safe practices to proactively identify safety issues are in place.
   1. These include the following:
      1. Conducting routine near-miss reporting
      2. Incorporating near-miss events by priority into team-based performance improvement
4. Opportunities to learn from mistakes are provided.
   1. These include the following:
      1. Reviewing all adverse events and serious near-miss events in a nonjudgmental process
      2. Providing emotional support for clinicians and staff involved with an adverse event
   2. Examples: Root cause analysis; case review moderated by a behavioral health specialist to address the emotional impact of mistakes.
5. Patients deserve to be engaged in discussions of safety and errors.
   1. This includes the following:
      1. Disclosing mistakes and errors to patients
      2. Apologizing to patients for mistakes and adverse outcomes (as allowable by state law and risk management)
   2. Examples: Role-playing sessions to facilitate conversations with patients, including a patient communication plan with remediation of a near-miss or adverse event.