Education in Quality of Care in an Internal Medicine Residency Program

Objective: Because resident physicians usually work at the “front lines” of care, they are ideally situated to become active in quality assurance and improvement activities in their institutions. We developed and pilot tested a curriculum designed to allow residents in our internal medicine residency program to learn and apply key concepts in the assessment and improvement of the quality of the care that they deliver at our institution. Description: We launched our program in 1999 with an interactive half-day seminar in which we presented an overview of the core curricular content. Terms such as quality of care, quality control, quality assurance, and quality improvement were defined. Concepts such as the technical and interpersonal dimensions of care, small-area variation in care, and the structure-process-outcome paradigm of health care quality were introduced. Tools used in the measurement and enhancement of quality were illustrated through case discussion and review of selected abstracts from the literature on quality of care. These included mortality and morbidity review, peer review, examination of critical incidents, medical audit, and methods in total quality management. The introductory seminar was followed by a series of monthly noon-hour sessions devoted to group review of selected episodes of care in which suboptimal quality had been identified. These sessions were organized by a resident peer leader, who presented the case scenarios in anonymous fashion and led the resident group through an examination of the processes and outcomes of the care delivered, and a discussion of how care might have been improved. At each session, selected aspects of the curricular content, introduced at the initial half-day seminar, were reviewed in the context of the case discussions. The residents were thus able to use these discussions as an opportunity to identify, in a constructive and nonthreatening fashion, both system-embedded problems and the gaps in knowledge, skills, or attitudes of the caregivers that might have contributed to suboptimal quality. The residents' knowledge of concepts in quality of care was demonstrated, using a pre-test (administered at the outset of the introductory seminar) and a post-test (administered at the conclusion of the last noon-hour session of the year), to have improved over the course of the year. Discussion: The residents responded favorably to the introduction of this seminar series into their curriculum. The case-discussion format allowed them to learn and apply concepts that previously they might have perceived as dry, mundane, disconnected from their everyday work, or even threatening. The residents also found that their intimate knowledge of hospital-based processes of care gave them insight into problems that were attributable to system, rather than individual, performance. Identification of such system problems through group discussion also served to stimulate their interest in seeking system-based solutions. Key to the success of this series were the involvement of a resident peer-leader from conceptual stage through implementation and evaluation, and the support of faculty members with interest and training in quality improvement methods.

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