UND medical students use a Quality and Patient Safety elective course to save lives by analyzing health system data.
In the past decade, health systems and medical schools around the nation began grappling with a chronic problem: medical school graduates were entering residency and fellowship programs – and residency and fellowship graduates were entering practice in clinics and hospitals – with little understanding of how an increasingly complex American health system functioned in a big-picture sort of way: quality improvement (QI), patient safety, high value care, population health.
“We know that in their careers physicians are leaders on their team; this means that what they understand, care about, and talk about is what their teams understand and talk about,” said Mallory Koshiol, Director of System Safety & Quality at Allina Health in Minneapolis, Minn., and the former Director of Quality for Sanford Health in Fargo, N.D. “So integrating safety and quality into the curriculum early on is not only advantageous for the system, but also for the care teams in delivering our promise of ‘zero preventable harm’ and delivering the right patient care at right place and right time.”
In other words, there was a disconnect, said quality leaders, between things like what the provider teams – physicians, nurses, therapists – knew and did in the realm of patient care, and what the systems understood about themselves as institutions, never mind how they worked.
The ‘science of health care delivery’
UND and safety & quality leaders wanted to change that – and hopefully improve the entire system in the process.
After a handful of conversations with health administrators and physicians in Fargo, including faculty at the UND School of Medicine & Health Sciences (SMHS), the Sanford Health Quality Team settled on the idea of an elective course for fourth-year medical students focused on what the pioneers in the field were starting to call “health systems science.”
“We jumped on board as one of the very few medical schools in the country doing this in a formal way,” said Dr. Dinesh Bande, chair of the SMHS Department of Internal Medicine, who offered to house the elective in his department. “My idea was asking: why do medical students need to learn about quality of care and not just quantity of care? How do we stimulate them to think about the outcomes that are important? There are a lot of things we can teach in this elective about how to make an organization safer, things not formally taught as part of basic sciences or clinical sciences, like medication errors, diagnostic errors, hospital acquired infections, hospital acquired pressure injuries, and falls in the hospital.”
Enter IMED 9240, also known by the rather prosaic title “Quality Improvement,” a course that sends SMHS medical students to either Sanford in Fargo and Bismarck or Allina in an effort to develop and execute a project-based quality improvement plan using data provided by the systems themselves.
As its syllabus suggests, the course’s objective is to give students “practical knowledge of interdisciplinary teamwork in healthcare settings” and help them identify and propose solutions to a quality improvement project based on the student’s third- or fourth-year clinical experience and health system’s quality improvement priorities.
From catheters to colonoscopy
And as far as students are concerned, the course is doing just that.
“What I liked about the elective is that it’s a way to see the work that you’re doing differently and help implement change in real time,” said Hallie Thompson, a first-year internal medicine resident at UND in Fargo who took the fourth-year elective last year through Sanford Health.
Describing how Sanford wanted to get a better handle on central line-associated blood stream infections (CLABSI) occurring in its facilities, Thompson said the system gave her the task of determining where and how the system could reduce the incidence of CLABSI in patients.
“My project was femoral line use in Fargo, compared to other hospitals in the Sanford system, and looking for trends in the data,” she continued, adding that although UND’s and the health system’s internal medicine teams took the lead on the course, projects can apply to any specialty. “We took that data and formed a multidisciplinary team with anesthesiology, infectious disease, vascular access nurses, and the infection prevention team and created a continuing education module for physicians and nurses to attend [with the goal of reducing CLABSI]. It was a lot of fun, and I learned what goes on behind the scenes in QI and the physicians’ role in that area.”
Smiling at her project’s results, Thompson added that nearly one year later, Sanford’s incidence of CLABSI is much reduced.
Thompson’s colleague Logan Schmaltz, a first-year internal medicine resident at UND and SMHS grad, related a similar experience.
Looking for a way to better clinically analyze Allina health’s at-home stool based testing program – fecal immunochemical test (FIT) kits were sent to more than 40,000 average-risk patients in the Allina system who might benefit from colorectal cancer screening in 2020 – Schmaltz called her time pouring over the provider’s data “amazing.”
“After looking at 800 patient charts, we found that half of the patients who had positive screenings [from their FIT kit] never had a follow-up colonoscopy,” she said. “So, there were over a dozen patients hanging out there that may have colon cancer but weren’t being treated for it. We found some holes in the Electronic Health Record that we could correct so that providers would be able to see this data more quickly. When you’re able to do those projects in real time and make actual changes as you’re moving along, we’re actually improving patients’ lives.”
All of this, said Tessi Ross, Allina’s Manager of Safety & Quality, is the value-add for systems: better care for more patients from an improved system.
“One example of something we’ve implemented this year because of Logan’s analysis is a centralized results hub for stool-based testing for colorectal cancer,” Ross explained. “Our registered nurses are now able to get patients educated on a positive result and schedule colonoscopies faster. That analysis motivated our leadership, who saw that we have an opportunity, and propelled the system to jump into solutions. A missed test or delayed diagnosis could be seen as ‘preventable harm’ and we are now addressing those positive tests better as a system.”
Sanford Quality and Safety Manager Laura Scott agreed.
“The Quality Improvement elective creates an opportunity to build a strong foundation for future physicians in regard to patient safety, experience, and outcomes,” said Scott, who has mentored over half a dozen quality projects with students. “Each medical student has brought a unique perspective to their project and has played a crucial role in influencing future care delivery at Sanford.”
“Oftentimes, these are projects that a health system’s safety and quality team may not have otherwise completed, at least not to this level of detail,” said Koshiol. “This elective allows us to choose projects that require detailed chart reviews and some clinical perspective and analysis. Then we have a presentation to help us move major initiatives forward in the organization. We’ve had five UND students at Allina and I can say confidently that every single project has been of tremendous value for the healthcare system.”
Such a course, continued Bande, overlays nicely with the recently revised SMHS medical curriculum, known around the School as “Curriculum 2.0,” which is getting students into the clinics and hospitals faster and offering them more elective options sooner.
“Historically, medical school curricula have a two-pillar system,” added Bande. “You learn your basic sciences in year one and year two, then you go to the wards and learn patient care at the bedside and practice clinical sciences. But in the past five years, multiple organizations have been emphasizing this third pillar of medical education, which has been health system sciences.”
Which, Bande said, UND was quick to adopt in partnership with area health systems, adding that it’s his hope that this third pillar can eventually become an integral part of UND’s curriculum.
“We’re thinking about how to build quality and safety into each of the clerkships and courses students do, no matter where they are in the health system,” he said. “Getting them to think about these things as central, not just an elective.”
Or if not in the medical curriculum, at least in early postgraduate residencies. To that end, Bande said he’s excited that Dr. Jennifer Raum, program director of UND SMHS-based internal medicine residency, has partnered with Kate Syverson, Director of Quality and Safety at Sanford, to require a one-month quality and safety unit for first-year internal medicine residents.
“We’re all looking at how to incorporate this into the medical curriculum right from the get-go,” said Syverson. “That’s a fundamental shift in medical education. What that requires is not just a small group of people thinking differently about how education is delivered; it challenges all instructors to invest in thinking differently about the courses they deliver.”
Adding that the program has been so successful that Sanford is looking to expand it already, Sanford Fargo’s vice president medical officer Dr. Douglas Griffin said he was excited to broaden the elective’s scope for his facilities.
“The medical students embedded with the quality team during the rotation have helped facilitate deeper looks at clinical issues, which has led to some very significant improvements in care of patients in our facilities,” said Griffin. “I have been impressed by their inquisitive nature and thoroughness of research. Being more senior students clearly has provided them a strong foundation for their work. We are, as an organization, very supportive of this work and look forward to seeing it continue.”
“Logan did such great work,” added Dr. Robert Quickel, vice president of Surgical Services at Allina, who sees the course as a sort of “evergreen” project. “From the health systems’ standpoint, it’s a good recruiting technique. We’re seeing these students and they’re getting exposure to our system. And they can go do their residency, but we keep an eye on them and when they’re applying for jobs they will have already had experience in our system – improving that system. That’s huge.”