Good morning! Let’s do something a little different today. I invite you to join me on a journey. This is a journey about residency. The metaphor I would like to use for residency is that of a pilgrimage. We’ll start with these pretty pink crocs, unsoiled and pristine, beginning the journey. I invite you to walk with me, together down this path, exploring residency as a journey or a pilgrimage.
We don’t talk of pilgrimage very much these days, but at one time it was more popular. This figure is the letter “o” from an illustrated manuscript from 1534. It was the first translation of a medical text, from Arabic to Latin, entitled the “Articella”. And here, within the letter “o” is a physician, reading from a book, and treating his sick patient. In these earlier times pilgrimages were much more commonplace, often associated with religion. Pilgrims traveled great distances to affirm their faith. Of course, not all pilgrimages are religious, but interestingly nearly every religion has pilgrimages.
A few years ago I had the opportunity to go on a pilgrimage myself. I joined a group from New Mexico that was headed to Rome for the beatification of a saint in the Roman Catholic Church. We flew from the US, and traveled by bus through Italy; to Milan, Florence, and Assisi.
And finally we ended up in Rome. Here at the Basilica of Saint Peter, the Pope led a four hour ceremony for the beatification of four saints. It was a beautiful day, filled with grand spectacle and crowds of people. There were bands and flags. I even got to see the pope-mobile! Along the way I heard a phrase that has stuck with me ever since. It came, not from a priest, or a nun, or the pope, but from one of the people on the bus.
The phrase was: A pilgrimage without transformation is just a journey. A trek. A long walk. A passage. To be a pilgrimage, there must be a deeper inner change, a transformation, that makes the journey more than just a long walk. Transformation of one’s self to a place of greater understanding. Thinking about residency, consider, “Does it feel like a passage, a trek, a journey for residents, or is it a pilgrimage?” Is it three years and out, take the boards and be done, or is it life-changing? If it feels like a passage, and not a pilgrimage, what is it that could give it deeper meaning for more residents? Lets continue to follow the path…
I’d like to share with you my personal pilgrimage. It’s not a religious pilgrimage. It is a pilgrimage about education and improving the care that patients receive. Like many of us, I went through medical school, residency and fellowship training. After completing this phase of my life, I had the good fortune to be in the army, stationed at Walter Reed Army Medical Center. One day I was called down to the General’s Office. This is never a good sign. (story about JCAHO) So very early in my career I was given permission to lead quality improvement efforts in my organization. I left Walter Reed in 1993, and joined the faculty at Johns Hopkins. I was again fortunate to have a leadership role, and headed a new committee in the medical school to evaluate emerging technologies. It was the efforts of the orthopedic department that really interested me. They decided as a group that, by standardizing the implants used for knees to a single brand, they could provide better care for patients and save considerable sums of money. Less expensive, but better care. Ten years ago, I moved to HealthPartners in Minnesota. HealthPartners is well known for its emphasis on improving what they call the “care model process.” Through process improvement in the clinics and hospital, care is delivered more effectively, more efficiently and more equitably. Most recently, through an organization called the AIAMC, I have learned the importance of aligning efforts to improve the quality of care with the goals of the hospital, to take advantage of the leverage that others bring to the improvement effort, and to create synergy at all levels of the care system. As a DIO, I have learned that aligning the activities of the residencies with the organization’s mission can be a powerful thing. Finally, through the AIAMC efforts, I have begun to enjoy a community of physicians and other leaders who understand that improving the safety and quality of the care we provide to patients is important, not only for patients ,but for health professionals as well. I share this with you, to show that an early exposure to QI, some training and an opportunity to lead can change one’s entire career. So, how does all this apply to emergency medicine residency programs?
These are challenging times in medicine, and particularly challenging times for EM. Many factors are contributing to stress in our emergency rooms. And the demands on emergency medicine are likely to increase over the short term. There are many more patients seeking care in emergency rooms, and fewer emergency departments to care for them. Patients are waiting far longer to seek care, and may not have the means to pay for care. The primary care system is failing in many places. And within hospitals issues of patient flow, regulatory compliance, staffing and resources contribute to the challenge of providing excellent care to every patient.
For program directors, these health system stressors become real issues for education and the health of the residency program. Systems of care are broken: the primary care network is ineffective, the safety net system is failing, systems within hospitals often do not work efficiently complicating life for residents and faculty, the demand of accreditation of the residency program seem to be more complicated and burdensome, funding for GME is imperiled at the federal and state levels, and within our organizations there is seemingly little recognition of the value that residencies bring to the hospital, in caring for patients and producing the physician leaders of tomorrow.
It is, however a time of change. We have seen this in the political environment and the financial markets. I am not advocating for one political party or another, only noting that change has been the essence of the current political process. There is a reason that President Obama took up the banner of change for his campaign. It is more than just changing the leader in the White House. It is emblematic of broader changes in our culture, in our society, in our history, that are coming to the forefront. I think that this is a time of change for residency programs as well.
In order to describe the reasons for the need for change now, and to talk about how we can use the force of change to improve residency education, I would like to introduce three concepts. They are symbolized by these three figures. The first symbol represents the resilience feedback loop. The second symbol represents the quality improvement cycle. And the third symbol represents theory U. Let’s continue to follow the path, and see how these three concepts are linked together, and how they might lead to a new way of positioning GME as a strategic asset.
The first of these symbols represents a process called the resilience feedback loop. This concept is the work of CS Holling, a Canadian ecologist, known to his friends as “Buzz”. Buzz studied ecological systems, and recognized certain patterns that were inherent in systems that had resilience. Resilience is the capacity to experience massive change and yet still maintain the integrity of the original. Resilience isn't about balancing change and stability. It isn’t about reaching an equilibrium state. Rather, it is about how massive change and stability paradoxically work together. In this model, a system undergoes rapid change after a long period of relative inflexibility. Say, for example, the phase “conservation” represents a fully mature pine forest. Every tree is alike, there is very little variation in the forest ecology. There is a high degree of order and a rigid, tight environment. It takes little to radically alter this kind of highly ordered environment: an insect invasion, a forest fire, for example, would release tremendous amounts of energy, and rapidly destroy the mature pine forest. With the release of energy, there comes a rebuilding phase. Many new plants and animals come into the new environment and begin as immigrants. Over time this period of renewal begins to transform the forest. The weaker species get pushed out, and a few dominant forms gain strength. There is growth, and there may be harvesting. Over time, the cycle repeats, with emergence of the more homogeneous environment. These cycles are seen in studies of ecological systems, but they may also be seen in political, economic, and social systems as well.
The cycles of the resilience feedback loop, over time, give the system adaptive capacity. That is, by creatively releasing the pent-up energy in the system, new ideas and forces can come to the surface and help to preserve the system as a whole. In 1904 the AMA created the Council on Medical Education, whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital . In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. Abraham Flexner was chosen to lead the study and author the report. Interestingly, he was not a physician, but a secondary school teacher. In 1910, his report led to the closing of many proprietary medical schools and ended the practice of medical apprenticeship in America. He sought to improve the scientific scholarship required of medical students, to better prepare them for evidence-based practice. Since that time, the structure of medical school and residency has not undergone radical change. And as more regulations and requirements are integrated into medical education, it begins to feel more and more like the mature pine forest. Reflecting on the system of health care in the US, it also feels like the mature homogenous pine forest, increasingly stressed, and ready for a total overhaul. At some point, it feels as if there will be a huge release of energy. But how can the energy be tapped to produce better patient care and better education for residents?
We know that the care of patients is not as safe as it could be. A small example: Two medication vials, that look nearly identical, but who’s physiologic impact are totally different. Can patients trust that they will be safe in our care? The system of care is in need of improvement at all levels, from simple things like labeling to complicated interactions, like transitions of care or improving access to care. The Institute of Medicine reports of the past decade have made it clear that many patients are needlessly injured while under our care. The IOM has suggested that there be 6 fundamental principles for care: Care should be safe, timely, effective, efficient, equitable and patient centered. To meet the expectation that care achieve these 6 principles, changes in the process of care must be made. As Paul Betaldin has noted, “every system is perfectly designed to produce the results it gets.” To improve the safety and quality of the care that is provided, quality improvement techniques are needed. Techniques or methods for improving processes have been widely available since the end of World War II, and in medicine for the past twenty years.
The second symbol of the three on our journey represents continuous process improvement. For those of you who have been associated with process improvement methods, the 4 part cycle will be very familiar. This method was popularized in industry after WWII, and has been used extensively by manufacturing companies to improve quality and efficiency all over the world. In medicine, the cycle of continuous process improvement gained its foothold about 1990, and has been growing slowly ever since. There are some institutions, like Virginia Mason Hospital in Seattle that have invested heavily in the entire organization becoming involved in a quality improvement method. And most organizations and hospitals have some program in place to improve care. There is little evidence, however, that residents and residency programs are linked into these care improvement initiatives in any significant way. David Stevens from IHI has noted: Residents are virtually invisible in the national efforts to improve the quality of care for patients.
The quality improvement cycle begins with picking a process to improve. A team is created of appropriate owners of the process, which in medicine could be nurses, physicians, techs, receptionists, patients, and anyone else involved with the process. The process might be something like decreasing waiting times in the ED, or decreasing the number of steps needed to be admitted. The cycle has four parts, planning an improvement, piloting the improvement (do), checking the data to see if there has been an improvement in the outcome, and acting to hold the gain. The cycle repeats over and over, until a higher steady state of improvement is attained. Typically we think of a process as having three parts: structure, process and outcomes. Improvements may involve changing the structure, or changing the process. As I mentioned: every process is perfected designed to produce exactly the outcomes that it gets. Without changing the structure or process, it is very unlikely that the outcome will change. Where the outcome is flawed patient care, there is an opportunity for improvement. But it takes motivation, and desire to improve to get things rolling.
Does continuous process improvement work? Yes. There are lots of examples, but one standout is the company Toyota. Toyota has used continuous quality improvement for decades, and is known for its quality products. From a competitive standpoint the strategy also has proven its merit. Toyota recently surpassed GM as the largest maker of automobiles in the world. Their quality is top rated. Of course, sales happen to be down at the moment. Quality improvement teams can improve the overall quality of a product, and they can improve the quality of care in hospitals. It might seem logical to just add quality improvement as an additional curriculum element for residents.
From the standpoint of regulatory compliance with the ACGME there might be an advantage to adding a residency requirement to learn about quality improvement. Quality improvement initiatives would address two of the ACMGE general competencies: system based practice and Practice Based Learning and Improvement. Seems like a natural fit. Just adding QI to the resident’s curriculum may, however, not be a great stand alone strategy.
“ Quality isn’t something you lay on top of subjects and objects like tinsel on a tree…it is the core from which the tree must start” Robert M. Pirsig 's Zen and the art of Motorcycle Maintenance. Adding QI or PI on top of an existing curriculum does not create a transformative moment, it just creates another requirement. Residents hate additional requirements. They are busy people with limited time. Engaging residents in making improvements in the care that is provided to patients requires more than adding pages to a curriculum. To truly engage residents requires that they participate, and even lead, in improving care. Doing so is also the basis of their transformation.
To better understand why adding another element onto the curriculum is not desireable, let’s move on to the third of the three symbols. This one stands for “Theory U”, a book by Otto Schirmer. Theory U attempts to explain why just adding more items to a curriculum, or coming to a quick solution to a problem, is ineffective in changing habits or hearts.
Where process improvement looks at structure, process and outcomes, Theory U looks at structure, process and thought. This is the people side of improvement and change. To change or transform people, have them examine the structure of the place they are in, the processes related to that place, and then reflect on how they can change to become part of a new reality.
This diagram greatly simplifies Otto Schirmer’s theory, but it should give you a taste of how the theory works. His approach starts with the patterns of the past. What has been. What is broken or what could be better, for example. The next step in the deep dive is to see the place with fresh eyes. This may be difficult. Over time we all become accustomed to how things look and feel. We may not even be aware that there could be improvements in the system. The human mind is very adept at not seeing what contradicts the assumptions of the status quo. Often what is heard is “that’s the way we have always done it here.” Seeing with fresh eyes is the first step in the deep dive. Deeper still is an opening of the heart. A sensing from the field. This is where connections are built internally with our knowing a place or object, or situation. There are also connections built externally, to other people, systems and the world. Presencing is deeper still. It is the place where perception begins to come from a place of future possibility, that depends on us to come into reality. In a way, it is seeing the light at the end of the tunnel. Presencing is the source of the emerging future whole. It is the future possibility seeking to emerge. Emerging from the deep dive, concepts begin to crystallize. The way forward becomes clearer. From the crystallization of ideas come prototypes, and eventually a new reality emerges. The deep dive is important to the development of the best ideas, and to the creation of commitment to a new reality. We all know how it feels to have someone impose their idea on us, even if it might make an improvement. As individuals we resist regulations, fiats and demands that do not engage us in a process of a deep personal dive. The deep dive is a useful concept for groups as well. Having all the parties to a problem situation engage in the deep dive together builds commitment to the solution, and to the eventual success of the entire project.
Importantly, deep knowledge is the nature of transformation. As residents engage in solving system issues to improve patient care, they transform themselves as well. They become invested in improving care, they build confidence that the system can be improved, and they become part of the solution to the broken system of care. Participation in Quality Improvement is not the only means of transformation, but it is one way that has benefits for residents, and the program, and patient care.
How does Theory U fit with the future of health care? There is a commission that is working on the future of physician competence. It is composed of dozens of leading physician and healthcare organizations, under the name of the National Alliance for Physician Competence. It is developing the vision for defining and assessing physician competence from medical school through retirement, as a continuous process. The National Alliance for Physician Competence sees physician competence shifting over time. The old paradigm is on the left: physician centered practice, individual physician autonomy, anecdotal idiosyncratic practice, and a judgmental culture, to patient centered practice, team collaboration, evidence based standards and system based practice, and a supportive culture for improvement. Can the transition to this new model be imposed? I doubt it. The transformation will require a deep dive, individually, collectively, and as a profession. I believe Emergency medicine is probably uniquely structured to make this transformation from the old paradigm to the new paradigm efficiently.
If this is a time of change, and the change should be to improve patient care, how can we engage residents in process improvement and the deep dive process of transformation? One way is to engage residents as part of a team, in initiatives that are initially small in scope, of interest to them and of significance to the hospital. Quality improvement initiatives that are too large will likely not succeed, as residents have limited time given their other responsibilities. Without a topic of interest to them, they will likely be unwilling to engage in the deep dive that make for a meaningful experience. And significance to the hospital becomes important in assuring that their work is fully appreciated.
In Emergency Medicine, what processes might need fixing or improvement? One way to approach this question is to ask residents. What do they see, as they care for patients and learn, that could be fixed, made better or improved? The improvement might be to patient safety, or to the educational environment or to other structures or processes within the institution.
Getting started is not difficult, but takes motivation and vision. Grab a handbook, like this one called the Team handbook, and learn how to bring a group together to solve a clinical process problem. This is not complicated, but it does take a little knowledge and some gumption. Most hospitals have some support for quality improvement. There probably is a facilitator who can get you started. Then make the quality improvement efforts part of the regular business of the department and residency program. Not an add-on, just the way we work every day.
Engaging hospital leadership is important. Yes, this work of Quality Improvement can be done at the department level with great success. But from the standpoint of the residency program, aligning the work of the residents with the hospital quality priorities will elevate the residency program in the eyes of the hospital leadership. Visit with the CQO and the CEO. Learn what their priorities are for the hospital, and see if your improvement initiative can fit within those goals. For the past two years I have been involved with a multi-institutional effort to engage residents in quality improvement projects through the Alliance of Independent Academic Medical Centers. 19 hospitals across the US were involved in 5 national meetings and hundreds of conference calls, coordinating the activities of residents in QI projects improving handoffs, drug reconciliation and infection control. Early on in this multi-institutional experience we linked our efforts with another organization: the Institute for Healthcare Improvement, or IHI. The IHI has, for the past 20 years, been at the forefront of improving the quality of care for patients in the United States, and across the world. I would thoroughly recommend your attending an IHI annual meeting if you had not attended before. There is incredible energy at these meetings, which revitalizes everyone around improving patient safety and the quality of care. The IHI has had two major campaigns that have engaged hospital leadership: The 100,00 lives campaign and the 5 million lives campaign… For the AIAMC National Initiative, we aligned our work with the IHI 5 million lives campaign, knowing that hospital boards would be aware of the goals of the campaign, and that there would be immediate recognition that the residencies in the AIAMC initiative would be helping them to achieve the hospital goals for patient safety and care. This strategy turned out to be very important to the success of our efforts. Once the hospitals goals are understood, and the quality improvement initiative in the department can be aligned with these goals: create a team, define the scope of the project, empower the participants and go.
Of course, not every initiative succeeds. Some fail because of lack of time, or resources. In my experience some fail because of lack of commitment. Perhaps the question being asked is not important enough to engage the interest of the group. If the project is too large, participants become discouraged. And it is important to engage the right people in the solution. All the stakeholders should be present at the table, to assure that everyone’s interests are considered. One final reason for failure is the absence of the deep dive. Superficial imposed fixes usually don’t stick and are not adopted. Teams need time and space to reflect on the problem, to take the deep dive and to allow for the crystallization of ideas. Teams need time for reflection. Physicians are problem solvers.
The Program Director has a key role in helping residents and faculty to engage in improving the quality of care for patients. The program director acts as a guide, a protector of time, and intercessor when too many priorities are presented at once, a leader in the voice of the future, a follower who assists resident leaders to succeed, and a sentry, watching over the process to see that the progress is orderly, sustained and meaningful.
Some other lessons from the AIAMC National Initiative concern leadership. In order to jump-start a quality improvement initative, and to keep it going, certain leadership skills are required. At the start, express the vision for the improvement clearly. What is the scope? How much time? Who? What is expected? To engage team members, add a sense of urgency. What is the problem that needs to be solved, and why does it need to be solved now? Over-communicate. Inform teams of the plan and remind them of their progress far more than you might think is necessary. 8 times, 8 ways. Create and use a supporting coalition. Are there other PDs that you can communicate with working on similar initiatives? How about other departments? Expect obstacles. Try to plan for them, and when they occur, look for assistance in getting around them. Go for small victories, and celebrate! Start to build a community around improving patient care, among the staff, faculty and residents. Learn together, and take opportunities to share successes and failures.
What might be the benefits of bringing process improvement initiatives into the residency program?
For the residents: the deep dive might give them a greater sense of being connected to the program, and to the patients that they serve. A sense of ownership may develop, which many residents now feel is missing. Along with a sense of ownership comes a sense of place. In a very fast paced world, improving a place, and making it one’s own, can be very reassuring. Going back to the general competencies, residents can also learn about teamwork, professionalism and leadership. All these are skills that will serve them well as attendings.
What are the benefits to the residency program?
Four that come to mind: Applicants from many medical schools have been acquainted with process improvement, and some are actually looking for programs that use these methods. Residents who have participated in quality improvement initiatives, aligned with the hospital priorities for care, are seen by hospital leadership as part of the solution. CEOs and hospital boards love to talk about how the residents are improving care. This repositions the residency program within the structure of the hospital, from an outlier pursuing its own goals, to a hospital asset improving care for patients. In a world of unstable GME funding and tight resources, it helps to have allies. Finally, the residency benefits by creating residents who have an understanding of the process of improving care, working with a team, and taking a leadership role. The program can shape the future leadership of its faculty, the department, and perhaps the hospital and beyond. Residents who understand how a deep dive feels, how to bring others with them through a complex problem and its solution, and who can implement a solution, will be valued assets of any department. Don Berwick, the Director of the IHI always gives a rousing speech at the annual meeting of the IHI. This past year, his speech was about his daughter, who is a medical student. He challenged the audience of 5,000 in the room and 15,000 on remote access, to change the way they provide care for patients so that in four or five years care will be safe. Specifically, he challenged the audience to make changes, so that his daughter, and her peers, would not learn a system of medical care that is unnecessarily unsafe for patients. As much as I respect Don Berwick. I think he missed an opportunity. The work of quality improvement must be accelerated, but it won’t be complete in 5 years. We need to provide medical students and residents with the tools to improve care over their lifetimes. Involving them in quality improvement initiatives early in their careers will shape their perceptions of great care, their ability to lead and eventually the entire medical system. Don Berwick’s daughter, and every medical student and resident, will need to have the tools and knowledge to continue to improve the quality of care, far into the future.
I believe GME is a strategic asset for any hospital. But I believe GME can reposition itself to be even more of a strategic asset by linking with the leadership of the hospitals to understand their core priorities, by aligning GME with hospital priorities through process improvement initiatives, solidifying its value by demonstrating that it can reliably improve care, communicating with internal and external stakeholders that it takes steps to improve the patient experience and patient outcomes, anticipating where the next challenges may arise, and leading others to improve patient care and experience.
The world has come a long way since 1534, and our nation is in a period of intense change. Health care is changing as well. Today President Obama is convening 150 national leaders in healthcare to start the transformation of the healthcare system. Where medical education will fit in this transformation is not clear. Education of physicians is expensive, and the value of educational programs is often not fully appreciated. I believe that improving the care we provide patients through resident’s participation in QI initiatives will greatly help to position GME for the future.
I want to thank Felix Ankel and the selection committee for the opportunity to speak to you today. I hope we all will take up the challenge of improving both patient care and the residency experience through integrating quality improvement and GME. This is not easy work, but it is deeply satisfying, as you know. To reflect: Every process is perfectly designed to get the results it achieves. The current system of care is not as safe as it could be. Now is the time for change. Empowering residents to participate and lead in quality improvement is of benefit to them, to the department, to the hospital and to our profession. Emergency medicine is at the point of the spear. Residents will need tools for improving the care that is provided as pressures increase well into the future. Program directors are well positioned to be leaders in this change.
One final thought: A pilgrimage of transformation happens when one person sets out on a journey and another returns. Thank you for joining me today on this brief journey. I hope it was, in a small way, a pilgrimage as well. Thank you.
Cord 7 Annotated
Transforming Residency Passage or Pilgrimage?
A pilgrimage without transformation is just a journey.
A Personal Pilgrimage Medical School Residency Fellowship Leadership Standardization Process Improvement Building Community Organizational Alignment
Challenging Times in Emergency Medicine Over-Crowding Uninsured Complicated Patients Broken Primary Care System Regulatory Compliance Patient Diversity Technology Advances Hospital Budgets Staffing Complex Decisions Flow
Pressure on Program Directors Broken Systems Accreditation Funding in Peril Leadership Recognition
Process Improvement <ul><li>Identify a process </li></ul><ul><li>Plan an improvement </li></ul><ul><li>Perform the improvement </li></ul><ul><li>Assess the effect </li></ul><ul><li>Act to maintain the gain </li></ul>
Work as Teams to Improve Processes Plan Do Check Act
Adding QI/PI as a Curriculum Requirement? <ul><li>System Based Practice </li></ul><ul><li>Practice Based Learning and Improvement </li></ul><ul><li>May not be a great stand-alone strategy </li></ul>
A pilgrimage without transformation is just a journey. ADD-ON
Scharmer describes this process of deep knowledge and creative release in “Theory U.”
Levels of Organizational Change – STRUCTURE – – PROCESS – – THOUGHT –
Patterns of the Past Performing Seeing with Fresh Eyes Sensing from the Field Presencing Crystallizing Prototyping
Deep knowledge is transformation. As residents transform the system they transform themselves.
The shifting paradigm of physician competence. Physician centered practice to patient centered practice Individual physician autonomy to collaboration as a team in a system Anecdotal practice to evidence-based standards “ Idiosyncratic” to system based practice Judgmental/punitive culture to supportive culture of improvement *National Alliance for Physician Competence
Physician centered practice to patient centered practice Individual physician autonomy to collaboration as a team Anecdotal practice to evidence-based standards “ Idiosyncratic” to system based practice Judgemental/punative culture to supportiveculture of improvement Physician centered practice to patient centered practice Individual physician autonomy to collaboration as a team in a system Anecdotal practice to evidence-based standards “ Idiosyncratic” to system based practice Judgmental/punitive culture to supportive culture of improvement
Residents participate as team members in initiatives that are small in scope, of interest to them, and of significance to the hospital. Beginning the Journey…
EM Opportunities: Handoffs Procedures Flow Coordination of Care Test Results Codes Multicultural Care Equipment Availability Medical Records Communications