Nirmish Singla, MD
Dr. Singla is a urology resident at the University of Texas Southwestern, Dallas
During residency, the challenge of studying urology, becoming an accomplished clinician and skilled surgeon, staying abreast of the latest research, and maintaining academic productivity is daunting enough. To top off these expectations, the Accreditation Council for Graduate Medical Education (ACGME) further mandates that all residents “actively participate in interdisciplinary clinical quality improvement and patient safety programs.”
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While this quality improvement (QI) requirement is viewed by many as simply another checkbox to mark off, it is worthwhile to take a moment to appreciate the underlying rationale behind it and the hidden gains QI involvement can offer.
QI can be defined or interpreted in multiple ways, and there are several avenues by which one can become involved. The underlying principle of QI is the expectation—both from patients and the hospital system—that physicians provide safe, cost-effective, and high-quality health care. QI initiatives can range anywhere from simple, commonly encountered grassroots issues to more complex, systems-wide implementation of changes.
Involvement in QI is by no means restricted to hospital administrators. One way to go about tackling a QI project is to begin by identifying a problem or frustration faced daily in clinical practice, if even seemingly minor in nature. Some varied examples may include infectious or hemorrhagic complications following outpatient urologic procedures such as prostate biopsies; Clostridium difficile
infections, thromboembolic events, or patient falls following urologic surgery; delayed starts to first operative cases of the day; delayed turnover between patients in the clinic or OR setting; unnecessary prolongation of hospital length of stay due to non-medical factors such as those that are socially or consultation-related; unnecessary patient calls or presentation to the emergency room following ureteral stent placement due to pain or hematuria; or inappropriate implementation of contact precautions.
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Additional background reading on the issue at hand and the current situation may be warranted. Resourcefulness is key. Once identified, it is a good idea to devise a structured plan on how to approach and further study the problem.
An important aspect to a successful QI initiative is to define tangible goals or intended outcomes that are achievable and to provide deadlines for each. A Gantt chart, which highlights milestones and tracks progress, may prove useful. For those familiar with lean intervention or Six Sigma techniques, root cause analysis is often an effective tool to thoroughly dissect an issue to its foundation. Root cause analysis breaks larger, more complex problems into simpler ones by constantly asking “why” something is problematic. This process is continually repeated until rudimentary causes finally surface (and “why” can no longer be answered).
Such analyses can help generate potential countermeasures for each root cause identified. The next step is to intervene by implementing countermeasures and finally to follow up on the progress made, making modifications as needed and repeating the cycle as issues evolve.
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There is no single best way to address a problem, and often it is the nature of the problem that directs its solution—of which there may be more than one. Small contributions to a larger problem are certainly valuable and should not be overlooked, as they play an important role.
There is a growing number of avenues by which QI is accessible to the urologic community. For example, the AUA created a Quality Improvement & Patient Safety Committee, which is a part of the larger Science & Quality Council, in order to improve the quality of care for patients with urologic disease. Among their many developments are the AUA Quality Registry, AUA Annual Census, AUA Data Grants program, white papers, and participation in the Choosing Wisely campaign. The AUA recently hosted its 2016 Quality Improvement Summit in April (resources from the summit are available here),
and last year the organization launched the Science and Quality Scholars Program.
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Aside from AUA efforts, QI committees may exist within individual departments (recently created in my own department to help residents identify potential projects and guide them in their progress) or as a collaborative effort among several practices (such as the Michigan Urological Surgery Improvement Collaborative).
Early exposure to quality improvement, patient safety concerns, lean methodology, strategic planning, budgeting and resource allocation, change management, and risk management encourages trainees to think critically about inherent problems facing our field and to devise innovative solutions that they can take into practice. At the same time, learning about operations and governance of health care systems can help foster effective future leaders in our field.
Hence, in my opinion, the goal of the ACGME’s QI requirement is to inspire many residents to become better urologists.