Author + information
- Wunan Zhou, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Wunan Zhou, Medstar Washington Hospital Center, Medstar Georgetown University Hospital, Washington, DC.
Throughout medical training, emphasis has traditionally been placed on basic, translational, and clinical sciences. As medical students, we learn the importance of various biochemical pathways. As medical residents, we learn about the art of patient care. Although quality improvement (QI) has deep roots dating back to the beginning of modern medicine, with Florence Nightingale’s observations of the association between poor living conditions and high death rates among soldiers treated in army hospitals (1), it has not been until recently that quality has moved to the forefront. The Institute of Medicine defines quality in health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2), and the U.S. Department of Health and Human Services describes QI as “systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups” (3). These statements highlight an increased attention to patient outcomes as important measures of QI initiatives in today’s health care environment.
For those of us who have focused our academic interests in the traditional areas of investigation, the area of QI may appear to be in uncharted territory. In fact, QI is part of fellowship training required by the Accreditation Council for Graduate Medical Education (4). Not only are fellows expected to work within the given health care system in an efficient and cost-effective manner, they must also work to advocate for high-quality patient care through identifying system errors and help to implement potential solutions (4). With the other rigorous demands in fellowship, these QI goals may seem challenging. However, there are some strategies that may be applied to make QI a rewarding experience and a fulfilling, high-yield component of fellowship training.
First and foremost, QI needs to be recognized as an important priority for both the fellow-in-training (FIT), as well as the training program. A relatively easy way to improve FIT participation is through assignment of FITs to hospital committees for QI in an area of clinical interest. For example, an FIT planning to specialize in cardiac critical care would serve well on the institution’s intensive care unit committee on strategies to decrease catheter-based bloodstream infections, ideally paired with a mentor who would help advance committee practice through fellow-driven QI projects. There is a plethora of opportunities available for improvement including, but not limited to, hand-offs, decreasing error, and decreasing hospital readmission rates. Another valuable experience is to participate in multidisciplinary QI committees focused on performing root cause analysis for poor patient outcomes. Such opportunities can not only help determine areas for improvement in a specific case, but also identify system-based deficiencies requiring broader, systemic attention.
Both the Accreditation Council for Graduate Medical Education core competency guidelines and ACC’s Core Cardiovascular Training Statement 4 advise that academic scholarship through research is imperative to developing leaders in cardiovascular medicine (4,5). As such, participation in research is integral to development from an FIT to an unsupervised attending cardiologist. FITs are uniquely poised to be on the front lines for observing areas that need improvement through daily clinical interactions. Although significant differences may exist between a QI and a research project, including rigidity of study design, potential benefit to current versus future patients, and goal of rapid adaption of changes into the local health care system (6,7), it is possible to design projects that not only result in immediate improvements in health care delivery through QI efforts, but also yield outcomes important enough to share with the wider medical community in the form of publications. Because projects that straddle the intersection of QI and research may pose increased risks for patients/subjects, they should be reviewed by the institutional review board and receive appropriate institutional and individual oversight; thus, a project that can satisfy QI parameters and answer research questions is not only desired, but also possible (7). Further, because QI has been traditionally under-reported, organizations such as the SQUIRE (Standards for Quality Improvement Reporting Excellence) Research Group have developed guidelines on ethical reporting of new knowledge focused on QI work (8).
Identifying a research question and developing a project while improving quality is a strategic process. A wise first step is to seek help, specifically, to find a like-minded mentor early in one’s training. Dr. Agarwal discussed the importance of and strategies to finding an effective mentor in the FIT Early Career section of a previous issue of the Journal (9). Although a mentor with experience in conducting research in QI is helpful, the lead mentor may also be someone who will open the doors to his/her professional network of experts, thus helping to effectively assemble a team. Not only should such a lead mentor help with idea generation and research planning, but he/she should also challenge the mentee to achieve milestones and push forward with the project through encouragement and feedback.
After finding a mentor, a fellow should think hard about what he or she hopes to accomplish with the research project. In the example of hospital discharge strategies to decrease heart failure readmission rates, will the mechanism of QI focus on using the measurement alone, public reporting, pay-for-performance, or some combination of these mechanisms? Many of these mechanisms have been shown to improve processes of care, but important questions often remain about whether and how these mechanisms improve patient outcomes (10). A prominent example is the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) trial, in which none of the process-based care measures were associated with lower hospital readmission rates or 60- or 90-day mortality (11). Increasingly, payers such as Medicare and governments on the state and federal levels are using patient outcomes data to determine health care reimbursement as well as using financial incentives to reward meeting and exceeding core measures, such as the pay-for-performance program. Thus, it is imperative that fellows formulate a research project that has not only clinical equipoise but also potential to improve tracked patient outcomes.
Because of the constraints of other fellowship responsibilities, the project should be focused and feasible. The PICO (12) method is an evidence-based medicine approach to do just that. This process begins with asking the patient about their problem or determining a population of interest (P). Then, the researcher must identify the planned intervention (I). The third step is to compare the intervention to the alternative (C). Finally, the last step is to specify the results and outcomes to be measured (O). By applying this method, the fellow maximizes his or her chance of constructing and completing a QI project over a 3-year fellowship with opportunities to submit results in the form or an abstract and/or paper.
In summary, participation in QI is a mandatory part of being a competent and effective cardiologist in today’s health care landscape. Although this aspect of medical practice has traditionally not been emphasized in training, there is a need and opportunity for FIT participation and leadership. Because of the vast pathology and clinical scenarios encountered during fellowship, FITs are in a unique position to both participate in QI clinical activities as well as develop meaningful research projects to further our specialty and improve patient care. As in any other aspect of our rewarding profession, being observant, creative, and dedicated are the keys to success in improving quality.
- Gregg C. Fonarow, MD ()
RESPONSE: Cardiovascular Quality Improvement
The Time Is Now and Beyond
Dr. Fonarow has served as a member of the GWTG (Get With The Guidelines) steering committee; has received significant research support from the Patient-Centered Outcomes Research Institute; and has served as an consultant to Amgen, Janssen, Novartis, and Medtronic.
Participation in quality improvement (QI) has been integrated as a required component of cardiology fellowship training by the Accreditation Council for Graduate Medical Education (1). Dr. Zhou has very nicely highlighted the rationale for this training requirement and the opportunities that exist during cardiology fellowship training to systematically analyze practice using QI methods, work in interprofessional teams to enhance patient safety and improve patient care quality, identify and overcome system errors, as well as help implement changes with the goal of practice improvement (1). Practical suggestions to make participating in or leading QI efforts during cardiology fellowship training productive and rewarding are provided. Active participation in cardiovascular QI, however, should not end with completion of fellowship training, but should extend well beyond to career-long efforts to drive improvements in cardiovascular care delivery and clinical outcomes in every clinical setting.
Although there have been very important advances in cardiovascular disease prevention, diagnosis, and treatment over the past few decades, there are frequently substantial gaps, variations, and disparities in how these evidence-based advances are applied in clinical practice. The health care system frequently falls far short of its full potential to deliver care in a safe, timely, equitable, efficient, evidence-based, and patient-centered manner (2). The need for QI in cardiovascular care delivery is particularly pressing as patients, physicians, health care delivery systems, and payers face rising costs, inefficiencies, fragmentation of care, reimbursement-influenced clinical decision making, and challenges in addressing patient safety. With increasing pressures to reduce costs, streamline health care operations, and focus on value, QI efforts have the potential for reducing inefficiencies in cardiovascular care and improving value, while enhancing safety, quality, and patient-centered health outcomes.
The development of cardiovascular registries and performance improvement systems has been instrumental in measuring and improving the quality of cardiovascular care by identifying treatment gaps along with providing tools that improve patient assessment, clinical decision support, delivery of evidence-based therapies, and timely benchmarked performance feedback (3). Improvements at the local, regional, and national level in acute coronary syndrome, heart failure, coronary artery disease, atrial fibrillation, primary/secondary prevention, and cardiovascular procedures quality of care and outcomes have been achieved through these registries, as well as through focused initiatives to improve specific aspects of cardiovascular patient care (3,4). Although not all QI efforts will be successful, many have led to meaningful improvement in care and outcomes (3). Cardiovascular QI efforts are increasingly drawing on the vast amount of data generated by leveraging the existing data infrastructure of clinical registries, electronic health records, administrative claims, and other sources to serve as data sources for examining the quality of care and clinical effectiveness of a variety of diagnostic tests, therapies, strategies, and delivery systems in cardiovascular care in every clinical setting. It also has been increasingly recognized that there are significant benefits to incorporating patient preferences and values into QI efforts.
To be a successful clinician and active participant in the continuously changing health care system, cardiologists should be contributing to the process of improving clinical care quality throughout their training and subsequent careers. Although the full cycle of QI requires multiple stages and participants, cardiology fellows and cardiologists are in an ideal position to be able to identify critical issues and gaps in cardiovascular patient care; elucidate the issues, barriers, and possible solutions; study the identified components of care; design and implement potential solutions; analyze the effect on desired outcomes; and disseminate the findings.
Only through collaboration, benchmarking, and sharing of best practices and active career-long participation in QI can we make meaningful progress in improving the lives of all individuals with or at risk for cardiovascular disease. There are now numerous outstanding examples of vibrant QI efforts taking place in cardiovascular disease that are producing tangible gains in care and outcomes. It is hoped that with the active participation of cardiologists throughout training and beyond, progress will further accelerate and the critical strategies and systems necessary to meet the needs of all cardiovascular patients, clinicians, and health care systems will be produced and fully implemented.
- ↵Accreditation Council of Graduate Medical Education. Common Program Requirements. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Assessed February 24, 2016.
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The author thanks Ana Barac, MD, PhD, for her mentorship and thoughtful review of this paper.
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- ↵U. S. Department of Health and Human Services Health Resources and Services Administration. Quality improvement. Available at: http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf. Accessed March 3, 2016.
- ↵Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in cardiovascular disease (internal medicine). Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/141_cardiovascular_disease_int_med_07132013.pdf. Accessed March 3, 2016.
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