Residents’ Elective TACKLES Quality Improvement Research

Lisa Shieh, MD, PhD (right), makes a point about quality improvement with medical residents

A unique offering of Stanford’s medicine residency program is one month spent exclusively on research. One research opportunity that has been growing in popularity is devoted to quality improvement (QI).

Lisa Shieh, MD, PhD, a clinical professor of hospital medicine, has been involved in the QI elective and explains its premise: “The goal of the quality improvement elective, which we’ve been running for five to seven years, is to give the residents a combination of seeing how the institution does QI and doing it themselves. When residents sign up we have them think about a QI project, we give them the support they need, and we try to align their project with institutional goals. We also provide opportunities for them to see how QI is done throughout the hospital: They sit in on leadership QI meetings and on working groups.”

The 'What Matters Most' Letter Project

One QI project pursued by several residents aimed to help patients inform their physicians about the things that most mattered to them. Shieh describes how the residents approached this topic: “Three of our projects this year were on the same theme: How can we help our patients share with us what is most important to them? This could be considered goals of care or end of life planning, which is challenging to talk about. It’s hard for both patients and families.”

This project was done in partnership with V.J. Periyakoil, MD, a clinical associate professor of primary care and population health, who created a “what matters most” letter that the residents used, and with Rabbi Lori Klein, JD, MA, from the Stanford Spiritual Care Program. The letter is a template for patients to explain to their doctors and their families the things that are most important to them as they approach the end of life. A patient can write, for example, that attending a daughter’s wedding or a son’s graduation is a primary concern or that dying at home matters most. Unlike advance directives and living wills, however, the letter is not a legal document.

One resident, Silvia McCandlish, MD, randomized a group of inpatients in her study so that half of her patients completed the letter and gave it to their physicians and half of her patients did not. Her study focused on the reaction of the physicians who received the letter from patients, in particular whether they found it useful. Shieh reports that “They found the letter to be more useful than other types of advance directives, which are often very vague. Most doctors don’t find such documents helpful to guide recommendations for treatment. While they are good things to have, the what-matters-most letter adds to them.”

For the residents who complete a project, there are multiple opportunities to submit their results to association meetings and often to both present and publish them. Several residents have recently received awards for their projects after presentations at regional and national meetings.

McCandlish’s project won a regional American College of Physicians (ACP) QI section competition and competed at the national Society of Hospital Medicine meeting, where it was among the top 15 abstracts out of hundreds submitted.

"The letter is a great TOOL because it's more personal...

Other residents worked on different aspects of the what-matters-most letter. Ilana Yurkiewicz, MD, studied the demographics of the patients who filled out the letter. Jessica Langston, MD, surveyed the providers of patients who filled out the letter and learned that many of them were unaware of the letter. When she showed them the letter, they found it very useful and wished they had known about it. As a result, workflows were changed so that the letter is pulled into the electronic medical record, where it will be available to each patient’s physician.

These QI projects don’t necessarily come to an end when the residents complete the elective. The what-matters-most letter, for instance, is now being worked on by palliative care fellows who are trying to get the letter to inpatient medicine and oncology patients. While there is much work still to be done, Shieh feels that the letter is a “great tool because it’s more personal and focuses on what matters to patients as opposed to the typical ‘do you want to be intubated’ kinds of questions that scare patients.”

Inappropriate Thrombophilia Testing Project

Shieh notes that the medicine residency program has been studying the impact of educational interventions. “One recent QI project educated residents about choosing wisely; we called it ‘the high value care curriculum.’ We talked about the cost of care and how it’s rising and that there is waste, and we talked about things in medicine to do and not to do,” she says.

One recommendation in hematology is not to order a number of labs that look for an increased risk of blood clotting—known as thrombophilia—in patients who don’t need it. In the inpatient setting a thrombophilia workup is almost never necessary. Two residents set about determining how prevalent such workups were among Stanford inpatients and how to educate physicians about not doing wasteful things that provide little or no value.

Eric Mou, MD, undertook a massive chart review to learn “how often we inappropriately ordered these tests at Stanford Hospital,” says Shieh. “Of the 1,817 orders analyzed, 777 (42.7 percent) were potentially inappropriate.” Mou was invited to present his project at a regional ACP meeting where it won the research competition; he also presented it at a national ACP meeting and American Society of Hematology meeting. The Journal of Hospital Medicine published his manuscript in September 2017.

Henry Kwang, MD, who worked with Mou on this project and coauthored the resulting manuscripts, looked at the impact of an educational intervention on inappropriate thrombophilia workups. He showed that the intervention was effective, which Shieh describes as “very unusual for educational interventions.” Kwang’s project went on to be a finalist at both the national ACP meeting and the national Society of Hospital Medicine meeting. In addition, it was a top 10 winner in the Stanford QI symposium.

In addition to learning the basics of research methods, residents who opt for the QI elective have the opportunity to see their projects come full circle from proposal to publication—plus another several lines on their curriculum vitae.