When Lisa Shieh, MD, PhD, clinical associate professor (general medical disciplines), was completing her residency at Stanford in internal medicine, the concept of quality improvement (QI) was an unfamiliar one. “I don’t remember learning much about it,” she recalled.  Today, Dr. Shieh and a group of physicians are leading the charge to teach these skills to a new wave of Stanford residents and students.

Building sustainable quality improvements into clinical care is a key component of the Department of Medicine’s mission.  For the past four years, Dr. Shieh and the Medicine Quality Council have been trying to figure out how to improve patient safety and quality of care while creating a culture that supports and sustains these initiatives.

By introducing residents early in their education to these processes, Dr. Shieh hopes not only to show them how a robust QI program fits into the healthcare system, but also to encourage them to be advocates for improvement. “QI efforts require change, and change is hard. It takes time and effort. We look for sustainability in QI, and we want people to become champions of QI efforts.”

For one month each year, residents and medical students have the opportunity to participate in the elective in Quality Improvement, Patient Safety, and Organizational Change.  During the elective, they are introduced to the fundamental concepts of QI, as well as QI leaders in the hospital and key QI project initiatives. They are also expected to work on their own project, with mentoring from Dr. Shieh and Kambria Evans, an education specialist. “This elective is our opportunity to work closely with residents and students on a problem they want to improve,” Dr. Shieh explained.  The QI residents also teach their peers about QI tools such as root cause analysis and PDSA cycles through a noon conference series, where they review a patient case to identify and teach about systems improvement opportunities. 

 “Every year I feel like we have more interest from the students and residents wanting to get involved in QI, which is great!”  The residents have even created their own QI newsletter, Quality Improvement News, which comes out quarterly and highlights the work of QI residents and pertinent hospital projects.

A Systemic Mindset

Residents and students leave the course with the skills to understand the structure of a system and develop ideas about it.  Many of their QI projects become oral or poster presentations at regional and national medical conferences, as well as publications.  For the past two years, Stanford residents have attended the regional American College of Physician (ACP) conference and have won awards in the QI improvement category. 

Many QI projects have stemmed from efforts to improve sepsis care at Stanford.  One particularly successful example is Septris (Sepsis + Tetris), a web-based game designed to train physicians to recognize and treat sepsis. Students and residents helped develop and test the game, which is now played internationally. Residents have also contributed to the development of an EMR alert to help identify sepsis earlier in hospitalized patients.   

Other QI projects have focused on improving patient satisfaction or physician efficiencies.  A 2013 project looked at the impact of whiteboards on patient satisfaction and awareness, and found that the use of whiteboards facilitated communication between patients and their care team, and significantly improved overall patient satisfaction. “It may sound low-tech,” Dr. Shieh said, but “you get a lot of information from a whiteboard and it is always in front of the patient and family.” Another resident project resulted in the adoption of PC tablets at the Palo Alto VA hospital by each medical team to increase efficiency and coordinate care.   

“The residents have done a lot of great projects, and many papers have come out of the QI elective, ” said Dr. Shieh.  Recent publications from the residents and students include: the use of smart phone group texting, EMR alerts to improve blood utilization, cost and turn around time display to decrease reference test ordering, improving communication of pending labs at discharge, and the use of an EMR discharge checklists.

According to Dr. Shieh, residents who complete the QI elective approach their clinical years with a more systemic mindset. “I think we give residents an opportunity to see quality improvement done from a very high level…and I think it really allows them to see that we are trying to improve care for the entire hospital.”