As they begin the course, clinician learners in Christiana Care Health System’s Advanced Quality & Safety Improvement Science Program have an idea they believe will improve care delivery.
Over the next nine months, they learn how to pinpoint the problem, design a solution and earn the support of colleagues necessary to shepherd their idea to fruition. The program prepares its graduates to spread the methods of continuous quality improvement across Christiana Care.
The effort, now wrapping up its fifth cohort of students, has attracted new attention with the National Academy of Medicine’s March publication of “Clinical Engagement for Continuous Learning.” The discussion paper was co-authored by Christiana Care president and CEO Janice E. Nevin, M.D., MPH.
“The extraordinary people who work at Christiana Care possess unparalleled expertise in caring for their neighbors,” Dr. Nevin said. “The Advanced Quality & Safety Improvement Science Program gives them the tools to innovate toward our shared goal of helping our patients live healthier, fuller lives.”
Since the first class enrolled in 2012, 57 participants across 21 disciplines have graduated from the program.
Collaborative leadership style
Diana Dickson-Witmer, M.D., FACS, surgeon and medical director of the Christiana Care Breast Center and Breast Program at the Helen F. Graham Cancer Center & Research Institute, said the course led her to develop a more collaborative leadership style. She credits the program with her recent success in starting a fellowship program.
“I think the course gave me many of the leadership skills that helped me bring together a faculty of almost 20 people and have them put together goals, objectives and a curriculum that allowed us to have a successful application,” she said.
The train-the-trainer focus of the course was identified in the National Academy of Medicine paper as one of the best practices in clinician education.
“Fostering the engagement and leveraging the insights of frontline clinicians in knowledge-generating activities will drive a continuously learning health system toward outcomes that are most relevant, easily translated and valuable to clinical practice and patients,” it says.
The Advanced Quality & Safety Improvement Science Program was created under the Value Institute Academy, which has since merged with the Christiana Care Institute for Learning, Leadership and Development, or iLEAD. The program aims to teach and inculcate the ethos of continuous performance improvement by engaging with those who are best equipped to improve patient care outcomes.
These clinicians bring extensive medical expertise to bear but sometimes find their core problem has relatively little to do with medicine.
Improving emergency discharge
As medical director of the Wilmington Emergency Department Geriatric Discharge Clinic, Ellen C. Finney, M.D., has seen firsthand the communication breakdowns that can occur following a trip to the Emergency Department.
Often, patients don’t understand their discharge instructions, which are in turn not adequately communicated to their primary care provider. Partly as a result, patients 65 and older have a higher likelihood of hospital admission in the month following discharge.
Dr. Finney’s quality improvement project sought to expand follow-up phone calls, previously made to some but not all patients. An Emergency Department nurse answers questions about the patient’s visit and discusses medications and follow-up treatment. Dr. Finney also established a discharge clinic at Wilmington Hospital for patients who were not able to be seen by their primary care provider in a timely manner.
The overall goal: Replace inpatient care with outpatient care while improving communication with patients and their primary care providers.
Like other graduates, Dr. Finney is collecting data and soon expects to learn whether the phone calls and discharge clinic had any effect on hospital admissions or 72-hour re-admissions to the Emergency Department.
“One of the deliverables at the end of the program is that they need to present the results,” said Quality & Safety Education Specialist Loretta Consiglio-Ward, MSN, RN, a key founding member of the program. “We also give them the opportunity to publish their work.”
Though some projects are published or presented at national conferences, the goal of the program is more modest, said Neil Jasani, M.D., MBA, FACEP, chief learning officer and vice president of Medical Affairs.
“Meaningful and actionable: They’re the adjectives that we strive for,” he said.
Along with Consiglio-Ward and Robert Dressler, M.D., MBA, quality and safety officer in the office of Academic and Medical Affairs, Dr. Jasani was among the founders of the program. Christiana Care created the course through its participation in an ongoing quality improvement effort through the Alliance of Independent Academic Medical Centers, a national network of large academic medical centers.
Come with an idea
Six years ago, when the team was creating the program, they decided experience would be the best teacher of quality improvement skills.
“Anybody could read a book or watch a video, but when you need to apply a process, you need to take into account that you’re asking for change from the people you work with,” Consiglio-Ward said. Additionally, having a clear focus related to one’s job serves as motivation for participants to give up their Tuesday evenings without financial compensation.
The original team crafted the 40-hour curriculum with the expectation that many enrollees were to have a requisite basic knowledge in quality improvement. Mentors also knew clinicians would bring their natural problem-solving skills to the course, but solving a medical problem is not always the same as changing a system.
For example, some plans engender resistance because they don’t engage the right stakeholders, Dr. Dressler said. Other times, the problem is the problem.
Fixing the right problem
When Dr. Dickson-Witmer was accepted into the class in 2015, she was trying to find a way to reduce the number of breast cancer patients who needed a return trip to the operating room. Her hypothesis was that the team wasn’t following the newest guidelines about when such a follow-up surgery was beneficial. But as she learned in class, identifying the real problem is a process unto itself.
“When I actually collected data, I saw that our teams were using the new guidelines even before they were published,” she said. Instead, surgeons are lowering the reoperation rate by doing a better job of removing all of the cancer cells the first time.
Using the latest techniques, Dr. Dickson-Witmer is reducing the percentage of her surgeries in which cancer cells are detected at the edge of a removed tumor. This measure is important because the presence of cancer cells at the border of the excised tumor, called a “positive margin,” is associated with a higher local recurrence rate.
She has shaved her positive margin rate from 24 percent, roughly the national average, to 10 percent. Her focus on a trackable, objective metric — rather than on reoperation more broadly, which can involve judgment calls — also helped earn support from the surgeons.
A mission to learn
Because Christiana Care is the largest teaching affiliate hospital of the Philadelphia-based Sidney Kimmel Medical College at Thomas Jefferson University, education is a key mission for the health system.
“What I really enjoy is watching people reach that ‘a-ha’ moment, to finally understand why we learned what we did,” Dr. Dressler said.
Margot Savoy, M.D., MPH, FAAFP, FABC, CPE, CMQ, medical director of the Department of Family & Community Medicine, said the course shows Christiana Care leaders are supporting a culture that values solutions.
“There’s nothing magical about quality improvement,” Dr. Savoy said. ”Every single person is responsible for quality. There’s no other way for it to work.”