Methods
Curriculum
We implemented this educational initiative at Tufts Medical Center Primary Care, Boston, Massachusetts, the primary care teaching practice for all 75 internal medicine residents at Tufts Medical Center. Co-located with the 415-bed academic medical center in downtown Boston, the practice serves more than 40,000 patients, approximately 7000 of whom are cared for by resident primary care physicians (PCPs). The internal medicine residents rotate through the primary care clinic as part of continuity clinic during ambulatory or elective blocks. In addition to continuity clinic, the residents have 2 dedicated 3-week primary care rotations during the course of an academic year. Primary care rotations consist of 5 clinic sessions a week as well as structured teaching sessions. Each resident inherits a panel of patients from an outgoing senior resident, with an average panel size of 96 patients per resident.
Prior to this study intervention, we did not do any formal QI teaching to our residents as part of their primary care curriculum, and previous panel management had focused more on chart reviews of patients whom residents perceived to be higher risk. Residents from all 3 years were included in the intervention. We taught a QI curriculum to our residents from January 2018 to June 2018 during the 3-week primary care rotation, which consisted of the following components:
- Institute for Healthcare Improvement (IHI) module QI 102 completed independently online.
- A 2-hour QI workshop led by 1 of 2 primary care faculty with backgrounds in QI, during which residents were taught basic principles of QI, including how to craft aim statements and design plan-do-study-act (PDSA) cycles, and participated in a hands-on QI activity designed to model rapid cycle improvement (the Paper Airplane Factory19).
- Distribution of individualized reports of residents’ patient panel data by email at the start of the primary care block that detailed patients’ overall rates of colorectal cancer screening and hypertension (HTN) control, along with the average resident panel rates and the average attending panel rates. The reports also included a list of all residents’ patients who were overdue for colorectal cancer screening or whose last blood pressure (BP) was uncontrolled (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg). These reports were originally designed by our practice’s QI team and run and exported in Microsoft Excel format monthly by our information technology (IT) administrator.
- Instruction on aim statements as a group, followed by the expectation that each resident create an individualized aim statement tailored to each resident’s patient panel rates, with the PDSA cycle to be implemented during the remainder of the primary care rotation, focusing on improvement of colorectal cancer screening and HTN control (see supplementary eFigure 1 online for the worksheet used for the workshop).
- Residents were held accountable for their interventions by various check-ins. At the end of the primary care block, residents were required to submit their completed worksheets showing the intervention they had undertaken and when it was performed. The 2 primary care attendings primarily responsible for QI education would review the resident’s work approximately 1 to 2 months after they submitted their worksheets describing their intervention. These attendings sent the residents personalized feedback based on whether the intervention had been completed or successful as evidenced by documentation in the chart, including direct patient outreach by phone, letter, or portal; outreach to the resident coordinator; scheduled follow-up appointment; or booking or completion of colorectal cancer screening. Along with this feedback, residents were also sent suggestions for next steps. Resident preceptors were copied on the email to facilitate reinforcement of the goals and plans. Finally, the resident preceptors also helped with accountability by going through the residents’ worksheets and patient panel metrics with the residents during biannual evaluations.
Evaluation
Residents were surveyed with a 10-item questionnaire pre and post intervention regarding their attitudes toward QI, understanding of QI principles, and familiarity with their patient panel data. Surveys were anonymous and distributed via the SurveyMonkey platform (see supplementary eFigure 2 online). Residents were asked if they had ever performed a PDSA cycle, performed patient outreach, or performed an intervention and whether they knew the rates of diabetes, HTN, and colorectal cancer screening in their patient panels. Questions rated on a 5-point Likert scale were used to assess comfort with panel management, developing an aim statement, designing and implementing a PDSA cycle, as well as interest in pursuing QI as a career. For the purposes of analysis, these questions were dichotomized into “somewhat comfortable” and “very comfortable” vs “neutral,” “somewhat uncomfortable,” and “very uncomfortable.” Similarly, we dichotomized the question about interest in QI as a career into “somewhat interested” and “very interested” vs “neutral,” “somewhat disinterested,” and “very disinterested.” As the surveys were anonymous, we were unable to pair the pre- and postintervention surveys and used a chi-square test to evaluate whether there was an association between survey assessments pre intervention vs post intervention and a positive or negative response to the question.
We also examined rates of HTN control and colorectal cancer screening in all 75 resident panels pre and post intervention. The paired t-test was used to determine whether the mean change from pre to post intervention was significant. SAS 9.4 (SAS Institute Inc.) was used for all analyses. Institutional Review Board exemption was obtained from the Tufts Medical Center IRB. There was no funding received for this study.