Quality Improvement is Not A Spectator Sport

Mrs. Surles was my 9^th grade algebra teacher. She was an impeccably dressed woman with piercing dark eyes that commanded attention and demanded excellence. She referred to her immature and precociously smug students, myself included, by our last names only and, in turn, created an environment of mutual respect and attention. Above her blackboard smattered with white chalk hieroglyphics that she magically turned into logical equations was a laminated banner made from old dot matrix printer paper. The pixelated font read, “Math is not a spectator sport!” With this, she set the stage that being proactive and willing to let yourself be lost in the details was the only way to learn your limits and grow.

On several occasions, students, residents, fellows, and faculty have asked me how to get started with surgical quality improvement (QI) and translate these efforts into an academic career. There are innumerable educational resources to learn about surgical QI, value-based care projects, and the science of implementation.  Resources include rigorous degree programs in public health, clinical research, or healthcare quality and patient safety offered at most major academic centers. Shy of a formal degree but still with rigor are courses offered by leading QI focused organizations such as Intermountain Healthcare’s Advanced Training Program (ATP).¹ These types of options are of tremendous educational value and provide surgeons with well-recognized credentials but can be costly and time consuming.  I don’t have to articulate to the readers of this blog that money and time are the two resources in shortest supply for most early career surgeons. Fortunately, alternative options do exist.  Some hospitals have created their own QI focused training programs and boot camps that are free to faculty and staff.^2,3 One of the best initial resources is the Institute for Healthcare Improvement’s (IHI) How to Improve.⁴ Once you have registered, this free resource provides a basic framework to navigate QI. To take things a step further the IHI’s ‘Open School’ curates a variety QI and patient safety of courses and certificates for a nominal fee (individual professional subscriptions are $300/year).⁵ Similar free, on-line curricula are available for value-based care programs⁶ and frameworks for implementation science.⁷

While these resources may provide theory and a foundation to build upon, we all understand that QI is local. The nuances about navigating QI at your own institution go beyond what didactic training or coursework can illuminate for you. The best way to learn is to embark upon your very own QI project. The obstacles to implementation and barriers to your success on one project will guide your future efforts.  You will find your own set of allies across disciplines to recruit to your QI team, and you will discovery your greatest opposition often within your own clinical ranks. In my own experiences, I have found it to be very easy to find colleagues in nursing, critical care, anesthesia, emergency medicine, and administration that share my passion for QI. These positive relationships provide the encouragement to persist in the face of Sisyphean tasks. You will find that for some all it takes is data to change culture and that with others it is in their culture to oppose all change despite the most rigorous data. The adage ‘you can catch more flies with honey than with vinegar’ comes to mind, and I have learned that to implement change we have to understand motivations and accept incremental progress toward shared vision. Acknowledge flaws raised by the naysayers and reset the improvement cycles as often as needed. To persist and slowly win the support of your biggest critics can be immensely gratifying. Conversely, realize and accept that 100% compliance is not required to achieve your goals. Through QI we are given insight to true character and core values of our institutions and leaders. These self-reflective exercises allow QI projects to illuminate how we as surgeons interact with our teams, assimilate new knowledge, and grow. The biggest lessons to learn to improve the quality of care we offer our patients are not found in surgical texts or in the science of QI, but exist in art of surgery and draw inspiration from fields such as cognitive psychology, economics, anthropology, and sociology.

All of these experiences, including those that fail to demonstrate intended QI, should be used to build you academic curriculum vitae. Publish your experiences in one of the plethora of specialty-specific or QI focused journals using the revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).⁸ Network in this growing space within surgery at national meetings, within professional societies, and seek out intramural and extramural funds to support your next QI project. Once your Division Head, Department Chair, and C-suite see the fruits of your labors, including the academic output and the improved care of your patients, advocate for protected time to continue on this path.

The process is rewarding. I have realized that I can influence the lives of many more patients through QI than in a lifetime of operating as a surgeon. Balancing my roles as a QI researcher and as a surgeon has been a rewarding journey on both fronts – often cross-pollinating my curiosity. My best research is born from clinical observations, and my greatest satisfaction from when my research improves the care of my own patients. I may not remember all of the lessons Mrs. Surles taught me about complex algebraic equations, but I will forever remember that best way to learn is by doing.  After all, QI is not a spectator sport!

REFERENCES

1. Intermountain Healthcare: Institute for Healthcare Leadership. Available at: http://intermountainhealthcare.org/qualityandresearch/institute/courses/Pages/home.aspx.  Last visited: 11/12/2018.
2. Cincinnati Children’s James M. Anderson Center for Health Systems Excellence. Available at: https://www.cincinnatichildrens.org/service/j/anderson-center/education/additional-programs.  Last visited: 11/12/2018.
3. Cleveland Clinic Improvement Model. Available at: https://my.clevelandclinic.org/departments/patient-experience/depts/continuous-improvement. Last visited: 11/12/2018.
4. Institute for Healthcare Improvement. How to Improve.  Available at http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.  Last accessed: 11/12/2018.
5. Institute for Healthcare Improvement: Open School. Available at: http://www.ihi.org/education/ihiopenschool/Pages/default.aspx.  Last accessed: 11/12/2018.
6. Herrmann LET, M., Beck J, Dewan M, et al. A faculty development workshop for high-value care education across clinical settings. MedEdPORTAL. 2018;14:10745. Available at https://doi.org/10.15766/mep_2374-8265.10745. Last Accessed: 11/12/2018.
7. The National Implementation Research Network’s Active Implementation Hub. Available at: https://implementation.fpg.unc.edu/modules-and-lessons.  Last accessed: 11/12/18.
8. Ogrinc GD, L., Goodman DB, P., Davidoff F, Stevens D. SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ quality & safety 2015.