The Quality and Patient Safety Fellowship is intended to develop the future leaders in systems-based improvements and scholars in quality and patient safety. Academic Medical Centers are charged with training the next generation of health professionals. As regulatory bodies heighten their emphasis on the quality and safety of patients in health care, it is evident that we must attempt to educate new physicians and students on the core concepts of quality improvement and patient safety. Recognizing the need for a comprehensive system wide cross disciplinary curriculum for quality and patient safety, the Cincinnati VA Medical Center, in collaboration with the University of Cincinnati, Department of Internal Medicine, designed the Quality and Patient Safety Fellowship.

Education of physicians is a priority in this effort. There is a need to teach providers how to view the delivery of individual patient care from the prism of improving overall value and quality of care for a larger group of patients within a healthcare system. The Quality and Patient Safety Fellowship Program offers a one year fellowship designed for scholars with an interest in promoting a culture of patient safety and quality improvement. Scholars will provide outreach to Internal Medicine residents and staff in systems-based safety and quality improvement activities.

Formal Training in Quality Improvement and Patient Safety

The Quality and Patient Safety Fellowship will train clinicians to be master internal medicine quality and patient safety educators through a curriculum that provides a balanced educational experience in training in a mentored environment and teaching in an environment that promotes innovation, scholarship, and dissemination.

Mentorship

Each applicant will have 2 levels of mentorship:

1. Mentorship committee comprising of VA-recognized experts in patient safety and quality improvement. The members of this committee are comprised of Dr. Charuhas Thakar (Program Director), Dr. Joel Tsevat, and Dr. George Smulian. The trainee and his/her project-specific mentor will meet with the mentorship committee quarterly to review progress and plan future direction.
2. Project specific mentorship will be provided within the division or specialty of the applicant related to the proposed project. Mentors will be identified in General Internal Medicine or subspecialties (Cardiology, Pulmonary, Infectious Diseases, Nephrology, Endocrinology, Rheumatology, Hematology/Oncology and Digestive Diseases) as appropriate to the candidate and the specific project of the trainee.

Didactic Training Options

1. The scholar will be required to complete the online modules in (i) Quality Improvement and (ii) Measurement through the James M. Anderson Center for Health System Excellence (CCHMC). These modules are designed to familiarize the scholar with concepts of quality improvement and measurement and enable them to be effective QI team members. Pre- and post-course evaluations will be conducted by the program director to ensure effectiveness of this didactic training.
2. Quality Improvement and Patient Safety course in the Clinical Epidemiology and Clinical Effectiveness track of the Master of Science in Clinical & Translational Research program (3 credit hours in autumn semester). This course covers the fundamentals of quality improvement and patient safety. It will use a framework of human factors to facilitate understanding complex system failures and successful strategies to reduce hazard in industrial and medical environments.
3. The scholar and faculty mentor(s) must attend at least two off-site meetings annually – including one training program involving the National Center for Patient Safety faculty and one gathering of all quality and safety sites.

Quality Improvement and Safety Projects

Projects will be resident/fellow-driven, mentored projects based upon interest of the applicant and a perceived need for improvement in quality of care and patient safety. The program will facilitate appropriate mentorship within the Cincinnati VAMC, depending on the scholar and the topic, and encourage cross-disciplinary collaborations. A detailed narrative including problem/issue identification, evaluation of remediation strategies, proposed implementation of intervention, pre- and post-intervention evaluation strategies, and final outcome improvement recommendations will be developed. The information technology within the Cincinnati VA Medical Center allows the prospective documentation of health indicators and outcomes. Additional statistical support for analysis may be provided through the statistical core of the Cincinnati Center for Clinical and Translational Science and Training. The scholar will be encouraged to undertake a project that will lead to a publication in a peer-reviewed journal.

Teaching and Leadership

Quality and Patient Safety Fellow-led teaching opportunities

1. Morning reports, morbidity and mortality conferences, academic half days, and other venues within the department of medicine.
2. Supervision of ACGME-required quality improvement projects

Other Opportunities

Electives

1. Cincinnati VAMC Safety committees: The scholar will be afforded the opportunity to attend and learn from many of the multidisciplinary committees such as the Environment of Care/Safety Council meetings, Clinical Executive Board, Radiation Safety, Quality Performance Committee and Tissue and Transfusion Committee. Attendance at these meeting will provide an understanding of the regulatory requirements and the mechanisms to influence change in clinical care.
2. Risk management: Introduction to the area of risk management can be provided through participation in Peer Review Committee and the tort claim process.
3. Systems Redesign: The Cincinnati VAMC has nationally-recognized expertise in Systems Redesign and is a pilot site receiving national funding for its Health Analytics program. Elements of the Systems Redesign efforts applicable to quality improvement will be accessible to the scholar. Some of the locally available resources related to systems redesign include:

• Management Systems Redesign Steering Committee. Committee activity includes aligning improvement efforts in a patient-centered manner to ensure strategic alignment with the mission of VA, as well as local prioritization of projects based on impact – effort analyses.
• VHA has a rich repository of data available for driving patient safety and quality initiatives. The facility uses data mining techniques to identify data for qualitative and quantitative indicators that offer the greatest improvement opportunities. In addition to standard data mining techniques, the Cincinnati VAMC is actively involved in the VA-Thomson Reuters Value Model, which was launched through the Operational Analytics and Reporting Office. The VA-Thomson Reuters model identifies facility specific opportunities for improvement in Quality, Patient Safety, and other key areas. In addition to opportunity identification, the VA-Thomson Reuters model lists 5-Star facilities to facilitate benchmarking and identification of best practices.
• In addition to Healthcare Analytics training, training has and continues to be provided in Lean Healthcare, Six Sigma, Team Facilitation, and other critical areas that promote Safe, Timely, Efficient, Effective, Equitable, and Patient-centered care as defined by the Institute of Medicine.

Additional training and research resources

• James M. Anderson Center for Health System Excellence at CCHMC offers education designed to support the transformation of the individuals and organizations and catalyze the cultural shift necessary to improving health.
• College of Nursing Center for Education Research, Scholarship and Innovation fosters excellence in research and innovations that improve teaching and learning in nursing.
• VA National Center for Patient Safety at the Lexington VA hosts VA fellows in patient safety and may provide interactive opportunities.
• Simulation Learning: Learning opportunities in the use of simulation training exist at the University of Cincinnati College of Medicine Simulation Center where learners can develop new skills and refine established ones in an educationally safe and sound environment. Programs designed for learners in the Simulation Center emphasize teamwork skills to enhance communication. In addition, Dr. Rosalyn Scott (Dayton VA) has active VISN collaborative developing virtual patients, and women’s health initiatives.
• VA Inpatient Evaluation Center (IPEC): In collaboration with their project mentors, the scholar may have access to IPEC analytic support and tools to develop quality improvement initiatives in their respective disciplines. This program has significant strength in development and analysis of outcome metrics – whereby process improvement is driven by systematic evaluation of real-time information, based on evidence-based quality improvement guidelines.

Program Assessment and Evaluation

Development of the scholar’s project will include the development of a specific assessment tools for evaluation of both the quality and patient safety scholar and the effects of the quality improvement or safety measure implemented during the project. Evaluation plans will include measures for:

1. Correspondence to stated educational objectives and documentation of the desired competencies. This will be monitored through the didactic training course taken and educational outcomes. The effects of the increase in safety and quality teaching provided to the residents will be assessed thorough an analysis of the scores obtained on the In-service Training Exam on questions related to safety, quality evaluation and health care systems implementation. Scores will be compared with historical scores on similar questions and will be assessed for residents who have performed a residency training rotation at the VAMC during the past year compared with those without a VA rotation. In addition, the residents self-reporting of systems improvement and competence in safety will be monitored in their program evaluation forms.
2. The scholar will create a QI/PS data dashboard for each team at the VAMC, and review this on a continuous basis with the teams. These data will be used as part of the formative and summative evaluations for the residents and faculty.
3. Faculty and/or staff satisfaction with the program will be evaluated on the annual employee survey for examination of short-term impact.
4. Impact of the specific project on institutional safety/quality based on metrics proposed as part of the research/implementation project.

Professional Development

The James M. Anderson Center for Health System Excellence offers an Advanced Improvement Methods program to train faculty in the advanced methods of quality improvement such as factorial design, advanced control charts and segmentation that allow them to publish rigorous quality-improvement projects in refereed journals and conduct quality-improvement research”; the scholar is encouraged to apply to participate in this intensive training program if appropriate.

Certificate course in clinical epidemiology and biostatistics can be achieved during this year, and credits towards a masters program are potentially possible.

Longer-term career development program include the VA National Quality Scholars Fellowship Program and the Quality Scholars Program offered through the Anderson Center. The program will also promote applicants to pursue federally funded mentored career development awards that focus on implementation/quality improvement/patient safety research (e.g. Veterans Health Administration/Agency for Healthcare Research and Quality).