It has been 10 years since the landmark Institute of Medicine report “To Err is Human” uncovered disturbing deficiencies in the quality of our nation’s medical care.
Progress in correcting these deficiencies remains frustratingly slow, and it has become clear that achieving the quality and safety improvements we seek will require us to examine our approach to medical education.
Although today’s newly minted physicians are well prepared in the science of medicine and practiced in the necessary patient care skills, too few are equipped with the knowledge and training necessary to improve the quality and safety of patient care.
If we’ve learned anything from our counterparts in the aviation industry about what it takes to reduce human error and improve safety, we can no longer consider quality and safety as “electives” in the medical school curriculum.
To fill the gap, modern medical education must integrate into the curricula processes and programs that foster the development of skills such as:
* Working effectively in teams
* Understanding work as a process
* Understanding how to collect, analyze, and display data on the outcomes of care
* Working collaboratively with other health professional managers, patients, and their families
* Acquiring the ability and willingness to acknowledge and learn from mistakes
Late this spring, the Lucian Leape Institute at the National Patient Safety Foundation published an interesting report entitled “Unmet Needs: Teaching Physicians to Provide Safe Care.”
The authors’ recommendations and proposed strategies for leveraging necessary changes include:
* Patient safety training that is treated as a basic science spanning all of medical education
* Commitments from medical school deans and teaching hospital CEOs to create learning cultures that emphasize patient safety, teamwork, leadership skills, communication, and performance improvement — and, importantly, providing the resources and incentives necessary to support these goals
* A shift in philosophy that recognizes the importance of training in the development of desired behaviors and skills — e.g., problem solving — as well as transmitting facts and information
* Adopting zero-tolerance policies for disrespectful, abusive, intimidating, and unethical behaviors by physicians
* Support from the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties (ABMS) for making patient safety training an educational priority and for developing/expanding related requirements
* Developing a system to monitor and publicly report compliance with new requirements
* Implementing financial (including state and federal funds), academic, and other incentives to leverage desired changes in medical education
Although I applaud the thoroughness of the report, I can’t help but think about the inevitable barriers to implementing these very basic changes in the culture of our medical schools and teaching hospitals.
How will buy-in and coordination be achieved among all of the important stakeholders, particularly the LCME, ACGME, and ABMS? Can such basic changes to medical curricula be mandated from “outside”? If so, does this imply that accrediting organizations and governments would generate and enforce reforms?
Money also becomes a problem. Many medical schools have experienced financial setbacks along with the rest of the country. Creating an unfunded mandate at this time would place a huge burden on them and would likely generate political opposition to reforms.
Nor do we have sufficient people equipped to teach quality and safety improvement. Many of the physicians working in these fields have learned on the job — and, in too many cases, on their own time.
Further, in order for physicians to achieve success on multidisciplinary teams in the workplace, they must be trained — together with those teams — in the context of a culture that supports quality and safety improvement (e.g., measurement, teamwork, patient-centered care) and that fosters structured problem-solving and respectful questioning.
Perhaps the most challenging aspect of implementing these reforms is that, once trained, new physicians need workplaces with cultures that support these values. Training in quality and safety improvement must transcend the medical school setting. So, practicing physicians, nurses, and other healthcare professionals must also receive training in the necessary skills in order to transform the culture in all healthcare settings.
Although there is no shortage of barriers to implementation, there are a number of things that medical schools and training hospitals can do to facilitate the integration of quality and safety into medical education.
First, universities and medical schools can recognize and appropriately value the work of their professionals in quality and safety improvement. This might take the form of time allocation, remuneration, and/or consideration for seniority/tenure for professionals who specialize in these areas.
Next, all stakeholders should consider what types of incentives, economic and otherwise, will encourage physicians and other healthcare professionals to work together in teams to improve healthcare quality and safety.
Finally, academic medical centers and teaching hospitals can develop strong curricula and educational programs for physicians and other health professionals. In addition to didactic sessions, these might include the use of simulation, case studies, and hands-on experience in quality/safety improvement.
David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.