Reply to letter to the editor – ‘resident safety: the perspective of quality improvement’

Abstract

Dr. Walsh emphasizes the importance of engaging residents in quality improvement processes. He outlines critical aspects of this engagement including recognizing opportunities to improve care, training resident in the use of continuous measurement techniques, working with interdisciplinary teams, and ensuring that goals are relevant to the resident's actual work. I fully concur, and would emphasize, that this curriculum should be integrated into the residents’ work and culture. Focused rotations and didactics can lay the foundation, but to achieve the transformation we envision, it needs to be part of daily practice. The mandate for this type of culture of improvement transcends residencies. The Institute of Medicine (IOM) promotes the concept of each hospital being a ‘Learning Healthcare System’ (1, 2). Although there are many technological, systems engineering, and administrative changes which are crucial and beyond the scope of a residency, the IOM points to the primacy of a culture of quality improvement on the front line. The prescription looks much like Dr Walsh's. We have a mandate to prepare our residents to function in these ‘Learning Systems’. Moreover, what better than a residency with its focus on training best practices to lead the development of a hospital's learning culture. Journal of Community Hospital Internal Medicine Perspectives provides a setting for community residency programs to share their experiences, especially regarding quality improvement projects. For residents interested in contributing to this discussion – two important resources help define how. The Hastings Center has contributed several articles that explore the bioethics of quality improvement projects, and how the traditional procedures of Institutional Review Boards need to be reformed. They argue that current guidelines both inadequately protect patients while also inhibiting publication of important information about quality improvement (3, 4). While these articles establish a philosophical foundation for this topic, on the practical level, it will help residents consider which types of projects may require consent from their subjects under study. The other fundamental resource is from the Standards for Quality Improvement Reporting Excellence (SQUIRE) working group. Their 2009 paper provides a basic reporting structure for both designing and writing about quality improvement efforts (5). Paul N. Foster, Program Director Internal Medicine Residency ProgramGreater Baltimore Medical CenterTowson, MD, USAEmail: [e-mail]