Quality Improvement: One Resident at a Time

Rahul K. Shah, M.D, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC When we discuss quality improvement, many of us speak at a high level, discussing interventions nationally, regionally, or within health systems. However, some of the biggest gains from the quality improvement initiatives begin at the ground level. In smaller settings, quality improvement initiatives can have a tremendous impact. On Saturday, July 15, 2011, I was part of such an opportunity with the second annual Otolaryngology Emergencies Boot Camp, in Washington, DC. The course directors were Academy members Ellen S. Deutsch, MD, Sonya Malekzadeh, MD, and Kelly Michele Malloy, MD. The course was so popular among residents that the course directors had to close off the registration due to space constraints—understandably, as it is impossible to have an unlimited number of participants in a hands-on simulation course. The stations were varied but focused on the key technical, communication, and knowledge-based skills that nascent residents desperately need, such as management of epistaxis, fundamental airway skills, and simulated team training exercises. What was most fascinating was watching the learning curve become steeper right in front of our eyes. For example, I was shocked by how many PGY-2s have never intubated a patient. However, as otolaryngologists, depending on the circumstances, everyone will be looking at them to intubate a patient in extremis after all the other team members have been unsuccessful. Similarly, how many PGY-2s in early July have placed a posterior nasal pack? There is great satisfaction for the faculty in knowing that next time a resident faces one of these scenarios, he or she has already been through the cognitive and hands-on part of the skill and will be able to take better care of the patient. The basic tenet of a quality improvement initiative is to produce something that when implemented can increase or improve the quality of care for our patients. The Emergencies Boot Camp is an example of such a program. The patients who will come under the care of those 30 residents in the ensuing weeks and months will perhaps have a better outcome or receive better care because their doctor had been to the Boot Camp. If the quality case exists, then a business case follows. The steep rise in the learning curve witnessed by the faculty gives credence to this model of teaching. Further, the students do not need to spend an inordinate amount of time in such a course, rather just be exposed to some basic, hands-on fundamentals. The return on the investment of attending the Boot Camp can be looked at from varying angles. With less time spent on such education by the primary institution’s faculty, there is more time for producing revenue.  Additional cost savings will be seen as the Boot Camp-educated residents do things right the first time, rather than setting instruments up, etc., for the first time during an emergency. Such emergency-ready residents can save resources and, potentially, a patient’s life. I am confident that by spending a Saturday at this course, the residents’ skills and confidence have increased tremendously. It is great for them and the patients whom they are going to be taking care of in the coming months. However, what about the residents across the country who did not attend this boot camp? When I was a resident, this concept did not exist and there was nothing as innovative as today’s simulators.  Typically it was a senior resident teaching the basics to the junior. You can immediately see the flaw in such teaching paradigm. A case can be made to have perhaps a dozen Emergencies Boot Camp sites across the country that PGY-2 residents can attend without traveling significant distances. The impact on the training programs and the patients under their care is significant. As more novel teaching programs come about, it is imperative that we make efforts to ensure that everyone can share in this learning and that the broadest number of patients benefit by teaching fundamentals in a quasi-standardized fashion—one resident at a time. We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.