At Hofstra-North Shore-LIJ School of Medicine, we have launched, with our inaugural class, a 4-year curriculum in patient safety, quality, and effectiveness, and established an IHI Open School Chapter. The Open School Chapter bridges the learning and implementation aspects of medical quality improvement by incorporating students onto existing interdisciplinary patient improvement teams that focus on microsystem level improvement. We have identified specific roles for students on these teams that fills gaps in team structure while allowing medical students to engage as active learners and full team participants. The students’ roles on the teams include: interviewing patients about their illnesses and hospital experiences to provide direct feedback on the effectiveness of a team’s interventions, speaking with patients to identify their perspective on areas needing improvement, collection of data, and taking an evidence based approach to medical literature to provide the most current research and guidelines on the management of a disease to their team. The goal is to engage students early on in improvement work by providing an experiential foundation in both valuing and performing this work. Alongside experience gained, medical students can provide beneficial contributions to improvement teams, and this model allows students to develop knowledge, skills and attitudes around the core areas of improvement methodology, including front-line data collection and analysis, data presentation, illness burden beyond pathophysiology, and viewing care delivery as processes which are measurable and amenable to change.

What Is Improvement Science?

The Institute of Medicine (IOM) released To Err is Human1 in 1999 and Crossing the Quality Chasm2 in 2001 as a means to convey the need to improve patient safety and quality of care and provided a background with which to approach the subject. Out of this literature arose the six “Aims for Improvement:”

Modified from Werlen, G., et al., 2000,Nature,406, 422-426.

The Clinical Microsystems approach is a conceptual framework that has been applied to various departments in the North Shore-Long Island Jewish Health System in order to improve patient safety. The basis of this approach is to identify a need in the hospital that may be targeted in order to improve the efficiency and efficacy of healthcare quality and delivery. The identification of such an obstacle may be achieved through a root cause analysis, a systematic method of identifying the root causes of problems or events. Once the objective for healthcare improvement is determined, a multidisciplinary team is created spanning one or more microsystems to target this specific barrier.

Medical Students on Teams: Rationale

Sickle Cell Team: An Example

In order to demonstrate the unique opportunities that medical students have to contribute to healthcare improvement teams, one should look at an existing improvement team at North Shore-LIJ healthcare system. The team was started in response to improper care of sickle cell patients that were admitted for “crises”. These patients were in the hospital and receiving no pain relief for days. This is when an interdisciplinary team was formed in order to relieve this problem.

This team was in existence for one and a half years before medical students began to participate. The main obstacles identified by the team to improving care for sickle cell patients were: (1) the time frame for pain reduction for patients admitted to the ED, and (2) a general lack of knowledge among the hospital regarding the excruciating pain crises sickle cell patients endure. After joining this team, medical students were able to contribute to the needs of the team to tackle these barriers to patient care. Currently, students are actively interviewing patients and collecting data to assess and analyze patient satisfaction with pain reduction in the ER and after being admitted to the floor. Additionally, their keen grasp on the pathophysiology of the disease process allows students to educate patients and nurses to promote awareness of sickle cell crises.

The basis of the healthcare improvement team is to identify a need in the hospital that may be targeted in order to improve the efficiency and efficacy of healthcare quality and delivery. Medical Students have successfully integrated themselves onto these teams and perform specific tasks that contribute to, and result in, improved care for patients.

Incorporating Improvement Science into Medical Education

1.  Kohn KT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.

2.  Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

The Multidisciplinary Team

The multidisciplinary team is the core of the Clinical Microsystems approach. The members of the team meet to address the objective by strategizing to improve care and determine measurable outcomes. The different members of the team provide different perspectives on the issues being addressed and can also attest to the experience of the population they represent. By having these various members, the barriers can be fully analyzed and the solutions can be realistically proposed. For example, patients and family members of patients are vital to the team as they provide a first-hand account of the barriers and all its dimensions. Healthcare professionals, including residents and nurses, are important as they deal with the intricacies of patient care and are most knowledgeable of the flow of healthcare within a hospital’s framework. Pharmacists can play a large role in providing crucial information to teams dealing with Cystic Fibrosis or Diabetes as an inherent challenge is medication administration. We believe medical students should be engaged as members of multidisciplinary improvement teams both for the unique contributions they can provide teams as well as the opportunity to provide experiential improvement science learning.

Why Medical Students?

Medical students have the opportunity to play a meaningful role in the functioning of a multidisciplinary team. Students provide a unique perspective as they are in the process of crossing the bridge from layperson to one of a medical professional and can relate to both the patients and the delivery of healthcare. Students can also contribute to a currently unfulfilled gap on multidisciplinary teams. They are actively learning both physiology and pathophysiology of disease and have the knowledge and time to educate others in these areas, whether it be other healthcare professionals or patients. As part of that process, students have the access and ability to perform literature searches to search best care practices and share this with the teams.

Medical students are also currently delving into early clinical experiences and are being empowered with the skills to interview and interact with patients. This can prove to be important when administering surveys to patients to gauge measures, such as patient satisfaction. Another important quality of the medical student is the fact that students are not yet entrenched in the practices of a hospital but, in contrast, are learning about the most ethical and sound practices. Thus, they are open to leaning ways to fix broken, inefficient systems – an integral part of improving healthcare.

Conclusion: What?

The traditional medical school curriculum has a heavy scientific focus, especially in the first two years. Frequent barriers include an already fully committed curriculum, insufficient subject knowledge amongst medical educators and institutional cultures that do not yet embrace improvement work and provide experiential learning opportunities. We propose and begin to demonstrate that improvement science can be incorporated into undergraduate medical education via the manners depicted above. By selecting efficient and effective methodologies, we can advance medical student understanding of improvement science despite the many existing barriers.

First Year Medical Students on Healthcare Delivery Improvement Teams Anne Press1; Reshmi Madankumar1; Ekjot Grewal1; Fatima Jaffrey, MD2; Samara Ginzburg, MD3

1MS1, 2Director of Outcomes Research and Performance Improvement, 3Associate Dean for Medical Education Hofstra North Shore-LIJ School of Medicine, Hempstead, New York

Clinical Microsystems Approach

Background: Teaching Healthcare Improvement to Medical Students

Conclusion: How?

Abstract

1 2 3 4

477 bp 379 bp

Conclusion: Why?

1. Patient-Centeredness 2. Safe Care 3. Effective Care 4. Efficient Care 5. Equitable Care 6. Timely Care

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3.  Ginzburg, S. Improvement Science – A Curricular Imperative. American Medical Association Journal of Ethics, 13.9; 2011: 620-25.

Teams at North Shore Long Island Jewish System

Roles of Medical Students Medical students have specific strengths due to their unique perspective and level in their medical education.

How will medical students contribute to interdisciplinary teams? Medical students will use their knowledge of pathophysiology, ability to research best practices, unique perspective and early clinical experiences to contribute positively to interdisciplinary teams. Additionally, medical students raise the capability of the team to assess the quality of the interventions as experienced by patients through both patient and staff interviews as objective observers, which members of the functioning microsystem teams without students are unable to do. These contributions will ultimately result in the improvement of patient care.

Anecdotal evidence pointing toward a trend of patients in sickle cell crises who

were waiting hours for

reductions in pain scale

Identification of major barriers to

care via root cause analysis

Goal: to reduce the time it takes patients to have

two point reduction in pain

Reduction of time it takes to achieve

two point reductions once

patient's are transferred to the hospital floor but data shows gap in

"ER" care

Medical students join healthcare

teams

Students preform literature reviews to research best

practices and collect additional data in order to

improve emergency care

for sickle cell patient's in crises.