Pursuing Excellence in Clinical Learning Environments

The University of Rochester Medical Center is one of only eight physician-training grounds in the U.S. selected to lead a four-year, nationwide effort to improve residency training for doctors. More than 50 medical schools and teaching hospitals applied to take part in the endeavor, which aims to improve the clinical learning environment of residency programs so that physicians are highly equipped to achieve better patient outcomes once they complete their residencies. 

Called Pursuing Excellence in Clinical Learning Environments, the national initiative is being led by the Accreditation Council for Graduate Medical Education (ACGME), the accrediting body for U.S. residency programs. Rochester’s effort is being led by Diane Hartmann, M.D., senior associate dean for Graduate Medical Education.

URMC was selected by the ACGME for its unique proposal to integrate its residents—more than 750 in 80 programs—into an existing quality and safety improvement model that has shown to be highly successful at improving patient outcomes. It is a model that other institutions can emulate, said Hartmann.

“We have tremendous potential to make sustainable improvements in health care quality and patient safety by integrating quality improvement principles into the training of every resident physician who comes through our doors,” said Hartmann, adding that about half of the practicing physicians in the Rochester area completed their residencies at Strong Memorial Hospital. “I’m very confident that we will see the impact of these improvements on the quality of health care across our community and beyond.”

Specifically, Rochester’s proposal expands on a 2013 effort by the School of Medicine and Dentistry and Strong to establish the Unit-based Performance Program (UPP) on 42 patient care units across the hospital.  Each patient care unit has an UPP team led by a faculty medical director and nurse manager, and staffed by key staff members of each clinical area. The UPP teams’ charge is to translate institutional quality and safety, patient- and family-centered care (PFCC), and efficiency priorities into projects that improve patient outcomes and satisfaction. 

The UPP team model has produced solid results. In 2015, nearly half the UPP teams were able to reduce the incidence of three types of hospital-acquired infections on their units by at least 10% over the previous year; 12 teams decreased the incidence of these infections by 40% or more during the same period. Those teams achieved similar improvements in PFCC measures (such as response to patient concerns or communication) and efficiency measures (such as resource use or hospital length-of-stay).

In its application to the ACGME, Rochester proposed embedding residents into its UPP teams, so that they can participate in unit-based quality and safety efforts in every specialty across the hospital, from pediatrics to neurosurgery.  Training will be offered to residents in quality and safety principles, and residents will be able to apply those principles in their role on the UPP teams.  Over time, residents will be integrated into all of Strong’s 42 UPP teams. ACGME will provide the University of Rochester with $300,000 over four years to help fund this effort.

“Creating an environment in which residents can work as part of an interdisciplinary team on projects that use data to drive measurable improvement in outcomes is, without question, the single most transformative step we can take toward safer, higher-quality, patient centered, and cost effective care,” said Hartmann.

The national movement to improve residency training stems from ACGME’s analysis of several years of physician performance and patient outcome data beginning in 1998. The analysis showed that when residents receive training at hospitals that deliver a higher quality of care and achieve better patient outcomes, they in turn, produce better outcomes for patients long after they complete residency training. In fact, these improvements in patient outcomes continued up to 15 years after physicians completed their residencies. The studies also showed that those who trained in environments with high complication rates carried that pattern forward in their careers.

Other medical schools and teaching hospitals selected to take part in the ACGME effort are The Cleveland Clinic, University of California-San Francisco, the University of Chicago, and the National Children’s Medical Center in Washington, D.C.

 “The University of Rochester School of Medicine and Dentistry has consistently been at the epicenter of reshaping our nation’s thinking about how best to produce doctors who are skilled in both the art and science of medicine,” said Mark B. Taubman, M.D., CEO of the University of Rochester Medical Center and dean of the School of Medicine and Dentistry. “From the genesis of the biopsychosocial model, to the integration of didactic and clinical learning, to the development of team-based learning, we have led major reforms to health care education. We are perfectly suited now to seize this historic opportunity to improve graduate medical education.” 

In January, at the URMC Board’s Annual Program ACGME chief executive officer Thomas Nasca, M.D., M.A.C.P., discussed the sometimes problematic connection between physician training and real-world practice in his keynote address.

In his speech, Nasca praised URMC as an “exemplar” for others because its clinical care and educational cultures are so tightly linked, and noted that isn’t always the case at institutions around the country.

 “Our goal is to help you and other teaching institutions be innovative in providing formative evaluation feedback and encourage you to keep doing what you’re doing well,” Nasca said in his remarks.