Student High Value Care Initiative: a Longitudinal Model for Student-Led Implementation and Scholarship

Abstract

Background

Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education.

Aim

To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives.

Setting

A tertiary medical center affiliated with a medical school in New York City.

Participants

First year medical students, junior faculty in hospital medicine, and a senior faculty course director.

Program Description

The Student High Value Care initiative is a longitudinal initiative comprised of six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4), Institutional support, (5) scholarship, and (6) student leadership.

Program Evaluation

During the first 3 years, 68 medical students and ten junior faculty participated in 10 quality improvement projects. Nine projects were successful in their measured outcomes, with statistically significant improvements. Nine had an abstract accepted to a regional or national meeting, and seven produced publications in peer-reviewed literature.

Discussion

In the first 3 years of the initiative, we successfully engaged medical students and junior faculty to create and support the implementation of successful quality improvement initiatives. Since that time, the program continues to offer meaningful mentorship and scholarship opportunities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-023-08100-y.

INTRODUCTION

High cost and suboptimal patient outcomes in the US health system have led to an increased focus on improving value for patients ¹. Educating medical trainees to practice high value care is now recognized as critical to system-wide change,^2,3 resulting in the development of programs designed to teach residents about high-value care, including de-implementation strategies for low value practices ^4,5. Medical students have also emerged as important participants in improving care and have been integrated into initiatives focusing on high value care ⁶. Steele et al. demonstrated that a high value care curriculum for first year medical students can help them acquire some skills to apply this concept in clinical practice ⁷. Similarly, Moriates et al. found that a similar curriculum for second year medical students impacted student attitudes regarding high value care and resulted in wider cultural changes ⁸. While these initiatives show the benefit of targeted curricula, the clinical impact of student-led value-based quality improvement initiatives has not been well-described.

There are several benefits to introducing high value care into the earliest parts of medical education. While students are likely to observe and model themselves after physicians who deliver unnecessary services,⁹ they may also be influenced by early experiences in value improvement. A focus on value at the student level could therefore be highly impactful, particularly if those efforts were student-led¹⁰ and fostered scholarship. However, students lack the clinical knowledge, experience, and understanding of the local environment needed to create effective change and therefore need guidance and support from faculty and their institution. We present the first 3 years of a successful model of medical student training and engagement in high value care that resulted in the implementation of successful value projects at our institution.

SETTINGS AND PARTICIPATIONS

In August 2015, we implemented the Student High Value Care (sHVC) Initiative at Icahn School of Medicine at Mount Sinai, in conjunction with the High Value Care (HVC) Committee. The initiative was set in an 1134-bed tertiary medical center in New York City.

A fourth year medical student chair (S.M.) and faculty director (H.C.) developed the sHVC initiative. All medical students at Icahn School of Medicine (n = 560) were invited to join the group through an application process, describing their interest in high value care and any relevant past experience (if any). Twenty-one students applied and all were accepted in the first year of the initiative. Junior faculty volunteers, defined as individuals less than 5 years out from residency, were recruited through an open invitation to attendings in the Division of Hospital Medicine.

The leadership group, composed of student chairs and the course director, met monthly to plan the curriculum, discuss team updates, and address any student and faculty concerns. Student members were divided into teams and each collaborated with a hospitalist faculty mentor to pursue a specific high value care project. Monthly meetings of the entire sHVC group included dedicated value improvement curriculum and discussion of individual team progress and barriers to project implementation. Each team met separately weekly to monthly to work on its project. Participation was voluntary; no formal credits from the medical school were offered initially.

PROGRAM DESCRIPTION

The sHVC longitudinal initiative included six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4) institutional support, (5) scholarship, and (6) student leadership.

Project Development

Projects had three phases of development: planning, presentation, and implementation.

Planning

At the start of the academic year, students were introduced to value-focused resources including Choosing Wisely® Lists and the “Choosing Wisely®: Things We Do For No Reason” series in the Journal of Hospital Medicine ^11,12. The students and faculty brainstormed inpatient project ideas in a large group setting, then split into groups based on project interest and refined the ideas. Students would then review the evidence supporting their project, obtain and evaluate the necessary pre-intervention data, and engage stakeholders (typically through surveys).

Presentation

The annual sHVC “Pitch Day” was an event held in early December of each year. In-person attendance was approximately 80–90 people, and it was broadcast live through the medical school social media sites on Facebook and Twitter. Each team presented their project and implementation ideas to their fellow medical students, residents, faculty, and staff, including four judges. This event provided students an opportunity to solidify institutional buy-in and awareness and receive formative feedback. Judges included hospital leaders and experts in overuse research. One winning team was selected by the judges’ panel and awarded a $1000 prize; a second team was selected based on audience input and awarded $500. Funding was provided by the Division of Hospital Medicine and intended to cover project-related expenses (such as promotional materials).

Implementation

We used the plan-do-study-act paradigm as a standard framework for the development and completion of each initiative ¹³. Projects were planned to last for a 1-year period. Regular check-ins and feedback occurred during the sHVC group meetings for all students, the High Value Care Committee meetings for faculty mentors and student chairs (held monthly), and at the sHVC leadership meetings (held monthly).

Student Value Improvement Curriculum

We created a curriculum to educate participants about value and quality improvement. Curriculum topics focused on leadership, value, safety, and scholarship (see Supplemental Materials). The curriculum was presented in monthly, hour-long sessions led by the faculty director. Students were required to attend these sessions in person, which lasted throughout the academic year. Lectures were compiled using teaching material and concepts previously presented in the Quality and Safety Educators Academy, Institute for Healthcare Improvement, and the Greater New York Hospital Association Clinical Quality Fellowship Program ^14,15.

Mentorship

Mentorship was a core element of the program, and existed on four levels: faculty to student, senior to junior faculty, peer mentoring, and reverse mentorship (Fig. 1).

Figure. 1.

Mentor relationships among sHVC faculty and students. Each directional arrow represents a mentor–mentee relationship. Bi-directional arrows represent mentorship provided by both individuals. A bi-directional arrow between a junior faculty and student represents reverse mentoring.

Faculty-Student

Each team averaged a 5–6:1 ratio of students to faculty. Faculty provided the students with clinical expertise during the brainstorming phase of the project. Faculty reinforced concepts taught in the curriculum and helped the students overcome any obstacles along the way. The course director provided additional guidance to the students as needed, including occasional attendance at their workgroup meetings to troubleshoot and improve engagement.

Senior-Junior Faculty

The Director of Quality, Safety, and Value of the Division of Hospital Medicine (H.C.), with formal fellowship training in QI, served as senior mentor for all sHVC faculty. The junior faculty had no formal quality training, QI experience, or prior publications. Mentorship included advice related to project progress or group oversight along with an informal introduction to QI.

Peer-Peer

We fostered peer-peer mentorship among students within and between teams. For example, a student skilled in data analysis and statistics delivered educational sessions and coached students in analyzing their project data. Another student shared skills gained as a health care consultant to help another team more effectively engage residents. In addition, as each year’s teams embarked on their projects, students and faculty from the prior year(s) provided advice and guidance based on their experience and lessons learned.

Reverse Mentoring

Finally, reverse mentoring, or mentorship from student to faculty, was also an important component of the program. Not only did student share their skills with their peers, they shared them with the junior faculty as well.

Institutional Support

Institutional support was obtained in the beginning stages of the sHVC initiative. The Chief of the Division of Hospital Medicine identified high value care as a divisional priority and championed the sHVC initiative as an integral part of this effort. Leaders from the Department of Medicine (DOM), the Institute of Health Care Delivery Science, and the institution’s clinical informatics group provided support for data collection and analysis. Additional data support was given through access to Premier database for select members of the sHVC leadership. The Icahn School of Medicine Student Council also provided modest resources for project necessities, including signs, food, website hosting, and conference travel. Hospitalist unit medical directors assisted with education and publicity campaigns in their local units. No funding or protected time was provided to faculty and directors.

Scholarship

Each team was expected to submit an abstract to present at a regional or national meeting and to consider submitting a manuscript to a quality improvement journal. The DOM Quality Improvement Committee provided expedited review of projects to determine their scope as being quality improvement or research.

Student Leadership

During the first year, students applied to be project leaders and were selected by the course director. Student leaders managed all facets of the initiative, including administrative tasks such as communication related to educational sessions, coordination of Pitch Day, and recruitment for the following academic year. In subsequent years, the outgoing student leaders interviewed and selected the incoming student leadership. As the program evolved, members of the student leadership were assigned to represent each team. As student team leaders, they assigned roles, worked closely with the faculty mentor, and ensured the project progressed towards completion.

PROGRAM EVALUATION

Three teams began in the first year of the initiative, four teams during the second year, and three teams during the third year, totaling 68 students and 10 junior faculty. All interventions were multifaceted, multidisciplinary, and included education with slogans, posters, and interactive engagement sessions. All teams incorporated systems changes, with five involving electronic medical record (EMR) changes. Two teams utilized targeted feedback. The projects targeted a variety of settings: three were multi-institutional, one involved a division, one involved multiple units, and three involved a single unit. Table 1 summarizes the projects.

Table 1.

Student High Value Care Projects

High value care projects	Target	Implementation strategies	Setting	Outcomes*	Scholarship
“A Student-Led, Multifaceted Intervention to Decrease Unnecessary Folate Ordering in the Inpatient Setting”	Total folate lab testing	Education Publicity Targeted feedback EMR change	Multi-institutional	Decrease folate ordering by 87% from average 98.4 tests per month to 37.5 Estimated annual cost saving of $26,719.56	Abstract: NY ACP Conference 2017 Award: Icahn Institute of Medical Education, Blue Ribbon Winner 2017 Manuscript: J Healthc Qual21
“‘THINK’ Before You Order: Multidisciplinary Initiative to Reduce Unnecessary Lab Testing”	Reduce recurrent lab test ordering for Complete Blood Count, Basic Metabolic Panel, and Complete Metabolic Panel	Education Publicity Gamification Checklist EMR change	Unit	Post-intervention effect estimate − 0.04 labs per patient day/month Estimated cost-saving of $94,269 during the intervention period 9709 potential lab tests were avoided	Abstract: SHM 2017 Award: Finalist abstract at SHM 2017 Manuscript: J Healthc Qual22
“A Sleep Hygiene Intervention to Improve Sleep Quality for Hospitalized Patients”	Improvement in Richards-Campbell Sleep Questionnaire Score Improvement in Hospital Consumer Assessment of Healthcare Providers and Systems Score on quietness at night	Education Publicity Systems change	Unit	Improved self-reported sleep depth, decreased awakenings after sleep onset, and improved sleep continuation after awakening Improved “quietness at night” from 34.1 to 42.5%	Abstract: SHM 2018 Award: Plenary Session at SHM 2018 Award: Icahn Institute of Medical Education, Blue Ribbon Winner 2018 Manuscript: Jt Comm J Qual Patient Saf23
“‘Lipase Only, Please’: Reducing Unnecessary Amylase Testing”	Reduce serum amylase testing in an academic hospital and community hospital	Education Publicity Systems change EMR change	Multi-institutional	Decrease from 3214 orders per month to 2348 orders per month Estimated annual cost-saving of $44,999	Abstract: SHM 2017 Manuscript: Jt Comm J Qual Patient Saf24
“D/C the Docusate”	Reduce docusate orders in an academic hospital and community hospital	Education Publicity EMR change	Multi-institutional	Decrease in ordering of docusate by 41%	Abstract: SHM 2018
“Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting”	Reduce in inappropriate ordering of antihypertensives and adverse events with IV antihypertensives	Education Publicity Treatment algorithm Champions Systems change EMR change	Multi-unit	Decrease in inappropriate ordering of antihypertensives from 8.3 to 3.3 orders per 1000 patient days Decrease in adverse events with IV antihypertensives from 4.4 to 1.9 events per 1000 patient days	Abstract: Lown Institute Research Symposium 2017, SHM 2019 Award: Audience Choice Award at Lown Institute Research Symposium 2017 Manuscript: JHM25
“Choosing Wisely to Mobilize Patients in Reducing Falls and Injury”	Reduce falls and falls-related injuries	Education Publicity Systems change	Unit	Relative risk reduction of 79.7% for falls with injury	Abstract: SHM 2017 Manuscript: Jt Comm J Qual Patient Saf26
“Stop the Flow if Your Patients PO: A Multi-faceted Intervention to Decrease Overuse of Continuous Intravenous Fluids”	Reduce total volume of maintenance fluids Reduce percentage of patients receiving fluids for > 24 and > 72 h	Education Publicity Targeted feedback Systems change	Division	Decreased volume of maintenance fluids of 746.6L/month to 607.8L/month Decrease in patients receiving fluids > 24 h from 18.3 to 15.6% and > 72 h from 4.8 to 2.9%	Abstract: SHM 2019 Manuscript: in submission
Home Hemodialysis		Education Systems change	Division	N/A	None
“A Multifaceted, Student-Led Approach to Improving the Opioid Prescribing Practices of Hospital Medicine Clinicians”	Decrease prescriptions > 7 days Increase follow up appointments within 7 days Increase documentation regarding review of state prescription monitory program registry	Education Publicity Systems change	Division	Decrease prescriptions > 7 days from 45.2 to 39.5% Increase follow-up appointments within 7 days from 38.6 to 65.9% Increase documentation regarding review of state prescription monitory program registry from 32.5 to 39.7	Abstract: SHM 2019 Manuscript: Jt Comm J Qual Patient Saf27

^*All outcomes reported were statistically significant

Nine of the ten projects were successful in their measured outcomes, with statistically significant improvements. After demonstration of initial success, two projects gained interest and elicited collaboration from other sites in our health system. Nine of the ten projects had an abstract accepted to a regional or national meeting. Additional recognition included selection as an abstract finalist and plenary session at the Society of Hospital Medicine Annual Conference, an abstract award at the Lown Institute Annual Research Symposium, and an abstract award at the Icahn School of Medicine Institute of Medical Education Research Symposium. Seven projects were published in peer-reviewed journals, with an additional submission currently under peer review. Finally, this initiative, as the cornerstone of a larger High Value Care Initiative, was given national awards from both the Society of Hospital Medicine and Society of General Internal Medicine.

DISCUSSION

We developed a successful student-led model for high value care implementation at one health system using junior hospitalist as faculty. The success rate of these projects far surpasses that found in trainee-involved quality improvement projects at other institutions, which has been reported as 25% ¹⁶. Moreover, the success of our projects was achieved over a wide array of clinical settings (from single unit to multi-institutional projects), targets (from lab ordering to opioid prescription patterns), and intervention types (from education initiatives to changes in the EMR). Most importantly, our initiative demonstrates that medical students can participate and lead HVC projects when provided with the necessary knowledge, skills, and mentorship.

Our model offered meaningful mentorship opportunities for students early in their training, specifically focused on quality and high value care. The program also offered junior faculty a rewarding opportunity to serve both as mentor and mentee while gaining valuable practical quality improvement experience. Traditionally, mentorship for academic hospitalist groups is challenging, with many having predominantly young leadership without formal structure for mentorship activities ¹⁷. Effective mentorship can help faculty publish and present regionally and nationally, which can increase career satisfaction and productivity and reduce the risk for burnout ^18,19. Our experience and results suggest that a properly structured and supported longitudinal program can provide education and experience for faculty and fulfill this growing institutional need.

There are challenges and limitations to our model. First, our initial recruitment outreach may not reflect the level of interest at other institutions. This limitation can be mitigated by creating fewer teams if fewer students or faculty are available. Program interest may also be generated in subsequent years when prior student participants can advocate for its value. Second, the institutional support we received, including the engagement of departmental leaders in QI, may not be feasible elsewhere. Identifying projects as quality improvement initiatives versus research studies requires established institutional infrastructure, and must fit within the timeline of the student program; this flexibility may not be available at other institutions. Third, we had an adequate number of faculty mentors who themselves were mentored by the course director, which may be challenging at smaller programs ²⁰. Fourth, we did not track educational outcomes measures, including attitudes, knowledge, and skills, among participants. Such outcomes will be important evaluate in the future to understand the true impact and effectiveness of this model. Finally, sustainability of these project outcomes needs further study. Most of the student team members started as first year medical students, and their time became limited late in their second year of school, as they prepared for their first licensing exam and began clinical rotations. Similar programs will need to anticipate periods where students are less available when developing timelines for project progress and completion.

The sHVC Initiative fostered student-led experiential learning in high value care and created the structure and support for the implementation of successful projects at our institution, along with opportunities for meaningful scholarship locally and nationally. The program has since expanded to include nursing students and now engages junior faculty in other divisions, including Emergency Medicine, Pulmonology, Obstetrics and Gynecology, and Infectious Disease. On the national landscape, innovative projects have been introduced since the launch of our initiative, including Choosing Wisely STARS (Students and Trainees Advocating for Resource Stewardship) at Dell Medical School. The success of both programs demonstrates that it is critical for educators to develop models to incorporate untapped interest in enhancing quality from medical students, hospitalist faculty, and their institution at large.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748).

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article, references, and/or its supplementary materials.

Declarations

Conflict of Interest

None of the authors report any conflicts of interest.