Over the past century, medicine and the delivery of healthcare have undergone constant change with a predilection for some common populist themes. Most of these have been driven by direct need – the Public Health agenda in Victorian times, development of triage and infection control in the Great Wars, and recently the explosion of the need to justify the way we do things with a strong evidence base. Over the past 10 years Quality Improvement has become the new challenge, a theme which is supported by both governments and health leaders. In some ways paediatricians have been at the forefront of quality improvement methodology. The need for clinical practice guidelines and standards of care, for example in neonatology, have been evident. However the implementation of new theories and practices in large health systems has always been a complex and frustrating process. Clinicians seldom embrace change easily and have not been trained in the theories and methodologies commonly used in other industries. Often intervention at an early stage of training is the key to enabling change to become ingrained in a clinician's day-to-day work.
Trainee doctors are integral to delivering patient care in many healthcare organizations. As a body, they have huge experience of system processes and how they differ from one organization to the other, moving, as they often do, from hospital to hospital. This group of doctors should be expected and supported to use these insights to identify areas where systems are under-performing, where risks might be reduced and safety enhanced, where processes are inefficient. Trainees are an untapped resource which could be directly involved in identifying solutions and effecting change. Trainees in paediatrics are no different, and one could argue its process driven nature make the specialty more receptive the quality improvement methodologies than others.
Batalden and Davidoff1 define quality improvement as ‘the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)’. Paediatric trainees in the UK have minimal or no meaningful involvement in the processes of improving the quality of the systems which deliver patient care. They simply are not taught the methodologies as part of their training, nor are invited to participate in quality improvement initiatives. Although it is a requirement that trainees demonstrate involvement in audit, the findings of these time and labour-intensive exercises are often never presented, and very rarely lead to meaningful and sustainable change (personal communication with Emma Stanton, 2010). Data gathering should not be the sole aim of the process (as is often the case in current trainee audit projects), but should rather have the aim of analysing systems, critically appraising process, proposing solutions, and being supported in implementing changes to improve clinical outcomes.
A quality improvement agenda, delivered within training programmes starting in medicals schools should not have to compete with the current curriculum and assessment burden that doctors in training in the UK currently face. It should be integral within it, as it will be vital for the future delivery of services. In the same way as evidence-based medicine now permeates throughout clinical practice (it is difficult to consider a clinical consultation in which the benefits of action or inaction are not considered) delivering high quality care should be regarded as an essential standard. In this context simply performing an audit would be considered an unacceptable training standard to promote. Although potentially a bitter pill to swallow for traditionalists, the benefits of this new approach are apparent for many stakeholders.
Children and their families
Quality improvement drives patient safety and experience – the aims of all healthcare organizations. Engaging trainees in examining the promoting the development of improvement programmes derived from audit or service evaluation will encourage safer practices.
Hospitals and healthcare providers
The large turnover in the trainee workforce makes constant locally relevant re-examination of systems possible. By re-defining the training requirement for participation in audit into participation in improvement programmes, trainees will be facilitated to make potentially significant contributions to departments and Trusts.
Trainees' professional development
Awareness and practical experience of quality improvement methodologies, and management and leadership skills will be promoted at an earlier career stage than is currently expected. This will facilitate a major culture shift in the NHS.
The medical profession
This approach will promote a culture of openness, cooperation and team-working. The flattening of hierarchy can help to reduce the all too common incidences of intimidation and bullying behaviours.
Worldwide the need to ingrain quality improvement methodology into medical education is now recognized.2,3 There are local initiatives (Wessex, UK) where this requirement for practical trainee involvement in quality improvement has been implemented with considerable success. Here trainees in the first year of their specialty training participate in a one-day patient safety and service improvement course. They then look at risks in their local environments and in conjunction with a facilitator undertake a variety of projects which are presented at a patient safety conference. This structure is now a compulsory part of the training pathway. There are also student-led improvement learning initiatives called Open School (www.ihi.org/openschool) at over 15 sites in the UK. We would recommend that training providers follow the leads of the students and refine training requirements in order to bring the methodologies of improvement and their practical application to trainees, hospitals and patients.
DECLARATIONS
Competing interests
DR is the Chair of the RCPCH Trainee's Committee; SH is vice-chair of the RCPH Trainee's Committee; PL is Teaching Faculty Fellow, NHS Institute for Innovation and Improvement
Funding
None
Ethical approval
Not applicable
Guarantor
DR
Contributorship
DR and SH came up with the initial idea; all authors contributed to the writing of the article
Acknowledgements
None
References
- 1.Batalden P, Davidoff F What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care 2007;16:2–3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hostetter M In Focus: Quality Improvement Training for Medical Students and Residents. Quality Matters 2010;Oct/Nov:1–6 [Google Scholar]
- 3.Sklar DP, Lee R Commentary: what if high-quality care drove medical education? A multiattribute approach. Acad Med 2010;85:1401–4 [DOI] [PubMed] [Google Scholar]