Recently, the Accreditation Council for Graduate Medical Education (ACGME) formalized institutional guidelines to include requirements for resident engagement in quality improvement (QI) education and problem-solving. However, many residents have not received an education in QI or have never participated in a QI project.
The E. Stephen Amis Fellowship, offered annually at the ACR, provides the opportunity for radiology and radiation oncology residents interested in quality and safety to be mentored by national leaders. As the 2024 fellows, we worked to identify ways to create meaningful resident engagement in quality and safety (Q&S) programs.
Looking at Residents and Their Quality Ideas
Residents are well-situated to identify Q&S opportunities, yet residents often lack formal QI education. It is often joked that residents are great complainers, but hidden amid these quips are real opportunities to improve practice. With multiple layers of quality checks from students, residents and attending physicians, mistakes are frequently caught before they become a problem. Whether catching an error in a scan protocol or correcting a mislabeled scan, many residents are poised to identify Q&S issues but lack the resources, mentorship and formal training to further their ideas.
Institutions and residency programs need a framework for residents to learn about and engage in QI initiatives and process improvement methodology. There are many online resources for programs and residents who are interested in self-directed education, including programs offered by the ACR Q&S Department, the Institute for Healthcare Improvement, the National Association for Healthcare Quality, the American Society for Quality, and the Society of Manufacturing Engineers. We suggest residency programs incorporate elements from these already available materials as a longitudinal component of resident education.
To truly support resident involvement in QI, institutions must think about infrastructure and how they can support processes that transform the “complainers” to the “changemakers.”
Investing in Quality Improvement
Education through self-directed modules or an annual lecture is not enough for meaningful change, however. QI is a process, and you learn by doing and by solving local problems you are passionate about. To truly support resident involvement in QI, institutions must think about infrastructure and how they can support processes that transform the “complainers” to the “changemakers.” Structured education, timely coaching with QI methodology, data analytics, project management, change management and small-scale testing and solution implementation are vital components to support QI. The institutions with the highest level of resident engagement in Q&S are also likely to be those who invest in Q&S initiatives as a core tenant of the institutional priorities. Residents do not have the experience or clout to drive change without mentorship, and mentors need institutional support. Thus, the best quality initiatives are those aligned with institutional priorities and impact everyone, including residents.
Potential opportunities on how best to support busy residents in QI work could include quality peer review as “case-based” learning during didactics, protected research time, integrating residents with ongoing efforts/initiatives, and data analyst/research assistant support.
Benefits of this invested time and effort are threefold:
- Engagement: Residents work on topics they are passionate about, which builds engagement within the local program and national societies.
- Leadership: Residents learn valuable problem-solving and leadership skills that can be applied toward future career goals and in professional societies.
- Innovation: Residency programs benefit from practical solutions that also fulfill ACGME QI milestones.
Fitting in Mentorship
Mentorship and sponsorship are the foundations of success in any endeavor, and QI is no exception. On a micro scale, mentors at the department level can be connected with mentees with mutual interest in quality projects. Mentors can help trainees navigate setbacks or facilitate multisystem processes that are out of the trainee’s circle of influence. Sponsorship can further help to build connections on a macro scale, either at the institutional level or on the national level in the form of grants and fellowship.
Projects that lack leadership support or are misaligned with institutional values may struggle to gain traction, administrative help and the funding necessary to succeed. Department leaders can further support success in mentor-mentee relationships through the development of a culture of safety at the workplace. Only when a resident feels safe to fail forward and reach out for senior advice will the symbiotic mentorship relationship flourish and yield strong results.
Case in Point: Lahey Hospital & Medical Center
At Lahey Hospital & Medical Center in Massachusetts, a patient-friendly reporting software was implemented to help patients better understand their medical report. This project required extensive collaboration with the institution’s legal team, IT, EMR services, and the third-party software vendor as well as within the radiology department. This was only possible with the guidance of the department chair of radiology who strongly believed in the product and what it would offer to our patient population. Without this leadership support and sponsorship, this project likely would not have succeeded.
Making Safe Peer Learning Essential
Peer learning is now recognized nationwide as the gold standard for improvement at a department level. Department culture should support psychological safety in identifying and calling attention to near-miss and safety events without fear of retaliation, which can be challenging in the resident role. Engaging with one another to highlight learning opportunities and deficiencies in an encouraging and non-punitive atmosphere is an important step toward fostering a culture of safety in the workplace. Anonymous case submissions for formal review at safety town halls or similar department-wide meetings are a great opportunity for collaborative learning.
A common mode of resident engagement among our fellowship cohort was the establishment of separate resident-driven peer-learning sessions. These sessions, often facilitated by a “chief resident of quality” or similar role, have yielded confidence in freely reviewing and discussing challenging cases and provided a safe environment for feedback from specialty attendings. This approach also builds an avenue for learning how to effectively review cases with providers outside of radiology and radiation oncology.
Finding Your Community
We felt a bit “alone in a crowd” until we connected with one another through the Amis Fellowship and realized that, despite vastly different upbringings, backgrounds, specialty interests and training, we saw similar challenges and opportunities in our programs. If you’re passionate about process improvement and patient safety, connect with others who have been there before and seek support from your organization or professional society. There is a community out there.
The E. Stephen Amis, Jr., MD, Fellowship in Quality and Safety
The Amis Fellowship provides an opportunity for up to four residents in diagnostic radiology, interventional radiology, integrated interventional and diagnostic, and radiation oncology to discover insights and gain experience with the ACR Department of Quality and Safety. You will learn about the work that ACR does to promote and support Quality and Safety. You will have an opportunity to meet leaders in the profession and launch your own leadership journey in your careers. The 2025 Amis Fellowship application will open in the spring of 2025.