From Quality Improvement to Systems Change: A Collaborative, Experiential Curriculum to Prepare Family Medicine and Primary Care Internal Medicine Residents in Systems Change and Quality Improvement

Investigator: Teresa Villela, MD
Sponsor: U.S. Health Resources and Services Administration

Location(s): United States


Underserved and vulnerable patients in publicly funded practices experience ongoing inequities in health and health care and often have not benefited equally from advances in public health, health promotion, disease prevention, and chronic illness care. Health care systems in safety net organizations—Federally Qualified Health Centers, Community Health Centers, Migrant Health Centers, National Health Service Corps sites—may not be able readily to provide the resources or infrastructure to ensure accountability to HHS National Quality Strategy principles, and fragmentation of care might jeopardize the timely identification of and provision of needed services. To meet this challenge, primary care physicians who work in safety net health centers will need to develop skills in systems improvement and change. Primary care physician educators, in turn, must face the unique challenges of preparing the next generation of physician leaders and ensure that systems improvement will be fully informed by the strengths and core values of primary care. Preparing primary care physicians who are leaders in systems improvement and change is essential not just for ensuring high-quality patient care but also the physician’s long-term professional fulfillment. While many training resources exist for improving quality and patient safety, relatively few educational efforts prepare primary care residents to become effective leaders in systems change in safety net practices. The San Francisco General Hospital residency programs in Family and Community Medicine (FCMRP) and Primary Care Internal Medicine (PCIMRP) have a combined experience spanning several decades in preparing family physicians and primary care internists to deliver highquality, cost-effective care to the urban poor – our respective curricula place special emphasis on providing care for the uninsured as well as access to care for those limited by illiteracy, language barriers, homelessness, or drug dependence. Of the two most recent graduating classes, totaling 36 graduates combined, 27 (75%) continue to practice in medically underserved communities. Funding for this proposal will allow us to use our expertise to build a comprehensive, collaborative, experiential curriculum to prepare family medicine and primary care internal medicine residents in skills necessary to lead systems improvement and change in safety net practices. Project Objectives 

• Residents will review key concepts of the continuous quality improvement process and apply them to their clinical practice. o Residents will review and define health disparities and health care disparities and describe how quality improvement and systems improvement might help narrow disparity gaps. 
• Residents will develop skills in team building, team leadership, and team membership and identify key members of an interprofessional, interdisciplinary team with which to collaborate on a systems improvement project. 
• Residents will develop skills in engaging patients, families, and community organizations in order to engage them and incorporate their perspectives in systems improvement. • Using the skills developed, and given information on their patient panel, practice clinical reports, and system-wide data, residents will collaboratively design and participate in a systems improvement project. o Residents will work in close partnership with faculty mentors from the core residency faculty as well as from among the leadership of community-based health centers. 
• Residents will reflect on the improvement projects and assess their potential for true systems change through evaluation and reporting on measures of performance, practice change, and sustainability.  Our evaluation will assess three categories of outcomes: 1) Learner-centered: e.g., resident knowledge, self-rated competence, curriculum evaluation; 2) Project- and patient-centered: e.g., completion of a PDSA cycle, quality of care metrics; and 3) Workforce-centered: e.g., tracking of graduate roles and activities. The proposed curriculum will be taught longitudinally in the second and third years of residency training; over the five years of grant funding, it will include a total of 130 individual trainees (86 in FCMRP and 44 in PCIMRP).