Quality improvement, quality measurement and medical education: a brewing culture clash?

To cite: Margolius D, Ranji SR. BMJ Qual Saf 2015;24:477–479. Front-line healthcare workers are the first to witness the everyday errors that occur in patient care—when a medication dose is delayed, or when an unnecessary test causes harm. Residents and interns are those front-line workers in academic medical centres, working for up to 80 h a week for at least 3 years (in the USA). Just as hospitals owe their patients a commitment to improving care and reducing errors, medical educators should ensure their trainees learn the skills required to improve quality and safety for the patients they will care for during and after training. In this issue, two accompanying viewpoint articles describe the benefits created from increased emphasis on quality improvement in the training setting—and the potential downside. One piece reflects the perspective of a resident in training who yearns for more opportunities to learn quality improvement. The other articulates the concerns of a physician working in a large system who feels the burden of excessive quality metric reporting requirements. Together, the authors suggest how medical educators and quality-improvement specialists can help trainees learn to be agents of change while balancing the need to preserve the traditional values of medical education. The first viewpoint introduces Lean methodology as an avenue for exposing more trainees to quality improvement and improving care in general. Lean is a management method derived from Toyota’s method for efficient production of defectfree automobiles. This approach to system improvement, when applied to academic medical centres, offers possible solutions as well as further challenges for residency education. Many healthcare systems have achieved success with their implementation of Lean. Virginia Mason Medical Center provides a well-known example—the hospital has even branded its own version of Lean called ‘Virginia Mason Production System’. Facing financial struggles and a medical error that led to a premature death in the early 2000s, the medical centre adopted Lean, and has since become a topperforming hospital in quality and safety. When a hospital adopts Lean as its management philosophy, its leaders hope to create an environment of continuous learning and improvement, seek out and reduce delays or surplus, which do not add value to the patient, and encourage all employees to become problem solvers. Healthcare systems that embrace Lean invest resources to identify processes that contain unnecessary steps, resulting in longer waits or higher costs for their patients. Eliminating waste in this fashion reduces inefficiencies and frees up resources for other priorities. The Lean approach offers a promising alternative to the usual way of systems improvement in academic medical centres. When implemented appropriately, Lean prioritises the input of front-line workers, and values their input in identifying and solving problems. Despite being on the front lines of patient care, trainees’ viewpoints often go unheard in qualityimprovement efforts. When their input is solicited, they are unlikely to see a suggestion come to fruition because they rotate services frequently. Lean, on the other hand, engages the people who are doing the work in the change process. Rapid process improvement workshops and kaizen events last only a few days—participants can suggest a change and then witness the transformation days later. Lean’s emphasis on reducing waste should benefit both patients and trainees, as workflow inefficiencies eliminated by Lean methodology should improve the patient experience while simultaneously allowing for increased dedicated educational time. EDITORIAL