The ASCO Quality Training Program: designing and implementing a medical specialty society-based quality improvement training program.

The launch of the ASCO Quality Training Program (QTP) is the next step in the evolution of ASCO quality initiatives; the QTP moves beyond the society’s quality measurement focus to implement a novel approach to practice improvement. ASCO developed the Quality Oncology Practice Initiative (QOPI) as a measurement program to allow practices to assess the quality of care that they provide their patients, test their performance against a variety of process measures, and compare their result with national benchmarks. It was expected that QOPI participants would identify areas where improvement opportunities existed, share results with their practices, implement changes, and rapidly improve their performance as demonstrated by future performance on QOPI measures. Further, it was imagined that these improvements in QOPI measures by individual practices would be sustained over long periods of time because of permanent fixes put into place.1 In hindsight, it was naive to imagine that simply sharing the results of process measures with QOPI participants would result in sustained improvement in practice performance. The results of a large analysis of QOPI practices that participated in more than one round of data collection show only small gains in composite performance over time, and these improvements were largely driven by only a few measures.2 Large, sustained improvement—which is what the founders of QOPI had imagined—was simply not identified. There is no doubt that some individual practices have meaningfully improved their performance, and scattered reports of improvement using QOPI measures have been published. For example, the Michigan Oncology Quality Consortium (MOQC), a large group of independent medical oncology practices, has demonstrated important improvement in end-of-life care.3 MOQC, however, is a high-functioning quality improvement collaborative that trained practices to use the tools of quality improvement to achieve their success. What ASCO and QOPI have recognized is that quality measurement alone does not reliably result in quality improvement. Two generations of quality scientists have demonstrated unequivocally that improving a process does not happen simply by exhorting staff to “do better.” A philosophy of improvement developed first in the manufacturing industry and then slowly, but surely, found its way into medicine. Physician leaders such as Donald Berwick, MD, MPP, Paul Batalden, MD, and Brent James, MD, sought out and studied with founders of industrial improvement science such as W. Edwards Deming and adopted proven principles and tools to improve medical care.4 The need to improve care, along with the requirement for a structured approach to improvement, is slowly being recognized by the medical community. The Accreditation Council for Graduate Medical Education (ACGME) now expects residents to be trained in quality improvement and to be involved in quality-related projects. The Next Accreditation System, which the ACGME now uses to track program adherence, and which became operational this year, assesses “how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes.”5 The American Board of Internal Medicine has changed the requirements for recertification to mandate that physicians undertake a quality improvement project (Maintenance of Certification Part IV) at least every 5 years.6 Both organizations make an implicit assumption that residency and fellowship program directors and practicing physicians have sufficient knowledge to successfully plan and direct quality improvement programs, yet this is not a standard part of the curriculum for most medical schools and is only now becoming an area of interest for the Association of American Medical Colleges. Educational programs such as the QTP offer a structured approach to process improvement that supports the need for lifelong physician learning and fill gaps that currently exist in medical school curricula. It is now generally accepted that, akin to medical education, training in quality improvement requires two distinct components: knowledge acquisition and skills development. Conceptual learning is required to understand the importance of, and context for, quality measurement and quality improvement, and is essential to establish knowledge of the science of improvement. Standard pedagogical learning approaches suffice to become knowledgeable in these areas. For the development of skills, however, experiential learning is essential, requiring hands-on training and expert coaching. Experiential learning is classic case-based learning, but applied to processes or systems, rather than to patients (Figure 1).7 Special Series: Quality Care Symposium