333Institutional/Hierarchical Factors
Institutional factors can also limit the success of QI/PS initiatives. This may be related
to lack of institutional support or institutional “buy-in” for a given idea [ 32 ]. Institutions
may vary widely on how much value is placed on QI [ 4 ]. Another factor may be related
to the hierarchy of medicine and healthcare preventing effective communication.
Ginsberg et al. (2013) suggested that there is impaired communication between nurses
and physicians related to hierarchy differences at some institutions. Trainee communi-
cation may also be impaired [ 38 ]. Teamwork must be emphasized to ensure the highest
possible quality of care and adequate communication.
Lack of Faculty Mentors
Some sources have suggested that there is an overall lack of qualified mentors avail-
able for trainees to support QI/PS projects. This may be related to inadequate
knowledge of quality improvement by faculty [ 4 , 14 ] versus a lack of mentors with
interest in quality improvement-related projects.
Limitations in Evaluating QI/PS Curricular Efforts
Many QI/PS attempts at curriculum reform are difficult to assess and analyze
because their outcomes are not easily quantifiable and, particularly in local proj-
ects, are tailored to specific needs by that institution. As many of these observa-
tional studies lack a control group, it is impossible to say definitively whether or
not a given intervention was truly successful or not [ 2 ]. In this way, it is often
difficult for QI-related projects and ideas to gain traction with other training
programs.
In addition, it is thought that acquiring meaningful data for QI/PS measures
can be challenging. Many database-driven large-scale projects are often retro-
spective and fail to show any clear benefit on health outcomes [ 2 ]. In the Medicare
patient population, the CMS has attempted to improve data reporting quality by
certifying data registries as qualified clinical data registries (QCDR). Many of
these organizations are national data registries mentioned earlier (ACS NSQIP,
AQUA, AHRQ, etc.), and other specialty-specific governing bodies are included
in this group of data registries [ 39 ].
Resources
There are many resources available at the disposal of students, residents, and faculty
to utilize for quality improvement projects. One of the most commonly used and
largest available resources is the American College of Surgeons National Surgical
Quality Improvement Program (ACS NSQIP). ACS NSQIP is a nationally validated
risk-adjusted outcomes-based program that is designed to measure and improve
19 Quality Improvement and Patient Safety