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more passive role in this strategy. In contrast, bottom-up approach begins with a
resident in the trenches who identifies a patient safety or quality issue. This approach
allows residents to identify issues that otherwise might be missed by the manage-
ment, permits residents to see the benefits of their efforts, and ensures that residents
are personally invested in the success of their project [ 57 , 61 ].
Faculty Participation
While residents are good at identifying patient safety and quality issues, faculty
participation is critical to make a complex, sustained intervention [ 79 ]. The role of
faculty members is to contribute their knowledge and mentorship, which may be
challenging if they lack formal training in QI. In this situation, faculty members
devoted to assess and improve their own clinical outcomes may serve as good role
models to help residents identify and carry out an intervention. Given the increased
pressure to deliver high-value care, many organizations are hiring QI professionals
and support staff. In the academic setting, this presents an opportunity for faculty
members devoted to QI to negotiate this responsibility into their workload so that
they may be compensated for their involvement [ 5 , 66 , 71 ]. Institutions have also
reported success by offering faculty credit for Maintenance of Certification as a
valuable incentive for their participation [ 6 ].
Institutional Buy-In
Perhaps the most challenging barrier to implement a QI program is institutional
buy-in; success is dependent on interdisciplinary communication and compromise.
Effective implementation of almost any QI intervention requires the support from
the administrative staff and senior officials within the organization at both the insti-
tutional and Graduate Medical Education office level [ 50 ]. Educators from Kansas
City University (Kansas City, Missouri) [ 49 ] reported the value in linking practice-
based learning and improvement to program and institutional accreditation, noting
that it increased the perceived value of involvement in a QI curriculum.
Conclusion
QI efforts benefit the institution implementing them, the employees in the orga-
nization, and the patients they are designed to serve. The application of practice-
based learning and improvement in conjunction with a QI curriculum permits
resident and faculty members to directly apply the ACGME core curriculum
competencies. Depending on the level of involvement within an institution, a QI
project may be implemented in a top-down or bottom-up approach. An effort
should be made to include faculty members who can serve as mentors, as well as
multidisciplinary staff within the hospital to deliver a comprehensive solution.References
- Amo MF. Root cause analysis. A tool for understanding why accidents occur. Balance
(Alexandria, Va). 1998;2(5):12–5. - Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The veterans affairs
root cause analysis system in action. Jt Comm J Qual Improv. 2002;28(10):531–45.
S. Helo and C. Welliver