The importance of educating the next generation of patient safety advocates goes beyond ensuring sustainability of current efforts to improve patient care. Engaging anesthesiology residents and practicing anesthesiologists in patient safety and quality improvement (PSQI) projects harnesses their creativity, enhances their understanding of patient care processes, and empowers them to initiate change. Anesthesiologists in training, as well as those who have just completed training, often have novel ideas about how to improve patient safety due to their ability to view processes from a fresh perspective. However, they may feel intimidated by the complexity of the medical system. When trained in methods for adverse event analysis, residents can develop safety-focused quality improvement (QI) projects to effect systemic change that can benefit them and their patients.

Anesthesiology residents should be encouraged and mentored in PSQI efforts for multiple reasons. All residents are required by the Accreditation Council for Graduate Medical Education (ACGME) to participate in interprofessional PSQI activities, such as root cause analyses or other endeavors that include analysis, formulation, and implementation of improvement.1 Trainees may be especially concerned about patient safety given their inexperience and may not understand that adverse events are often the result of systems defects rather than individual culpability. Training in PSQI projects helps them understand systems causes of patient safety issues. Residents, in particular, are crucial to these efforts as they can look critically at workflows without historical bias and provide novel ideas about how processes can be improved. Engaging in a safety-focused QI project can help residents understand the complexity of the perioperative workflow and empower them to enact change. This skillset can translate into the career-long pursuit of improved safety. Being involved in patient safety initiatives may also dispel the myth that QI is focused solely on cutting costs.2 

Residents, as well as new graduates, may be the ideal cohort to engage in PSQI, as they have enough clinical experience to understand the gap between actual care and ideal care. They likely will not be as entrenched in practice patterns as more senior clinicians who may be reluctant to change or who have been discouraged by previous improvement efforts. On the other hand, attempts to teach medical students these concepts have often proved ineffective, as students frequently lack the breadth and volume of clinical experience to appreciate system complexities and the context in which PSQI work takes place.3 

PSQI education should include two components: a didactic curriculum and experiential learning with a project.4 The concepts taught via these two methods, as well as exposure to safety culture through faculty mentorship, are summarized in the Figure. The curriculum provides a foundation in PSQI terminology, the principles, and tools for adverse event analysis. It should be tailored to the concerns of anesthesiologists so residents will understand the relevance to their working environment.5 Longitudinal projects deepen their understanding of systems processes while empowering them to improve patient safety.

Figure: Elements of PSQI education.

Figure: Elements of PSQI education.

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The curriculum should include the following topics:

Safety culture: The perception of an individual's psychological safety in recognizing and responding to vulnerabilities in their hospital system. This includes understanding how interactions between human factors and complex systems lead to potential for error or adverse events and how mitigating these risks occurs.

Adverse event analysis: Methods such as root cause analysis, the “five why's,” and fishbone “Ishikawa” diagrams help drill down to the system factors leading to patient safety issues.

QI versus research: The differences between these two related but distinct fields should be clarified. Research seeks to contribute to generalizable knowledge, whereas QI is the implementation of best practices (often directly from research) in a specific environment.

QI processes: Learners need exposure to structured approaches to implementing a new QI process, such as Plan-Do-Study-Act cycles (e.g., AHRQ).6 

Metrics: Residents should learn the strengths and weaknesses of process, structure, and outcomes measures in determining whether improvement is detectable.

Interpreting data: Learners should develop an understanding of run charts, control charts, and other tools commonly used in QI projects to know if a change resulted in improvement.

Change management skills: While residents are well positioned to fight entrenched practice patterns, they can feel powerless to alter the practice of more experienced providers or systemic norms. Along with strong mentorship, learning strategies to influence behavior will position them for success in leading change.

Learning theoretical concepts is insufficient to educate residents in how to approach PSQI; experiential learning with a project is essential and mandated by the ACGME.7 Finding an appropriate project for residents to work on can be difficult. Resident engagement is higher when the endeavor originates with their own ideas.2 However, some of their ideas may be too ambitious to be realistic. Change is difficult, and change that impacts multiple groups is even more challenging. Helping residents choose a feasible project that aligns with hospital or department goals will increase their chance of success.5 

Trainees often have preconceived notions of quality improvement and may approach projects with a solution already in mind. Successful delineation of relevant systems issues requires a shift in mindset to use improvement-focused tools. Problems should be approached with genuine curiosity, stakeholder buy-in, process mapping, data collection, and implementation science. Residents often want to develop a protocol or jumpstart an educational program. However, these are not PSQI endeavors by themselves, as the PSQI work requires investment in sustainability or repeat Plan-Do-Study-Act cycles.

Regularly scheduled meetings with teams, mentors, and PSQI coaches are essential to check both understanding of PSQI principles and project progress. PSQI projects are dependent on data acquisition; baseline and postintervention data are needed to assess impact. This can be greatly facilitated by utilizing departmental data analysts.

With careful selection of an appropriate project, long-term engagement by residents, and strong mentorship, a PSQI project can be worthy of presentation at a national conference. This can be especially beneficial as feedback from those outside of the organization can help provide previously unrecognized insights into the strengths and weaknesses of the project, with opportunities for improvement. This type of recognition can be rewarding and may encourage future efforts in patient safety.

“Trainees may be especially concerned about patient safety given their inexperience and may not understand that adverse events are often the result of systems defects rather than individual culpability. Training in patient safety and quality improvement projects helps them understand systems causes of patient safety issues. Residents, in particular, are crucial to these efforts as they can look critically at workflows without historical bias and provide novel ideas about how processes can be improved.”

Resident engagement in PSQI can be challenging due to lack of time, the need to balance critical thinking skills versus standardization of care, data availability, health care system alignment, and appropriateness of faculty mentors. The demands of individual rotations and other training expectations can outweigh perceived benefits of engaging in a longitudinal PSQI experience.2 Even when residents are invested in a project, they may be unable to attend meetings due to clinical duties. Astute mentorship can reduce some of these barriers, and an institutional focus on safety culture will emphasize the importance of PSQI endeavors.

Residency training hones critical thinking skills through individualized anesthetic plans. As trainees pursue PSQI work, they can be confused or discouraged in their implementation efforts by colleagues who see process standardization attempts as threats to independent thinking.8 Mentors can help residents understand the nuance between protocols versus pathways or complete standardization versus care plans that need to be tailored to individual patient needs.

In addition, obtaining data can be tedious, with limited support available for automated data retrieval. Departments that invest in data support beyond what is offered by their health care systems may reap the rewards of having stronger clinician engagement in PSQI through more efficient access. Where this is not available, finding creative ways to tie resident projects to hospital-wide initiatives can bridge this gap. Patient safety initiatives mandated by institutions traditionally focus on regulatory imperatives such as optimizing chronic disease prevention and avoiding infectious complications. Often, little bandwidth remains to support PSQI interests of individual groups, even though addressing challenges in providing optimal care may be aligned with the same safety priorities.9 For example, optimizing intraoperative glycemic control can be directly tied to a hospital-wide initiative to improve postoperative wound infection rates.

PSQI work seems less relevant to trainees who perceive that faculty lack the expertise to be effective PSQI project mentors.3 Because of the lack of visibility of PSQI work in academic departments, many residents may not see it as a worthwhile academic pursuit.8 It is vital that PSQI work become more consistently recognized as scholarly activity for promotion in the academic setting. This will also foster an environment where faculty pursue their own training in PSQI, allowing them to be more effective mentors. A department can use formal training courses for all faculty members or train some members, who then serve as mentors/coaches for their own colleagues.

Nurturing the next generation of patient safety advocates requires sustained investment in PSQI education during anesthesiology residency. Residents and new attendings are the ideal cohorts to teach these concepts. Learners need both foundational knowledge of PSQI principles and mentored experience implementing QI tools in a project to gain the understanding and confidence to be patient safety champions throughout their careers.

Candace Chang, MD, MPH, ASA Committee on Patient Safety and Education, ASA Committee on Global Health, Director of Non-Operating Anesthesia at University of Utah, and Associate Professor (Clinical), University of Utah, Salt Lake City, Utah.

Candace Chang, MD, MPH, ASA Committee on Patient Safety and Education, ASA Committee on Global Health, Director of Non-Operating Anesthesia at University of Utah, and Associate Professor (Clinical), University of Utah, Salt Lake City, Utah.

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Ian R. Slade, MD, ASA Committee on Trauma and Emergency Preparedness, Assistant Professor, Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, and Section Chief for Clinical Quality and Safety in Anesthesiology, Harborview Medical Center, Seattle, Washington.

Ian R. Slade, MD, ASA Committee on Trauma and Emergency Preparedness, Assistant Professor, Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, and Section Chief for Clinical Quality and Safety in Anesthesiology, Harborview Medical Center, Seattle, Washington.

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Scott Lindberg, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Transplantation, ASA Committee on Resident and Medical Students, Vice Chair, UNOS Membership and Professional Standards, and Shareholder, US Anesthesia Partners, Houston Methodist Hospital, Houston, Texas.

Scott Lindberg, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Transplantation, ASA Committee on Resident and Medical Students, Vice Chair, UNOS Membership and Professional Standards, and Shareholder, US Anesthesia Partners, Houston Methodist Hospital, Houston, Texas.

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James Gregory (Greg) Balfanz, MD, ASA Committee on Patient Safety and Education, ASA Committee on Patient Blood Management, Associate Professor and Vice Chair of Patient Safety and Quality Improvement (for Department of Anesthesiology), University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.

James Gregory (Greg) Balfanz, MD, ASA Committee on Patient Safety and Education, ASA Committee on Patient Blood Management, Associate Professor and Vice Chair of Patient Safety and Quality Improvement (for Department of Anesthesiology), University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.

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