How I Teach
“How I Teach” is ASH Clinical News’ forum for sharing best practices
in teaching hematology to medical students, residents, and fellows.
We invite essays providing insight into teaching and modeling clinical
practice (history-taking, the physical exam, informed consent, giving
bad news), successful research mentoring, disease-specific tips, or more
general advice. In this edition, Colleen Morton, MBBCh, MS, medical
director of Clinical Coagulation at Regions Hospital, HealthPartners, and
an assistant professor in the Department of Hematology, Oncology, and
Transplantation at the University of Minnesota in Minneapolis, talks about
teaching quality improvement.
HOW I TEACH QUALITY
s clinicians, we are charged with providing
patient care, and we also have a duty to
improve care. Quality improvement –
though it is probably most commonly
thought of in terms of cost-containment
– is essentially an opportunity to improve patient care. While cost-containment is certainly
a goal, improving the full patient experience is always
our objective. What more reason do we need to make
quality improvement a part of training?
Quality is quickly becoming a larger part of our lives
as hematologists. Programs from the Centers for Medicare & Medicaid Services (CMS) like Hospital ValueBased Purchasing, the Physician Quality Reporting
System, and the Merit-Based Incentive Payment System,
are changing the way we practice.
Right now, these measurements don’t include many
hematologic parameters, but it is the way we’re all moving. We have to prove that we are delivering quality care
more and more.
Historically, quality has not been a standard part
of the training curriculum. Quality improvement – an
evolving cycle of identifying a problem, planning a solution, executing that plan, and evaluating its progress – is
a new concept for medical educators.
Learning to Teach Quality
Randy Hurley, MD, head of the Department of Hematology and Oncology at HealthPartners, and I joined
other University of Minnesota faculty in completing a
Teaching For Quality Program (Te4Q). The Te4Q program, sponsored by the Association of American Medical Colleges, trains clinical faculty on how to effectively
teach quality improvement.
We learned what we needed to have in place to
implement a quality improvement training program for
our hematology/oncology fellows, how to evaluate trainees, and, in turn, how to have the trainees evaluate us.
The biggest hurdle to overcome, though, was actually getting people to understand the value of this kind
of training! Our residents and fellows have been raised at
academic institutions, where the emphasis has always been
placed on research and publishing. Quality improvement
hasn’t been thought of in the same way as research.
I only started to appreciate the value of quality
improvement when I participated in a Quality Improve-
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ASH Clinical News
With Colleen Morton, MBBCh, MS
ment Advanced Training Program at the Park Nicollet
Institute and realized that the quality improvement
project I planned had failed miserably.
In an effort to reduce inappropriate testing for
heparin-induced thrombocytopenia (HIT) at my institution, I developed an electronic medical record (EMR)based decision support that asked clinicians to calculate
patients’ 4Ts score before ordering the HIT test. My
goal was to reduce the number of HIT tests ordered and
to reduce inappropriate testing. At first, the numbers
suggested that the project was successful: the number of
tests ordered was reduced by 17 percent and the number
of positive tests increased by 50 percent.
But, when I looked deeper into the orders and
medical records and followed the proper quality improvement process, I discovered that, in reality, I had
accomplished nothing! Half the tests ordered were still
inappropriate, and a survey of clinicians revealed that
two-thirds of providers were not using the decision tool
or the 4Ts score. Furthermore, 25 percent of patients
who had a positive HIT result did not receive treatment.
Following the quality improveme nt process, I reevaluated the project to determine what went wrong. The
flaw of the protocol was that clinicians could ignore what
I added into the EPIC system to try to alter practice. Also,
we didn’t track the use of the tool or of the 4Ts score, but
just assumed that people would embrace it.
Today we have a newly designed tool that forces
clinicians to run the 4Ts score and, when placing the
order for the HIT test, it directs clinicians in how to
administer therapy.
This project taught me a basic principle of quality
improvement: You don’t know what you’re doing until
you can measure it properly.
How We Teach Quality Improvement
While our program is still in its infancy, we are lucky
to have access to a training program for fellows and
residents from Park Nicollet. This includes an online
training component and lectures. With faculty support,
we also require the fellows to execute a quality improvement project, so it’s a hands-on approach in which
learners apply knowledge to real-world clinical practice.
This is a crucial element, because if trainees don’t
go through the process themselves, they aren’t likely
to understand the value of quality improvement
training. Having trainees design and implement their
own projects helps them grasp the reasons behind
quality improvement, the importance of these efforts,
and how to use these tools in their clinical practice
going forward.
When we work with fellows, we help design the
project, implement it, and then collect and analyze
the data. The fellows are welcome to come up with
their own projects, but we also have a list of potential
projects that we think would be good for the fellows
to tackle. We meet with a statistician during the initial
planning stages so that we can have his or her input
from the beginning, to ensure that we’ll end up with
usable, relevant data to determine if the project was
successful. Even if a project is unsuccessful, we still
learn about other aspects that might have been overlooked in the initial stages.
How Our Fellows Are Tackling
Quality Improvement
I am working with four fellows on their quality
improvement projects. One is looking at improving
fibrinogen testing in patients who receive massive
transfusions. As part of a Transfusion Committee
review, we discovered that only 20 to 30 percent of
patients who received a massive transfusion had
fibrinogen activity tested.
Fibrinogen, of course, is crucial for clotting, so if a
patient’s fibrinogen level is low, he or she won’t clot. We
also discovered that 38 percent of the patients in whom
fibrinogen was measured had low fibrinogen levels. Of
these patients, 40 percent did not receive cryoprecipitate
to increase their fibrinogen levels.
We designed an EMR-based tool that automatically
orders labs (including fibrinogen activity testing) as part
of the massive transfusion protocol (MTP). The EPIC tool
is built with a best-practice alert: If the results of the labs
show the fibrinogen activity is low, the clinician is alerted
to order two units of pooled cryoprecipitate. This is an
ongoing project; we are collecting data (including patient
demographics, lab results on admission, anticoagulant
use, use of blood and other products), and plan to analyze
the effect that this amended protocol has on fibrinogen
testing, cryoprecipitate use, and outcomes.
In another example, a fellow is examining the placement of inferior vena cava (IVC) filters in non-trauma
May 2016