Special Report
patients are referred for suspicion of angina, with only 39.2 % of referred patients exhibiting significant obstructive coronary disease.23
Finally, in the subset
of patients undergoing percutaneous coronary intervention who are at the highest risk of bleeding complications, registry data demonstrate that only 14.4 % received bleeding avoidance strategies such as vascular closure devices and use of bivalirudin24 for improvement.
—a clear opportunity
Our Approach to Managing this Challenge— Teaching the Language and Concepts of Quality Improvement and Patient Safety As directors of cardiology training programs, we are obligated to position our graduates for clinical/academic practice and board eligibility. Many of us probably lack sufficient expertise to provide sophisticated training in the specific area of quality improvement and patient safety. There are no clear guidelines other than the existing ACC statements described above, and a review of publications describing effective teaching of these concepts to trainees shows that data are limited to medical students and resident-level physicians.25
As such, many fellowship
programs may have concluded, as we have, that these efforts to educate and improve clinical outcomes are best addressed at a department,26
hospital, or medical center
level. Under the auspices of the University Medical Center’s Quality and Patient Safety Office, the Evidence-based Practice Policy Group has produced practice resources for common cardiovascular diseases (acute coronary syndromes, heart failure, atrial fibrillation, infective endocarditis prophylaxis). These incorporate the ACC/AHA guidelines and ACC quality measures into a single document, available on the hospital intranet. When referenced by fellows on the wards or in clinics, they serve as a quick reference for both treatment and documentation. As a complement, fellowship leadership have partnered with the administration of the Richard M Ross Heart Hospital, our free-standing 150-bed facility containing all of our diagnostic and treatment laboratories, to provide a monthly morbidity and mortality conference focused on quality and safety. This is a modification of the traditional ‘M and M’ structure where biopsy or post-mortem data are used to refine diagnostic skill, focusing instead on guideline-based decision-making and opportunities to learn from complex clinical situations that led to suboptimal outcomes. Fellows also receive a yearly lecture, as part of their core curriculum, that is focused on the basic structure and current state of the healthcare system in the US.
For those with specific interest, our Office of Graduate Medical Education has recently created a pilot four-week
104 Cardiology Fellowship Education
The American Heart Hospital Journal
rotation—a ‘Quality Elective’—where house staff are immersed in a combination of self-driven reading, participation in medical center committee work, and completion of a targeted quality improvement project focusing on error investigation and root-cause analysis.
These are only rudimentary first steps, but the field itself is continually evolving and the attainment of ‘quality’ care is a moving target. Most important is to provide our fellows with the skills to become lifelong learners in their clinical practice with quality and safety in context—“to do their work and to improve it.”27
In the coming academic year
we hope to develop a curricular framework for fellows to undertake their own small-scale quality improvement projects as a learning tool, probably enrolling in and using components of the ACC’s NCDR—Acute Coronary Treatment and Intervention Outcomes Network (ACTION), Carotid Artery Revascularization and Endarterectomy (CARE), CathPCI (diagnostic catheterizations and percutaneous coronary interventions), ICD, Improving Pediatric and Adult Congenital Treatment (IMPACT), and PINNACLE (
www.ncdr.com). Conversely, a parallel priority is to educate them about the disadvantages and shortcomings of quality/performance measures and future implications in their practice. While well-intended, the phenomenon of ‘pay for performance’ has also been found to have unintended negative consequences in the state of Massachusetts, as an example. At the least, physicians are finding themselves being relegated to lower tiers of insurance reimbursements due to an opaque system rating their care by performance measures and, what is most concerning, creating an environment where physicians shy away from complex cases to avoid being associated with poor outcomes.28
All of these issues will continue to evolve since the passage of the Patient Protection and Affordable Care Act in March, 2010, making familiarity with terms and concepts highly important to graduating cardiology fellows preparing to enter practice.
Conclusions from Our Fellowship Training Program
Clearly, the training of future specialists in cardiology, as with all of medicine, becomes increasingly complex with each passing year. At The Ohio State University Medical Center, much of our recent focus has been adapting to increasingly complex training requirements from the ACC, managing the demands imposed by regulations issued by the ACGME, and providing fellows with an adequate introduction to quality improvement and patient safety concepts. For program leadership, fellowship committee members, and key faculty, these efforts have been an
Winter 2011
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