- Email: [email protected]
Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors
Author's Accepted Manuscript Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors Justin B. Ziemba, MD, Brian R. Matlaga, MD, MPH, Christopher D. Tessier, MD
PII: DOI: Reference:
S2352-0779(17)30172-3 10.1016/j.urpr.2017.08.001 URPR 308
To appear in: Urology Practice Accepted Date: 8 August 2017 Please cite this article as: Ziemba JB, Matlaga BR, Tessier CD, Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors, Urology Practice (2017), doi: 10.1016/j.urpr.2017.08.001. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Title: Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors Authors: Justin B. Ziembaa, MD; Brian R. Matlagab, MD, MPH; and Christopher D. Tessierc, MD.
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Affiliations: a Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. b Department of Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD. c Departments of Urology and Medical Informatics, Oregon Health & Science University, Portland, OR.
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Corresponding Author: Justin B. Ziemba, M.D. Division of Urology Perelman Center for Advanced Medicine West Pavilion, 3rd Floor 3400 Civic Center Boulevard Philadelphia, PA 19104 Email: [email protected] Phone: 215-662-2891 Fax: 215-662-3955
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Email Addresses: a [email protected] b [email protected] c [email protected]
Key Words: Quality Improvement; Quality of Health Care; Education; Internship and Residency; Urology
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Conflicts of Interest: The authors did not receive payment from a third-party for this work. BRM discloses that he is a consultant for Boston Scientific Corporation, but that this relationship is not related to this work. JBZ and CDT have no commercial or financial relationships related to this work to report. The authors have no patents related to this work. There are no other conflicts of interest to report.
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Acknowledgements: We would like to thank the Society of Academic Urologists for partnering with us and helping to distribute the survey invitation to its membership. Abstract Word Count: 249
Manuscript Word Count: 2,517
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education
Abstract:
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Purpose: A key physician competency outlined in the Urology Milestone project is engagement in quality improvement (QI). Despite this mandate, little is known about the attitudes of urology residency program directors (PDs) regarding the relative importance of QI education. Therefore, we performed a national survey of PDs.
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Methods: A 25-item survey was developed to investigate PD knowledge and training in QI methodology, participation in QI related activities, curriculum support for resident QI educational activities, and attitudes regarding the relative importance of QI education. The survey was sent via email (11/1/2016) to all PDs affiliated with the Society of Academic Urologists (n=116/134; 87% of ACGME programs).
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Results: A total of 36 PDs returned a completed survey for a response rate of 31% (36/116). Only 22% (8/36) of PDs reported receiving formal education or training in QI methodology. A total of 44% (16/36) of PDs reported that their program offers formal education or a curriculum in QI methodology for their trainees. PDs expressed a strong desire for residents to learn QI methodology (positive response, 32/36; 89%) and understand how to apply it to conduct a QI project (positive response, 30/35; 86%). PDs strongly believe that a urology-oriented QI curriculum would be a valuable resource (positive response, 31/36; 86%) with a need for support from our professional society (positive response, 29/36; 81%).
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Conclusion: A minority of programs have QI education available for residents. However, PDs agree that QI is an integral part of residency training, which should be promoted by our profession.
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education Introduction:
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With the release of the Institute of Medicine’s “Crossing the Quality Chasm” report in 2001, delivery of high quality health care in America became a national priority.1 To achieve this goal, the report outlined several transformative recommendations, including transitioning the health care workforce.1 One step in this process was a redesign of clinical education and training to prepare professionals for new methods of health care delivery.1
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Contemporaneously, the Accreditation Council for Graduate Medical Education (ACGME) in 1999 developed Core Competencies, which would serve as the basis for resident education across all specialties.2 The six Core Competencies include patient care, medical knowledge, practice based learning and improvement, interpersonal skills, professionalism, and systems-based practice.2 By developing educational outcomes for each of these domains, it became possible to assess residents individually and residency programs collectively.2 In fact, the ACGME’s Core Competencies served as the basis for the development of the Next Accreditation System (NAS), which began with phased implementation in 2013.3
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Under the NAS, specialty-specific educational milestones are developed for residents who are expected to demonstrate a progressive level of achievement from program entry to graduation.3 Urology was one of the first specialties to adopt the NAS.3, 4 In consultation with the American Urological Association (AUA), a total of 22 subcompetencies each with 1-2 milestones per achievement level across the 6 core domains were created.4, 5 Of these, 3 directly address the delivery of quality medical care including SBP2-value, SBP3-patient safety (PS), and PBLI6-quality improvement (QI).5 In addition to the specific milestones, the NAS requires that the learning environment created by the sponsoring institution also be assessed.3, 6 Under the Clinical Learning Environment Review (CLER) Program, 6 domains are examined with an emphasis on support for PS and QI activities.6
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Despite this mandate by the ACGME under the NAS that continuous improvement in the health care delivery system be an educational priority, early evidence suggests that programs and sponsoring institutions are falling short.7-9 In response, the ACGME has re-prioritized PS and QI in their updated Common Program Requirements.10 Specifically, residents must have access to training in QI methodology, quality metrics, and participation in QI activities with the goal of being able to apply these skills to their future unsupervised practice.10
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Despite the emphasis by the ACGME, it is unclear how these requirements are translated into an educational curriculum for urology residents. Urology residency program directors (PDs) are in a unique position as they control the educational content. However, to date, little is known about the attitudes of PDs regarding the relative importance of QI education and participation to a resident’s overall training. In addition, it is unclear what resources are available at the program level for QI education or projection participation. To answer these questions, we performed a cross-sectional survey of urology residency PDs affiliated with the Society of Academic Urologists (SAU). By conducting this needs assessment, we hope to gather important information that may be useful in the design of QI training programs for urology residents.
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Methods: Survey Design
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Unfortunately, no validated survey instrument exists to assess QI educational resources within a residency program. However, a literature review identified three prior similar needs assessments that were performed within the specialties of physical medicine and rehabilitation (PM&R), pediatrics, and general surgery.11-13 The survey content from these publications was analyzed to determine if it would be applicable for inclusion in our survey instrument targeting urology residency PDs. Applicable content served as the foundation to build our survey instrument. Additional content was then added by an expert in health policy for the delivery of quality medical care (author CDT) and an expert in quality improvement education (author JBZ).
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The final 25-item survey aimed to investigate PDs knowledge and training in QI methodology, participation in QI related activities, curriculum support for resident QI educational activities, and attitudes regarding the relative importance of QI education to overall resident training (see supplement 1). Demographic items included PD year of urology residency completion, total number of residency positions, residency program structure, number of clinical faculty within the department/division, and program location (i.e. AUA Section). A free-text comment option was available at the end of the survey to gather additional qualitive information/opinions (N=3; see supplement 2 for complete responses). Survey Sample
Data Analysis
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The SAU is an organization representing university affiliated urologists, urology chairpersons, and urology residency program directors. Under an agreement with the SAU, the survey instrument was distributed via email to its membership. At the time of survey distribution in 11/1/2016, a total of 116 urology residency programs had a PD who was a member of the SAU. This represented 87% (n=116/134) of all ACGME accredited urology residency programs in the United States. After the initial invitation, 2 reminders were sent via email to increase participation. An introductory statement was included with each invitation to explain the purpose of the survey, that participation was voluntary, responses were anonymous, and that completion implied consent for study inclusion.
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Data was collected and managed using Qualtrics (Qualtrics, Provo, UT) housed at the Johns Hopkins School of Medicine. Questions pertaining to respondents’ attitudes were summarized as a positive (strongly agree and somewhat agree) or negative (neutral, somewhat disagree, and strongly disagree) response. Partial responses were included in the analysis (N=1). To assess for nonresponse bias, we performed a sensitivity analysis comparing the program characteristics between respondents to that of all residency programs in the US with information publicly available through the AUA.14 Univariate statistics were performed with continuous data analyzed with a Student’s T-test and categorical data with a chi-square test. To determine what individual program and PD factors may influence the presence of a QI curriculum, we performed a pointbiserial correlation for interactions between nominal and continuous variables and a phi correlation
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education between nominal variables. Analyses were conducted with IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY: IBM Corp.) with statistical significance set at a p-value of 0.05. Results:
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A total of 36 PDs returned a valid survey for a response rate of 31% (36/116). There were no differences in the distribution of AUA Section, program structure, housestaff number, or faculty size between programs who responded and all accredited US residency programs (all p>0.05). Program characteristics of responding PDs are outlined in Table 1.
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Table 2 outlines the characteristics of the PD and their participation in QI activities. More than half of PDs (19/36; 53%) reported that a urologist recognized as a QI leader is responsible for supervising QI activities within the department. The remaining programs (15/36; 42%) responded that a urologist is simply assigned to that role, regardless of their training or experience in QI.
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Only 44% (16/36) of PDs reported that their program offers formal education or a curriculum in QI methodology for their trainees. Characteristics of the curriculum provided by these 16 programs is outlined in Table 3. Table 4 displays the correlation coefficients between individual program and PD factors and the presence of a QI curriculum.
Discussion:
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PDs expressed a strong desire (positive response, 32/36; 89%) for residents to learn QI methodology during training. Similarly, having residents understand how to apply this methodology to conduct a QI project was also of importance (positive response, 30/36; 83%). PDs strongly believe that a urologyoriented QI curriculum would be a valuable resource (positive response, 31/36; 86%) with a need for encouragement and promotion from urological professional societies (positive response, 29/36; 81%). Specifically, what resources PDs would request from the AUA to support this mission is displayed in Figure 1.
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In this cross-sectional survey of PD affiliated with the SAU, we identified that PDs are not well-trained in the science of QI with less than a quarter confirming formal education. Less than half of urology residency programs sampled offer a curriculum in QI methodology for their trainees. Furthermore, only 38% of the curriculum instructors are urologists with qualifications suitable to be a QI expert or leader. Despite these deficiencies, PDs express an overwhelming desire for their trainees to learn the science of QI with a request from our professional societies to provide support, particularly in the form of a urology-oriented QI curriculum. Although these results are disappointing, they are not surprising. In a recent survey distributed to PDs of general surgery residency programs, only 35% of PDs reported formal QI training, which is close to the number we observed.12 Only 58% of programs reported that their residents participated in QI teams and the median percentage of residents within each program who participated in a QI project outside of morbidity and mortality conference was only 50%.12 This suggests that approximately half of programs facilitate resident learning of QI science, which again is similar to our study. In contrast to our results, the non-surgical specialty residency training programs of PM&R and pediatrics have demonstrated a greater affinity for incorporating QI education.11, 13 For example, in a survey distributed to PM&R PDs, all sampled programs reported that their residents participated in QI projects, 5
ACCEPTED MANUSCRIPT Urology Quality Improvement Education of which 71% were resident-led.11 Similarly, in a survey of pediatric PDs, 85% of sampled programs had a QI curriculum, of which 88% of these required a project.13
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The higher performance of the non-surgical specialties to incorporate a QI curriculum into residency training highlights the gap that needs to be addressed within the surgical disciplines. One barrier is the lower availability of QI training resources tailored to the surgical specialties. In a recent meta-analysis of the literature on QI curriculum for use in graduate medical education, only 24% (12 articles) were specific to a surgical discipline, of which none were related to urology.9
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Although a urology specific curriculum does not yet exist, our colleagues in general surgery with support from the American College of Surgeons (ACS) have produced the Quality In-Training Initiative (QITI).9, 12, 15, 16 This program incorporates a surgery-specific resident QI curriculum, faculty development to train the trainer, and National Surgical Quality Improvement Program (NSQIP) quality reports for residents to track their patient’s outcomes.9, 12, 15, 16
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Unfortunately, merely making a QI curriculum like the QITI program available is not sufficient to make QI an educational priority. There needs to be a commitment from all stakeholders. Our results suggest that there is a strong desire by PDs to include QI methodology training and experiential learning into their residency programs. Despite our correlations not reaching statistical significance, there were modest effect sizes when PDs reported receiving QI education (rφ=0.237), self-identified as a QI leader (rφ=0.333), and conducted QI education themselves (rφ=0.358). This suggests the need to not only train residents in QI methodology, but also the faculty. Our respondents specifically recognized the role that organizations like the AUA should play to catalyze this effort.
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To help facilitate this transformation, we propose several initial steps. First, we recommend the development of urology-specific QI and patient safety resources for education of not only residents, but also practicing urologists. This resource was requested by almost all of the PDs in our survey. Currently, the AUA Core Curriculum, which serves as the foundation of knowledge for all practicing urologists contains no information about quality, safety, or value.17 Therefore, embedding this content within the Core Curriculum would be ideal. We envision the creation of short video modules. First, covering basic terminology, then strategies and tools, and finally, application with case based examples. The cases can highlight how current infrastructure like morbidity and mortality conference can be enhanced with the application of tools for systems based learning.18 By placing this education within the context of urological care that the learner may encounter, it is our hope that this information will be relevant and actionable. Second, the AUA can emphasize the value of QI and patient safety both as beneficial for patients, but also as a means of academic success for residents.19 To achieve this, we recommend highlighting quality, patient safety, and value improvement projects performed by residents through publication in a dedicated, standing subsection of a urology journal. Similar endeavors are already underway in the field of internal medicine through the Journal of Hospital Medicine and American Journal of Medicine.20, 21 Third, we believe that opportunities for students, residents, practicing urologists, and sponsoring institutions to share their work, collaborate, and exchange ideas is critical towards developing and sustaining a culture across the urological community that values improvement in health care delivery. We acknowledge that the AUA has taken steps to achieve this goal with the introduction of a topicfocused Quality Improvement Summit and inclusion of health policy podium and poster sessions at the 6
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Annual Meeting. However, we propose a broader, dedicated, stand-alone yearly conference sponsored by the AUA where attendees can learn the latest science and trends through keynote speakers and instructional sessions. The conference would also allow submission and presentation of research abstracts. This resource was popular among our surveyed PDs and with this level of support we hopefully can achieve success similar to that of the ACS Quality and Safety Conference.22
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Although much of our strategy relies on support at the professional level, we accept that there will be barriers, particularly at the sponsoring institutional level. However, these are starting to be addressed by the ACGME.7 It is our hope that simultaneous efforts at multiple levels will be synergistic resulting in a sustained cultural change.
Conclusions:
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We acknowledge that this survey represents the views of only a single stakeholder in urological graduate medical education. There are certainly other groups, such as urology residents who should also be surveyed. We are currently investigating avenues to conduct this assessment. We also realize that the evidence for our strategy is based on the attitudes and desires of a relatively small sample of PDs who were affiliated with the SAU. However, a low response rate, which is common for physician surveys should not be equated to nonresponse bias.23, 24 In fact, our sensitivity analysis demonstrated no difference in the program characteristics of our respondents as compared to those of all accredited AUA residency programs, which suggests limited nonresponse bias (all p>0.05). Our survey instrument did not undergo psychometric evaluation or external validation as a metric to capture PDs perceptions about QI education. However, we believe that our survey does have external validity given the target population was PDs who are responsible for residency program educational priorities, which are likely similar to all other residency programs due to common ACGME requirements.5, 10 Lastly, we realize that this survey is cross-sectional in nature, capturing only a single point in time, and limited in scope, thus it may not identify all resources or PDs attitudes. Despite these limitations, our results provide a unique insight into the current resources for and attitudes of PDs towards QI education during residency training.
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In this cross-sectional survey of urology residency PDs, we identified that less than half of urology residency programs sampled offer a curriculum in QI methodology for their trainees. Despite this, PDs express an overwhelming desire for their trainees to learn the science of QI with a request from our professional societies to provide support. To help facilitate this transformation, we propose several initial steps. We believe that now is the time for further attention, resource allocation, and funding directed towards this important aspect of health care delivery.
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education References:
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7. 8. 9. 10. 11. 12.
13. 14. 15. 16. 17. 18. 19. 20. 21.
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Richardson, W. C., Berwick, D. M., Bisgard, J. et al.: Crossing the quality chasm: a new health system for the 21st century: Institute of Medicine, National Academy Press Washington, DC, 2001 LaMantia, J.: The ACGME core competencies: getting ahead of the curve. Academic Emergency Medicine, 9: 1216, 2002 Nasca, T. J., Philibert, I., Brigham, T. et al.: The next GME accreditation system--rationale and benefits. N Engl J Med, 366: 1051, 2012 Swing, S. R., Beeson, M. S., Carraccio, C. et al.: Educational milestone development in the first 7 specialties to enter the next accreditation system. Journal of graduate medical education, 5: 98, 2013 Coburn, M., Amling, C., Bahnson, R. R. et al.: Urology milestones. Journal of Graduate Medical Education Supplement, 5: 79, 2013 Weiss, K. B., Wagner, R., Nasca, T. J.: Development, testing, and implementation of the ACGME Clinical Learning Environment Review (CLER) program. Journal of graduate medical education, 4: 396, 2012 Mate, K. S., Johnson, M. B.: Designing for the Future: Quality and Safety Education at US Teaching Hospitals. J Grad Med Educ, 7: 158, 2015 Wagner, R., Patow, C., Newton, R. et al.: The Overview of the CLER Program: CLER National Report of Findings 2016. Journal of graduate medical education, 8: 11, 2016 Medbery, R. L., Sellers, M. M., Ko, C. Y. et al.: The unmet need for a national surgical quality improvement curriculum: a systematic review. J Surg Educ, 71: 613, 2014 ACGME Common Program Requirements (Section VI) with Background and Intent: Accreditation Council for Graduate Medical Education, 2017 Jaffe, A., Klein, M., McMahon, M. et al.: Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment. Am J Med Qual, 2016 Kelz, R. R., Sellers, M. M., Reinke, C. E. et al.: Quality in-training initiative--a solution to the need for education in quality improvement: results from a survey of program directors. J Am Coll Surg, 217: 1126, 2013 Mann, K. J., Craig, M. S., Moses, J. M.: Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors. Acad Pediatr, 14: 23, 2014 Accredited Listing of U.S. Urology Residency Programs: American Urological Association, vol. 2017, 2017 Sakran, J. V., Hoffman, R. L., Ko, C. et al.: The ACS NSQIp quality in-training initiative: educating residents to ensure the future of optimal surgical care. Bull Am Coll Surg, 98: 30, 2013 Sellers, M. M., Reinke, C. E., Kreider, S. et al.: American College of Surgeons NSQIP: quality intraining initiative pilot study. J Am Coll Surg, 217: 827, 2013 American Urological Association Core Curriculum: American Urological Association Education and Research, Inc., vol. 2017 Pronovost, P. J., Holzmueller, C. G., Martinez, E. et al.: A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf, 32: 102, 2006 Patow, C. A., Karpovich, K., Riesenberg, L. A. et al.: Residents' engagement in quality improvement: a systematic review of the literature. Acad Med, 84: 1757, 2009 Johnson, P. T., Pahwa, A. K., Feldman, L. S. et al.: Advancing High-Value Health Care: A New AJM Column Dedicated to Cost-Conscious Care Quality Improvement. Am J Med, 130: 619, 2017 Feldman, L. S.: Choosing wisely®: things we do for no reason. Journal of hospital medicine, 10: 696, 2015
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Conference Objectives: American College of Surgeons, vol. 2017 Cull, W. L., O'Connor, K. G., Sharp, S. et al.: Response rates and response bias for 50 surveys of pediatricians. Health Serv Res, 40: 213, 2005 Kellerman, S. E., Herold, J.: Physician response to surveys. A review of the literature. Am J Prev Med, 20: 61, 2001
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 1: Residency Program Characteristics N=36 Northeastern New England New York Mid-Atlantic North Central Southeastern South Central Western
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Median Number of Residency Program Positions (IQR) Residency Program Structure (%) Number of Clinical Urology Faculty (%)
2 (6) 1 (3) 4 (11) 3 (8) 5 (14) 10 (28) 6 (17) 5 (14) 15 (10-18)
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American Urological Association Section (%)
30 (83) 6 (17) 1 (3) 11 (31) 12 (33) 5 (14) 7 (19)
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1 Surgery +4 Urology 1 Surgery +4 Urology + 1 Research <5 5-9 10-14 15-19 >20
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Interquartile Range (IQR)
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 2: Program Director Characteristics and Participation in Quality Improvement Activities
Received Formal Training in QI Methodology
N=36 1994 (1985-2002)
No Morbidity and Mortality Conference Representative to a QI Committee Teaching QI Methodology Participating in a QI Project Participating in a QI Registry Other
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QI Activity Involvement (%)*
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Median Number of QI Projects Completed in the Last Year (IQR) *Multiple Responses Possible, May Not Add to 100% Interquartile Range (IQR) Program Directors (PD) Quality Improvement (QI)
36 (100) 33 (92) 29 (81) 22 (61) 12 (33) 12 (33) 5 (14) 3 (8) 8 (22)
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Direct Patient Care Clinical Research Clinical Education Administration QI Leader or Educator Division Chair Department Chair Basic Science Research Yes
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Median Year of Residency Graduation (IQR) Additional Practice Roles (%)*
28 (78) 36 (100) 19 (53) 16 (44) 10 (28) 9 (25) 2 (6) 2 (1-3)
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 3: Quality Improvement Curriculum Characteristics Didactic Self-Directed Case-Based Web-Based Experiential Learning with a Project QI Electives or Rotations Other Do Not Know Curriculum Content (%)* Plan-Do-Study-Act LEAN Six Sigma Root Cause Analysis Other Do Not Know Curriculum Instructor (%)* Urologist, QI Leader Urologist, Non-QI Leader Urology Resident, QI Leader Urology Resident, Non-QI Leader Surgeon, QI Leader Surgeon, Non-QI Leader Non-Surgeon, Physician QI Leader Non-Surgeon, Physician Non-QI Leader Non-Physician, QI Leader Other Do Not Know Assessment of Participants (%)* Direct Observation with Feedback Written or Oral Exam Completion of a QI Project None Do Not Know *Multiple Responses Possible, May Not Add to 100% Quality Improvement (QI)
N=16 14 (88) 6 (38) 5 (31) 8 (50) 6 (38) 2 (13) 2 (13) 0 (0) 7 (44) 4 (25) 6 (38) 9 (56) 1 (6) 3 (19) 6 (38) 2 (13) 1 (6) 1 (6) 3 (19) 0 (0) 6 (38) 0 (0) 5 (31) 2 (13) 1 (6) 8 (50) 2 (13) 8 (50) 3 (19) 2 (13)
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Curriculum Format (%)*
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 4: Correlation of Individual Program and Program Director Characteristics with the Presence of a Quality Improvement Curriculum
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p-value 0.327 0.937 0.885 0.574 0.732 0.135 0.100 0.933 0.649 0.435
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Correlation Coefficient (r) 0.168 0.014 0.025 0.098 0.237 0.333 0.358 0.062 0.155 0.215
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Factor Residency Program Structure Number of Program Faculty Number of Program Housestaff Year of Urology Residency Completion Received Formal QI Methodology Education Self-Identified as a QI Leader Conducting QI Methodology Education Representative to a QI Committee Participation in a QI Project Participation in a QI Registry Quality Improvement (QI)
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Figure 1: Resources Program Directors’ Request from the American Urological Association to Support Quality Improvement Education
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Quality Improvement (QI)
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Abbreviations: Accreditation Council for Graduate Medical Education (ACGME) American College of Surgeons (ACS)
Next Accreditation System (NAS) Patient Safety (PS) Program Directors (PDs)
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Physical Medicine and Rehabilitation (PM&R) Quality Improvement (QI)
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Quality In-Training Initiative (QITI) Society of Academic Urologists (SAU)
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American Urological Association (AUA)
PII: DOI: Reference:
S2352-0779(17)30172-3 10.1016/j.urpr.2017.08.001 URPR 308
To appear in: Urology Practice Accepted Date: 8 August 2017 Please cite this article as: Ziemba JB, Matlaga BR, Tessier CD, Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors, Urology Practice (2017), doi: 10.1016/j.urpr.2017.08.001. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Title: Educational Resources for Resident Training in Quality Improvement: A National Survey of Urology Residency Program Directors Authors: Justin B. Ziembaa, MD; Brian R. Matlagab, MD, MPH; and Christopher D. Tessierc, MD.
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Affiliations: a Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. b Department of Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD. c Departments of Urology and Medical Informatics, Oregon Health & Science University, Portland, OR.
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Corresponding Author: Justin B. Ziemba, M.D. Division of Urology Perelman Center for Advanced Medicine West Pavilion, 3rd Floor 3400 Civic Center Boulevard Philadelphia, PA 19104 Email: [email protected] Phone: 215-662-2891 Fax: 215-662-3955
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Email Addresses: a [email protected] b [email protected] c [email protected]
Key Words: Quality Improvement; Quality of Health Care; Education; Internship and Residency; Urology
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Conflicts of Interest: The authors did not receive payment from a third-party for this work. BRM discloses that he is a consultant for Boston Scientific Corporation, but that this relationship is not related to this work. JBZ and CDT have no commercial or financial relationships related to this work to report. The authors have no patents related to this work. There are no other conflicts of interest to report.
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Acknowledgements: We would like to thank the Society of Academic Urologists for partnering with us and helping to distribute the survey invitation to its membership. Abstract Word Count: 249
Manuscript Word Count: 2,517
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Abstract:
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Purpose: A key physician competency outlined in the Urology Milestone project is engagement in quality improvement (QI). Despite this mandate, little is known about the attitudes of urology residency program directors (PDs) regarding the relative importance of QI education. Therefore, we performed a national survey of PDs.
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Methods: A 25-item survey was developed to investigate PD knowledge and training in QI methodology, participation in QI related activities, curriculum support for resident QI educational activities, and attitudes regarding the relative importance of QI education. The survey was sent via email (11/1/2016) to all PDs affiliated with the Society of Academic Urologists (n=116/134; 87% of ACGME programs).
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Results: A total of 36 PDs returned a completed survey for a response rate of 31% (36/116). Only 22% (8/36) of PDs reported receiving formal education or training in QI methodology. A total of 44% (16/36) of PDs reported that their program offers formal education or a curriculum in QI methodology for their trainees. PDs expressed a strong desire for residents to learn QI methodology (positive response, 32/36; 89%) and understand how to apply it to conduct a QI project (positive response, 30/35; 86%). PDs strongly believe that a urology-oriented QI curriculum would be a valuable resource (positive response, 31/36; 86%) with a need for support from our professional society (positive response, 29/36; 81%).
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Conclusion: A minority of programs have QI education available for residents. However, PDs agree that QI is an integral part of residency training, which should be promoted by our profession.
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education Introduction:
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With the release of the Institute of Medicine’s “Crossing the Quality Chasm” report in 2001, delivery of high quality health care in America became a national priority.1 To achieve this goal, the report outlined several transformative recommendations, including transitioning the health care workforce.1 One step in this process was a redesign of clinical education and training to prepare professionals for new methods of health care delivery.1
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Contemporaneously, the Accreditation Council for Graduate Medical Education (ACGME) in 1999 developed Core Competencies, which would serve as the basis for resident education across all specialties.2 The six Core Competencies include patient care, medical knowledge, practice based learning and improvement, interpersonal skills, professionalism, and systems-based practice.2 By developing educational outcomes for each of these domains, it became possible to assess residents individually and residency programs collectively.2 In fact, the ACGME’s Core Competencies served as the basis for the development of the Next Accreditation System (NAS), which began with phased implementation in 2013.3
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Under the NAS, specialty-specific educational milestones are developed for residents who are expected to demonstrate a progressive level of achievement from program entry to graduation.3 Urology was one of the first specialties to adopt the NAS.3, 4 In consultation with the American Urological Association (AUA), a total of 22 subcompetencies each with 1-2 milestones per achievement level across the 6 core domains were created.4, 5 Of these, 3 directly address the delivery of quality medical care including SBP2-value, SBP3-patient safety (PS), and PBLI6-quality improvement (QI).5 In addition to the specific milestones, the NAS requires that the learning environment created by the sponsoring institution also be assessed.3, 6 Under the Clinical Learning Environment Review (CLER) Program, 6 domains are examined with an emphasis on support for PS and QI activities.6
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Despite this mandate by the ACGME under the NAS that continuous improvement in the health care delivery system be an educational priority, early evidence suggests that programs and sponsoring institutions are falling short.7-9 In response, the ACGME has re-prioritized PS and QI in their updated Common Program Requirements.10 Specifically, residents must have access to training in QI methodology, quality metrics, and participation in QI activities with the goal of being able to apply these skills to their future unsupervised practice.10
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Despite the emphasis by the ACGME, it is unclear how these requirements are translated into an educational curriculum for urology residents. Urology residency program directors (PDs) are in a unique position as they control the educational content. However, to date, little is known about the attitudes of PDs regarding the relative importance of QI education and participation to a resident’s overall training. In addition, it is unclear what resources are available at the program level for QI education or projection participation. To answer these questions, we performed a cross-sectional survey of urology residency PDs affiliated with the Society of Academic Urologists (SAU). By conducting this needs assessment, we hope to gather important information that may be useful in the design of QI training programs for urology residents.
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Methods: Survey Design
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Unfortunately, no validated survey instrument exists to assess QI educational resources within a residency program. However, a literature review identified three prior similar needs assessments that were performed within the specialties of physical medicine and rehabilitation (PM&R), pediatrics, and general surgery.11-13 The survey content from these publications was analyzed to determine if it would be applicable for inclusion in our survey instrument targeting urology residency PDs. Applicable content served as the foundation to build our survey instrument. Additional content was then added by an expert in health policy for the delivery of quality medical care (author CDT) and an expert in quality improvement education (author JBZ).
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The final 25-item survey aimed to investigate PDs knowledge and training in QI methodology, participation in QI related activities, curriculum support for resident QI educational activities, and attitudes regarding the relative importance of QI education to overall resident training (see supplement 1). Demographic items included PD year of urology residency completion, total number of residency positions, residency program structure, number of clinical faculty within the department/division, and program location (i.e. AUA Section). A free-text comment option was available at the end of the survey to gather additional qualitive information/opinions (N=3; see supplement 2 for complete responses). Survey Sample
Data Analysis
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The SAU is an organization representing university affiliated urologists, urology chairpersons, and urology residency program directors. Under an agreement with the SAU, the survey instrument was distributed via email to its membership. At the time of survey distribution in 11/1/2016, a total of 116 urology residency programs had a PD who was a member of the SAU. This represented 87% (n=116/134) of all ACGME accredited urology residency programs in the United States. After the initial invitation, 2 reminders were sent via email to increase participation. An introductory statement was included with each invitation to explain the purpose of the survey, that participation was voluntary, responses were anonymous, and that completion implied consent for study inclusion.
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Data was collected and managed using Qualtrics (Qualtrics, Provo, UT) housed at the Johns Hopkins School of Medicine. Questions pertaining to respondents’ attitudes were summarized as a positive (strongly agree and somewhat agree) or negative (neutral, somewhat disagree, and strongly disagree) response. Partial responses were included in the analysis (N=1). To assess for nonresponse bias, we performed a sensitivity analysis comparing the program characteristics between respondents to that of all residency programs in the US with information publicly available through the AUA.14 Univariate statistics were performed with continuous data analyzed with a Student’s T-test and categorical data with a chi-square test. To determine what individual program and PD factors may influence the presence of a QI curriculum, we performed a pointbiserial correlation for interactions between nominal and continuous variables and a phi correlation
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education between nominal variables. Analyses were conducted with IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY: IBM Corp.) with statistical significance set at a p-value of 0.05. Results:
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A total of 36 PDs returned a valid survey for a response rate of 31% (36/116). There were no differences in the distribution of AUA Section, program structure, housestaff number, or faculty size between programs who responded and all accredited US residency programs (all p>0.05). Program characteristics of responding PDs are outlined in Table 1.
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Table 2 outlines the characteristics of the PD and their participation in QI activities. More than half of PDs (19/36; 53%) reported that a urologist recognized as a QI leader is responsible for supervising QI activities within the department. The remaining programs (15/36; 42%) responded that a urologist is simply assigned to that role, regardless of their training or experience in QI.
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Only 44% (16/36) of PDs reported that their program offers formal education or a curriculum in QI methodology for their trainees. Characteristics of the curriculum provided by these 16 programs is outlined in Table 3. Table 4 displays the correlation coefficients between individual program and PD factors and the presence of a QI curriculum.
Discussion:
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PDs expressed a strong desire (positive response, 32/36; 89%) for residents to learn QI methodology during training. Similarly, having residents understand how to apply this methodology to conduct a QI project was also of importance (positive response, 30/36; 83%). PDs strongly believe that a urologyoriented QI curriculum would be a valuable resource (positive response, 31/36; 86%) with a need for encouragement and promotion from urological professional societies (positive response, 29/36; 81%). Specifically, what resources PDs would request from the AUA to support this mission is displayed in Figure 1.
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In this cross-sectional survey of PD affiliated with the SAU, we identified that PDs are not well-trained in the science of QI with less than a quarter confirming formal education. Less than half of urology residency programs sampled offer a curriculum in QI methodology for their trainees. Furthermore, only 38% of the curriculum instructors are urologists with qualifications suitable to be a QI expert or leader. Despite these deficiencies, PDs express an overwhelming desire for their trainees to learn the science of QI with a request from our professional societies to provide support, particularly in the form of a urology-oriented QI curriculum. Although these results are disappointing, they are not surprising. In a recent survey distributed to PDs of general surgery residency programs, only 35% of PDs reported formal QI training, which is close to the number we observed.12 Only 58% of programs reported that their residents participated in QI teams and the median percentage of residents within each program who participated in a QI project outside of morbidity and mortality conference was only 50%.12 This suggests that approximately half of programs facilitate resident learning of QI science, which again is similar to our study. In contrast to our results, the non-surgical specialty residency training programs of PM&R and pediatrics have demonstrated a greater affinity for incorporating QI education.11, 13 For example, in a survey distributed to PM&R PDs, all sampled programs reported that their residents participated in QI projects, 5
ACCEPTED MANUSCRIPT Urology Quality Improvement Education of which 71% were resident-led.11 Similarly, in a survey of pediatric PDs, 85% of sampled programs had a QI curriculum, of which 88% of these required a project.13
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The higher performance of the non-surgical specialties to incorporate a QI curriculum into residency training highlights the gap that needs to be addressed within the surgical disciplines. One barrier is the lower availability of QI training resources tailored to the surgical specialties. In a recent meta-analysis of the literature on QI curriculum for use in graduate medical education, only 24% (12 articles) were specific to a surgical discipline, of which none were related to urology.9
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Although a urology specific curriculum does not yet exist, our colleagues in general surgery with support from the American College of Surgeons (ACS) have produced the Quality In-Training Initiative (QITI).9, 12, 15, 16 This program incorporates a surgery-specific resident QI curriculum, faculty development to train the trainer, and National Surgical Quality Improvement Program (NSQIP) quality reports for residents to track their patient’s outcomes.9, 12, 15, 16
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Unfortunately, merely making a QI curriculum like the QITI program available is not sufficient to make QI an educational priority. There needs to be a commitment from all stakeholders. Our results suggest that there is a strong desire by PDs to include QI methodology training and experiential learning into their residency programs. Despite our correlations not reaching statistical significance, there were modest effect sizes when PDs reported receiving QI education (rφ=0.237), self-identified as a QI leader (rφ=0.333), and conducted QI education themselves (rφ=0.358). This suggests the need to not only train residents in QI methodology, but also the faculty. Our respondents specifically recognized the role that organizations like the AUA should play to catalyze this effort.
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To help facilitate this transformation, we propose several initial steps. First, we recommend the development of urology-specific QI and patient safety resources for education of not only residents, but also practicing urologists. This resource was requested by almost all of the PDs in our survey. Currently, the AUA Core Curriculum, which serves as the foundation of knowledge for all practicing urologists contains no information about quality, safety, or value.17 Therefore, embedding this content within the Core Curriculum would be ideal. We envision the creation of short video modules. First, covering basic terminology, then strategies and tools, and finally, application with case based examples. The cases can highlight how current infrastructure like morbidity and mortality conference can be enhanced with the application of tools for systems based learning.18 By placing this education within the context of urological care that the learner may encounter, it is our hope that this information will be relevant and actionable. Second, the AUA can emphasize the value of QI and patient safety both as beneficial for patients, but also as a means of academic success for residents.19 To achieve this, we recommend highlighting quality, patient safety, and value improvement projects performed by residents through publication in a dedicated, standing subsection of a urology journal. Similar endeavors are already underway in the field of internal medicine through the Journal of Hospital Medicine and American Journal of Medicine.20, 21 Third, we believe that opportunities for students, residents, practicing urologists, and sponsoring institutions to share their work, collaborate, and exchange ideas is critical towards developing and sustaining a culture across the urological community that values improvement in health care delivery. We acknowledge that the AUA has taken steps to achieve this goal with the introduction of a topicfocused Quality Improvement Summit and inclusion of health policy podium and poster sessions at the 6
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Annual Meeting. However, we propose a broader, dedicated, stand-alone yearly conference sponsored by the AUA where attendees can learn the latest science and trends through keynote speakers and instructional sessions. The conference would also allow submission and presentation of research abstracts. This resource was popular among our surveyed PDs and with this level of support we hopefully can achieve success similar to that of the ACS Quality and Safety Conference.22
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Although much of our strategy relies on support at the professional level, we accept that there will be barriers, particularly at the sponsoring institutional level. However, these are starting to be addressed by the ACGME.7 It is our hope that simultaneous efforts at multiple levels will be synergistic resulting in a sustained cultural change.
Conclusions:
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We acknowledge that this survey represents the views of only a single stakeholder in urological graduate medical education. There are certainly other groups, such as urology residents who should also be surveyed. We are currently investigating avenues to conduct this assessment. We also realize that the evidence for our strategy is based on the attitudes and desires of a relatively small sample of PDs who were affiliated with the SAU. However, a low response rate, which is common for physician surveys should not be equated to nonresponse bias.23, 24 In fact, our sensitivity analysis demonstrated no difference in the program characteristics of our respondents as compared to those of all accredited AUA residency programs, which suggests limited nonresponse bias (all p>0.05). Our survey instrument did not undergo psychometric evaluation or external validation as a metric to capture PDs perceptions about QI education. However, we believe that our survey does have external validity given the target population was PDs who are responsible for residency program educational priorities, which are likely similar to all other residency programs due to common ACGME requirements.5, 10 Lastly, we realize that this survey is cross-sectional in nature, capturing only a single point in time, and limited in scope, thus it may not identify all resources or PDs attitudes. Despite these limitations, our results provide a unique insight into the current resources for and attitudes of PDs towards QI education during residency training.
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In this cross-sectional survey of urology residency PDs, we identified that less than half of urology residency programs sampled offer a curriculum in QI methodology for their trainees. Despite this, PDs express an overwhelming desire for their trainees to learn the science of QI with a request from our professional societies to provide support. To help facilitate this transformation, we propose several initial steps. We believe that now is the time for further attention, resource allocation, and funding directed towards this important aspect of health care delivery.
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education References:
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13. 14. 15. 16. 17. 18. 19. 20. 21.
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Richardson, W. C., Berwick, D. M., Bisgard, J. et al.: Crossing the quality chasm: a new health system for the 21st century: Institute of Medicine, National Academy Press Washington, DC, 2001 LaMantia, J.: The ACGME core competencies: getting ahead of the curve. Academic Emergency Medicine, 9: 1216, 2002 Nasca, T. J., Philibert, I., Brigham, T. et al.: The next GME accreditation system--rationale and benefits. N Engl J Med, 366: 1051, 2012 Swing, S. R., Beeson, M. S., Carraccio, C. et al.: Educational milestone development in the first 7 specialties to enter the next accreditation system. Journal of graduate medical education, 5: 98, 2013 Coburn, M., Amling, C., Bahnson, R. R. et al.: Urology milestones. Journal of Graduate Medical Education Supplement, 5: 79, 2013 Weiss, K. B., Wagner, R., Nasca, T. J.: Development, testing, and implementation of the ACGME Clinical Learning Environment Review (CLER) program. Journal of graduate medical education, 4: 396, 2012 Mate, K. S., Johnson, M. B.: Designing for the Future: Quality and Safety Education at US Teaching Hospitals. J Grad Med Educ, 7: 158, 2015 Wagner, R., Patow, C., Newton, R. et al.: The Overview of the CLER Program: CLER National Report of Findings 2016. Journal of graduate medical education, 8: 11, 2016 Medbery, R. L., Sellers, M. M., Ko, C. Y. et al.: The unmet need for a national surgical quality improvement curriculum: a systematic review. J Surg Educ, 71: 613, 2014 ACGME Common Program Requirements (Section VI) with Background and Intent: Accreditation Council for Graduate Medical Education, 2017 Jaffe, A., Klein, M., McMahon, M. et al.: Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment. Am J Med Qual, 2016 Kelz, R. R., Sellers, M. M., Reinke, C. E. et al.: Quality in-training initiative--a solution to the need for education in quality improvement: results from a survey of program directors. J Am Coll Surg, 217: 1126, 2013 Mann, K. J., Craig, M. S., Moses, J. M.: Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors. Acad Pediatr, 14: 23, 2014 Accredited Listing of U.S. Urology Residency Programs: American Urological Association, vol. 2017, 2017 Sakran, J. V., Hoffman, R. L., Ko, C. et al.: The ACS NSQIp quality in-training initiative: educating residents to ensure the future of optimal surgical care. Bull Am Coll Surg, 98: 30, 2013 Sellers, M. M., Reinke, C. E., Kreider, S. et al.: American College of Surgeons NSQIP: quality intraining initiative pilot study. J Am Coll Surg, 217: 827, 2013 American Urological Association Core Curriculum: American Urological Association Education and Research, Inc., vol. 2017 Pronovost, P. J., Holzmueller, C. G., Martinez, E. et al.: A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf, 32: 102, 2006 Patow, C. A., Karpovich, K., Riesenberg, L. A. et al.: Residents' engagement in quality improvement: a systematic review of the literature. Acad Med, 84: 1757, 2009 Johnson, P. T., Pahwa, A. K., Feldman, L. S. et al.: Advancing High-Value Health Care: A New AJM Column Dedicated to Cost-Conscious Care Quality Improvement. Am J Med, 130: 619, 2017 Feldman, L. S.: Choosing wisely®: things we do for no reason. Journal of hospital medicine, 10: 696, 2015
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Conference Objectives: American College of Surgeons, vol. 2017 Cull, W. L., O'Connor, K. G., Sharp, S. et al.: Response rates and response bias for 50 surveys of pediatricians. Health Serv Res, 40: 213, 2005 Kellerman, S. E., Herold, J.: Physician response to surveys. A review of the literature. Am J Prev Med, 20: 61, 2001
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ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 1: Residency Program Characteristics N=36 Northeastern New England New York Mid-Atlantic North Central Southeastern South Central Western
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Median Number of Residency Program Positions (IQR) Residency Program Structure (%) Number of Clinical Urology Faculty (%)
2 (6) 1 (3) 4 (11) 3 (8) 5 (14) 10 (28) 6 (17) 5 (14) 15 (10-18)
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American Urological Association Section (%)
30 (83) 6 (17) 1 (3) 11 (31) 12 (33) 5 (14) 7 (19)
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1 Surgery +4 Urology 1 Surgery +4 Urology + 1 Research <5 5-9 10-14 15-19 >20
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Interquartile Range (IQR)
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 2: Program Director Characteristics and Participation in Quality Improvement Activities
Received Formal Training in QI Methodology
N=36 1994 (1985-2002)
No Morbidity and Mortality Conference Representative to a QI Committee Teaching QI Methodology Participating in a QI Project Participating in a QI Registry Other
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QI Activity Involvement (%)*
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Median Number of QI Projects Completed in the Last Year (IQR) *Multiple Responses Possible, May Not Add to 100% Interquartile Range (IQR) Program Directors (PD) Quality Improvement (QI)
36 (100) 33 (92) 29 (81) 22 (61) 12 (33) 12 (33) 5 (14) 3 (8) 8 (22)
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Direct Patient Care Clinical Research Clinical Education Administration QI Leader or Educator Division Chair Department Chair Basic Science Research Yes
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Median Year of Residency Graduation (IQR) Additional Practice Roles (%)*
28 (78) 36 (100) 19 (53) 16 (44) 10 (28) 9 (25) 2 (6) 2 (1-3)
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 3: Quality Improvement Curriculum Characteristics Didactic Self-Directed Case-Based Web-Based Experiential Learning with a Project QI Electives or Rotations Other Do Not Know Curriculum Content (%)* Plan-Do-Study-Act LEAN Six Sigma Root Cause Analysis Other Do Not Know Curriculum Instructor (%)* Urologist, QI Leader Urologist, Non-QI Leader Urology Resident, QI Leader Urology Resident, Non-QI Leader Surgeon, QI Leader Surgeon, Non-QI Leader Non-Surgeon, Physician QI Leader Non-Surgeon, Physician Non-QI Leader Non-Physician, QI Leader Other Do Not Know Assessment of Participants (%)* Direct Observation with Feedback Written or Oral Exam Completion of a QI Project None Do Not Know *Multiple Responses Possible, May Not Add to 100% Quality Improvement (QI)
N=16 14 (88) 6 (38) 5 (31) 8 (50) 6 (38) 2 (13) 2 (13) 0 (0) 7 (44) 4 (25) 6 (38) 9 (56) 1 (6) 3 (19) 6 (38) 2 (13) 1 (6) 1 (6) 3 (19) 0 (0) 6 (38) 0 (0) 5 (31) 2 (13) 1 (6) 8 (50) 2 (13) 8 (50) 3 (19) 2 (13)
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Curriculum Format (%)*
ACCEPTED MANUSCRIPT Urology Quality Improvement Education Table 4: Correlation of Individual Program and Program Director Characteristics with the Presence of a Quality Improvement Curriculum
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p-value 0.327 0.937 0.885 0.574 0.732 0.135 0.100 0.933 0.649 0.435
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Correlation Coefficient (r) 0.168 0.014 0.025 0.098 0.237 0.333 0.358 0.062 0.155 0.215
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Factor Residency Program Structure Number of Program Faculty Number of Program Housestaff Year of Urology Residency Completion Received Formal QI Methodology Education Self-Identified as a QI Leader Conducting QI Methodology Education Representative to a QI Committee Participation in a QI Project Participation in a QI Registry Quality Improvement (QI)
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Figure 1: Resources Program Directors’ Request from the American Urological Association to Support Quality Improvement Education
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Quality Improvement (QI)
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Abbreviations: Accreditation Council for Graduate Medical Education (ACGME) American College of Surgeons (ACS)
Next Accreditation System (NAS) Patient Safety (PS) Program Directors (PDs)
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Physical Medicine and Rehabilitation (PM&R) Quality Improvement (QI)
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Quality In-Training Initiative (QITI) Society of Academic Urologists (SAU)
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American Urological Association (AUA)