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To Teach Big Ideas, Think Small: Lessons from Launching a Hands-On QI Program

By Stephanie Onguka | Tuesday, January 22, 2019

KABU

Pictured from left to right in front of Valley Hospital: Dr. Geoffrey Wechuli, Head of Department, Dr. Bramwel Wekesa, 2nd year resident, Dr. Stephanie Onguka, Medical Education Coordinator, Dr. Mourine Melenia, 2nd year resident, Dr. Joy Murage, 2nd year resident, Dr. Musa Saruti, 2nd year resident, Dr. Sarah Kiptiness, 2nd year resident, Dr. Gad Igiraneza, 2nd year resident, Dr. Hilary Kositany, 2nd year resident, and Dr. Kevin Shannon, Visiting Faculty.

Through a new program, we introduce our Family Medicine residents to IHI’s Open School courses in their first year. In a class on Physicianship, they begin with the introductory modules on quality improvement (QI) and patient safety. As it unfolds, the curriculum emphasizes learner-centered teaching methodologies. Our learners conduct their own QI projects to achieved deep learning by putting theories into practice.

We have held the seminar twice at the same local hospital with good results. Both QI projects showed immediate measurable improvement in the first Plan-Do-Study-Act (PDSA) cycle, with ready cooperation from administrators and staff, indicating that the IHI QI approach is indeed readily applicable in our local private hospital environment.

The first cohort of residents in our four-year Family Medicine residency program at the Kabarak University (KABU) School of Medicine & Health Sciences will graduate in December 2019. KABU is a not-for-profit Christian university established in 2001 by the former President of the Republic of Kenya and the Chancellor of the University, Daniel T. Arap Moi. It sits on President Moi’s farm, west of Nairobi. Our 28 residents come from Kenya, Burundi, Democratic Republic of Congo, Ethiopia, and Uganda. All residents have an interest in and commitment to serve in low-resource settings in Kenya or their home countries, and the curriculum focuses on these aspects of service.

KABU faculty work with a hospital to select a clinical setting for a QI project. Just before their third year, residents have a week-long intensive seminar on QI, led by visiting faculty Kevin Shannon, MD, MPH, Associate Professor at Loma Linda University and Assistant Chief Medical Officer for Quality & Safety at the Social Action Community Health System of San Bernardino, California. During the seminar, interactive morning sessions on QI principles are followed by afternoons engaging with a local hospital in designing an intervention.

At the end of the week, residents gather around a staff meeting table at that hospital to present their results to hospital management. In a relatively short time, residents gain a strong grasp of QI principles and put them to good use for the benefit of a local hospital. Thus far, two cohorts have completed this course with projects addressing these clinical systems issues:

  • Improvement of time to hospital admission from the emergency setting
  • Reduction of unpaid bills from insured patients receiving outpatient services

The first project aimed to shorten the time from admission decision to arrival in the ward by 10 percent over a four-day period. The residents’ meetings with hospital staff and observations on the very first day shaped mostly low-effort, high-yield interventions. This included assigning one team the responsibility of transferring the patient from the outpatient department to the inpatient ward. The residents also suggested electing a member of that team to be responsible for patient admission and assigning that member a mobile phone (because most hospitals don’t use landlines in Kenya).

When the residents presented the results of their improvement project, I thought to myself, “Surely this is not rocket science.” It was wonderful to see the residents grasp that so quickly and be equally excited because there are so many low-hanging fruits in our hospitals. Such small changes of communication, leadership, and teamwork can have profound effects on efficiency and overall patient safety.

In addition to this experiential learning, residents go on to earn the IHI Open School Basic Certificate in Quality and Safety. The QI seminar itself is only one week and probably could use more time. We try to identify local experts, and when local faculty are not available on a given subject, we draw on volunteer international faculty. Dr. Shannon is a tremendous resource and generous to give us a week of his very busy schedule back home. We’d love to give this subject more time, but we try to maximize the limited time we have.

We hope this novel approach to QI training can be replicated for other health professional training programs. If you would like to apply lessons from our program, keep the following in mind:

  • Connect locally. First, see if any IHI contacts can be made within your country for instruction. Understanding the context is paramount. Find ways to network and build connections to roll out more QI education and training.
  • Meet residents where they are. Try to incorporate QI training during the clinical training period. We do it during non-clinical course work at the university campus because our residents train across four different hospital sites. This consolidates the training, so we need only one faculty member. However, it would better serve the residents if it could be done in a hospital they know well and that knows them in return. If that isn’t possible, engage a local hospital that would be receptive.
  • Think small. In the year following the QI seminar, the residents must carry out a full QI project at their training hospital. However, we need to keep working with our faculty to help the residents “think small,” since the tendency for them is to “go big” — almost like a mini-thesis — and that’s not what we’re aiming for. Faculty should be briefed on examples of QI projects that can benefit the hospital and that truly model principles of rapid, iterative PDSA cycles.

Dr. Stephanie Onguka is the Medical Education Coordinator at Kabarak University.

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