Now we want to move on to some QI pointers and tips from the pros. We've discussed experiences with fellow in training projects with several training program directors and quality improvement professionals and wanted to pass along some high-yield pearls on mentoring quality improvement projects that we have learned. First, FITs need to clearly define and scope the quality improvement or patient safety problem to be addressed. As we had mentioned earlier that problem needs to clearly state elements of who is contributing to the problem, what is contributing to the problem, where the problem is occurring, when it is occurring, and what the extent of that problem or on the converse side the opportunity is. This problem, given that we are all health care providers and inherently interested in improving patient care should be framed in the context of the patient. Again, a business case should also be present for the problem such that resources will be able to be channeled from your health care organization. Next, encourage your fellows in training to work on quality improvement projects as a team instead of into individual projects. We have found success with teams being led by one to two fellows who have a particular interest in quality improvement, patient safety, or health care operations. This allows a project to keep moving, to be led by the team, but still to have work done by all the other fellows who support those project leaders. This builds camaraderie and teamwork skills among fellow in training and make sure to include other members of the care team including nurses, therapists, and other members of the multidisciplinary team. Another aspect is if possible it would be helpful if fellow in training time during business hours could be protected to work on this quality improvement project. The ideal way to have this done is to have a fellow on a rotation, perhaps on a lighter rotation, to have an afternoon or a portion of their time carved out to work on this project. Therefore, as fellows rotate through that particular rotation and they can pick up the quality improvement work that has been done by fellows who are on their team who were previously on that rotation and the project can keep moving through the year. Additionally, many other members of the health care organization which fellows may need to interact with only may be available to meet during the day. So this will be useful time to get that work and those meetings done. One of the most important parts of a successful quality improvement or patient safety project is to develop a clear set of quality improvement project measures. And most projects need at least one process measure, one outcome measure, and one balancing measure. So here are some examples of the metrics we mentioned on the previous slides. This slide will be about a project that addresses door-to-balloon time in the emergency department, a topic near and dear to all of our hearts. So the ultimate outcome of a type of project that's aimed at that issue is, in this case, the number of patients with a door-to-balloon time of less than 90 minutes in the emergency department between April 1st, 2015 and December 31st, 2015. So you can see that this outcome measure is directly related to why we're undertaking the project and is very specific, meaning it has a specific timeframe associated with it as well as a specific location associated with it. So the definition is not ambiguous. Next, you have a process metric. In this case would be the amount of time from STEMI phone call to the arrival of a cardiology team member in the emergency department. So this isn't the actual outcome we're interested in in this particular project, but it's a step along the way to achieving that outcome. So it's important to understand this step and to see if this is one of the issues that needs to be addressed in building our quality improvement intervention. Finally, a type of metric that you may be less familiar with is a balancing metric. In this case, a balancing metric could be the rate on days when a STEMI was activated that patients leave the emergency department without being seen. And balancing metrics typically describe situations or unanticipated problems or anticipated problems that may occur as a result of the quality improvement intervention. And the goal is to be able to ideally anticipate these problems and then measure whether they're actually occurring. As we had hinted at earlier, it's important as project mentors that you ensure your fellows in training are smart about the aims and the goals of their project. So when thinking about quality improvement projects or the goals of a quality improvement projects, they should be along the SMART framework, meaning the goals should be very specific, they should be measurable, they should be attainable by fellows in training with generally a heavy clinical load. They should be relevant both to the fellows, to our patients, and to the healthcare organization at large. And they should be time-bound, meaning there should be some time frame associated with achieving the aims and goals of the project. Our final pointer is that as a training program director, you should act as a champion for your FITS quality improvement and patient safety projects. And this can be done through, as mentioned earlier, protecting time to complete quality improvement and patient safety work during the day and potentially during later rotations. You should help connect them to both division, department, and health system resources. And successful quality improvement work and even quality improvement work that's in progress that may have some small wins should be promoted. And venues in which they can be promoted could be grand rounds or other fellowship or divisional or even departmental meetings where fellows who lead teams and the fellows who participate in those teams can be recognized for their good work and encouraged to continue it. We wanted to include one slide on quality improvement and patient safety scholarly work. Quality improvement and patient safety work that is rigorously performed is increasingly finding its way into top tier conferences and journals, including some in the space of cardiovascular medicine. In order to maximize the potential for scholarly dissemination, try to encourage your FITS to submit their project for consideration by your institution's IRB at the beginning of the projects. IRBs will oftentimes fast-track QI projects or have a shorter application for them. Typically an IRB is a requisite part of a high-impact publication, so it would be great to have this component done to prepare for publishing a quality improvement project in the future. Once completed and once projects are completed, encourage your fellows in training to present work at conferences receptive to QI and patient safety projects, including the ACC Scientific Session, the American Heart Association Scientific Sessions, the American Heart Association Quality of Care and Outcomes Research Scientific Sessions, the American Association of Medical College Integrating Quality Conference, the Institute for Healthcare Improvement National Forum, and the Academy Health Annual Research Meeting. To circle back to our learning objective, we hope you are now able to articulate the rationale for quality improvement and patient safety education in cardiovascular medicine fellowship and apply a framework for fellow quality improvement and patient safety education to develop local curricula in those fields. We wanted to end with a list of high-yield additional resources. We would like to thank a number of individuals and organizations for their help in creating this module. First, from the Hospital of the University of Pennsylvania, Drs. Frank Silvestri and Jennifer Myers, as well as the Cardiovascular Medicine Fellows, and from the University of Pittsburgh Medical Center, Drs. Catherine Berlacher and Gregory Bump. That brings us to the end of this module. Thank you for taking the time to view and listen to it, and please feel free to contact us at the email addresses listed on the title slide for further information or assistance in creating your own quality improvement and patient safety curriculum.

mentoring

quality improvement projects

fellows in training

problem definition

teamwork