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Reforming Way Medical Students and Physicians Are Taught About Quality and Safety
Susan I. DesHarnais, PhD, MPH and David B. Nash, MD, MBA
Thomas Jefferson University, Philadelphia, PA

OUTLINE
WHAT ARE PATIENT QUALITY AND SAFETY? HISTORY IN TWENTIETH CENTURY Early 1900s Medical Education Mid-1900s to Late 1900s TWENTY-FIRST CENTURY: FIRST 2 DECADES Response to Poor Quality and Safety in Healthcare Barriers to Change Some Possible Solutions WHAT CAN BE DONE NOW? CONCLUSION

ABSTRACT
The purpose of this article is to briey review the history of how quality and safety have been addressed in the United States by those who have been teaching medical students and residents, and then discuss why and how this training must change in the future to more effectively address the problems of improving healthcare quality and safety. Although it has become clear that the curriculum in medical schools should encompass quality and safety training, medical schools have been very slow to implement the reforms that are necessary to accomplish such a goal. These changes, although desirable from a rational perspective, involve basic changes in the

culture of medical schools and teaching hospitals. Moreover, the cost of implementing these changes would be very large, and, if imposed by outside agencies, would likely constitute an unfunded mandate. It should also be noted that at the present time there are very few people who are well trained to develop and teach these classes. In order to accomplish the goal of improving patient safety, it is essential that we provide much more training and knowledge regarding patient safety to medical students, including knowledge of interventions known to be effective in preventing errors; education in technical performance; information about organizational and team issues; and training in disclosing errors to patients. This training should occur early in the training of professionals, preferably while they are still in school, if such training is to change the culture of medicine. Some suggestions and plans for implementation are discussed, using some innovative programs as examples. Mt Sinai J Med 78:834841, 2011. 2011 Mount Sinai School of Medicine Key Words: medical schools, quality, safety. The report on medical education authored by Abraham Flexner in 1910 provided major criticisms of the manner in which medical schools were run. As Donald Berwick and Jonathan Finkelstein wrote in 2010 (100 years later), the challenge now is to explicitly connect an analysis of problems and proposed solutions for todays medical education with todays social need. The nature of the public interest may have changed with the times, but it is still paramount.1 The purpose of this article is to briey review the history of how quality and safety have been addressed in the United States by those who have been teaching medical students and residents. This is followed by a discussion of why and how the medical-school curricula must change in the

Address Correspondence to: Susan DesHarnais School of Population Health Thomas Jefferson University Philadelphia, PA Email: sdesharnais5@aol.com

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI:10.1002/msj.20302 2011 Mount Sinai School of Medicine

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future, to improve physicians training, knowledge, and skills in monitoring and improving the quality and safety of the care they provide to their patients. Proposed changes, and barriers to changes, are then discussed and recommendations are made.

WHAT ARE PATIENT QUALITY AND SAFETY?

Patient safety can be dened as a commitment by healthcare providers to reduce, or even eliminate, adverse events that occur while patients are being treated. It is recognition of the many and complex causes of these adverse events, including human factors, systems factors, teamwork and communication. Quality improvement, according to the Ofce of Technology Assessment, is a commitment to increase the probability of outcomes desired by the patient, and reduce the probability of undesired outcomes, given the state of medical knowledge.2

HISTORY IN TWENTIETH CENTURY

Early 1900s Medical Education
In 1910, Dr. Abraham Flexner did an extensive evaluation of medical schools in the United States, in a report to the Carnegie Foundation for the Advancement of Teaching.3 He was critical of the existing schools, and his report was instrumental in closing 60 of the 155 schools by 1920. Admission requirements were revised, as well as curricula, in the remaining medical schools.3 By 1910, several state licensing boards had adopted requirements for 1 or 2 years of premedical college training as a prerequisite for medical school, and 22 states required a 4-year curriculum for medical schools.4

Mid-1900s to Late 1900s

After the Flexner report and subsequent changes in medical education, many more reforms occurred. Technological and scientic innovations led to the need for a very different type of education. During this same time period, there were also great changes in thinking about improving the quality and safety of healthcare delivered in hospitals and other settings. Much was written about how to measure and improve the quality and safety of healthcare, especially between the mid-1900s and the late 1900s. There were many important pioneers in the eld,

both individuals and organizations, including Avedis Donabedian, who wrote extensively about measuring and improving quality in the 1960s and afterward.5,6 His inuence was great, as he classied the ways in which quality had been measured, developed a broad framework for conceptualizing quality of care, and described the methods that one needs to use to do valid and useful studies. The evidence-based medicine or evidence-based practice movement, with its focus on efcacy, is associated with Dr. David Sackett, who dened this movement as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.7 This focus on scientic evidence that is then tailored to the individual patients needs gives a somewhat different role to the physician, who should not be justifying decisions based on such rationale as I have always done it this way or in my experience. Donald Berwick, along with a group of visionary individuals, formed the Institute for Healthcare Improvement (IHI) in the late 1980s. This group envisioned a health care system no longer plagued by errors, waste, delay, and unsustainable social and economic costs.8 They believed that they could achieve this transformation through a systemic focus on quality improvement. More than 2 decades later, IHI is still giving guidance to a growing movement in an ever-changing environment. Through its Open School, IHI makes information on education regarding quality and safety available to a worldwide audience, and focuses particularly on students in the health professions. Don Berwick served as IHIs president and CEO from its founding until 2010, when he became administrator of the Centers for Medicare and Medicaid Services.8 In 1993, the American College of Physician Executives, a membership organization headquartered in Tampa, Florida, committed to an agenda focused on professional education in quality and safety. Through its Three Faces of Quality program, it has educated >5000 physicians in these tenets. It should also be noted that a variety of textbooks on quality and safety improvement were written during this time period, primarily for teaching courses in quality management and quality improvement to students in business schools and in health administration programs.9 11 However, these types of courses were not being taught in medical schools. What are the goals set forth by these leaders in the movement to teach and improve patient safety and quality improvement? How has the culture evolved? What are the older versus modern approaches toward medical errors? What are some of the objectives of teaching about quality and safety?
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How do teachers in this eld hope to inuence the attitudes, skills, and knowledge of medical students and physicians? The goals are to develop a culture that is cooperative, team-oriented, patient-centered, avid for measurement, tolerant of risks, and friendly for learning.1 Instead of blaming the physician who is responsible for an error, one should instead take a systems approach. What was there about the process of care that allowed such an error to occur? How can we x the process so that this cannot happen in the future? Open communication and teamwork are to be encouraged, and skills taught in how to do these things. Transparency is encouraged, as well as disclosure of errors to the patient. Measurement is encouraged, and both quantitative and qualitative methods are used to measure whether processes are out of control or patient satisfaction is poor. As part of this training, medical students are to be encouraged to become involved by asking questions, taking responsibility for some quality- and safetyimprovement activities, and functioning as a member of a team. Interdisciplinary learning is encouraged as teams manage patient care together. There are many different ways of teaching about quality and safety, including lectures, online teaching, and simulations. Simulations can include training in doing various procedures as well as training in patient assessment and teamwork dynamics/communication. Students are also encouraged to become involved early in their training in projects with tutorials and a work-group focus.

result in subsequent readmissions and/or involve medical errors that harm patients. Changes in payments to hospitals are occurring for some types of errors and readmissions.

It has become widely known and reported that Americans are receiving poor-quality and unsafe care, as demonstrated by To Err Is Human, The Quality Chasm, and several other books and publications by the Institute of Medicine and a number of other writers.
Following an era of banking and regulatory problems, there is increased emphasis on transparency/public reporting regarding provider performance, including quality problems and errors. There is also a movement toward encouraging healthcare providers to disclose and apologize to patients and their families when mistakes are made. There is a much greater awareness that there are solutions that actually work to improve safety and quality. For example, Dr. Pronovost has written about how the use of a checklist has greatly reduced central-line infections.13 The Accreditation Council on Graduate Medical Education (ACGME), with its Outcomes project, highlighted new competencies (practice-based learning and improvement and systems-based practice projects) that explicitly focused on the need to teach quality and safety. The World Health Organization, through publication of its Patient Safety Curriculum Guide for Medical Schools, has dened important areas of learning about healthcare quality and safety.14 The purpose of this guide is to enable and encourage medical schools to include patient safety in their courses.14

TWENTY-FIRST CENTURY: FIRST 2 DECADES

Response to Poor Quality and Safety in Healthcare
It has become widely known and reported that Americans are receiving poor-quality and unsafe care, as demonstrated by To Err Is Human,12 The Quality Chasm,2 and several other books and publications by the Institute of Medicine and a number of other writers. As a consequence: Expectations are rising among patients, businesses and health insurers, who are beginning to demand that something be done to address these problems. The rising cost of poor-quality healthcare and of errors is resulting in the federal government reconsidering payments for hospital stays that
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Barriers to Change
With all of these positive contributions, why, then, is it taking so long to x the system? Barriers to change are many. It is difcult to change the curriculum to encompass quality and safety. Although this goal seems clear, medical schools have been very slow to implement programs to accomplish such a goal. As Wong reports, very few medical schools provide any formal training to medical students in how

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to provide safer care.15 Wong also reported that of the 41 curricula that met the authors criteria, 14 targeted medical students, 24 targeted residents,

Very few medical schools provide any formal training to medical students in how to provide safer care.
and 3 targeted both.15 Alper and his colleagues presented ndings from their study showing that only 25% of medical schools had explicit curricula in patient safety, although many more acknowledged its importance.16 Berwick and Finkelstein1 offer an insightful discussion of the reasons for this resistance. In a recent special issue of Academic Medicine on medical education in September 2010, they cite the following barriers to change: Limitations in available time in the medical-school curriculum, requiring curricular integration in order to add material. Difculties in engaging students in understanding systems if they are temporary participants for short blocks of time. Atmospheres in many medical schools that may not be cooperative, team-oriented, patient-centered, avid for measurement, tolerant of risks, and friendly for learning.1 Berwick and Finkelstein make it clear that many overall changes would be required to overcome these barriers.1

engage these types of activities makes it difcult for physicians who are interested in improving quality and safety to dedicate their time and efforts to this work. Although such work is often both costeffective and helpful in terms of reducing risk to the hospital due to lawsuits about errors, still the incentives are small when it comes to promotion and/or tenure, which is generally a result of research dollars and contributions. This makes it difcult for junior physicians to engage in quality- and safetyimprovement activities.17

Some Possible Solutions

Several possibilities exist to get started on the needed changes in educating medical students and physicians about quality and safety. These recommendations are all beginnings; but perhaps, if they are successful, there will be more widespread adoption of these approaches. The following approaches, which are not mutually exclusive, will be discussed: Teaching physicians about healthcare quality and safety outside of their medical-school education, or simultaneous to medical school but not within the medical-school curriculum. Medical schools voluntarily making a decision to teach in a manner that includes quality and safety within an integrated curriculum. Outside agencies involved and inuential in medical education, along with major payors for healthcare, working together to develop and implement buy-in by medical schools to integrate the teaching of quality and safety in their curricula, with possible rewards for compliance and penalties for lack of compliance. A research program to identify desirable outcomes of these various approaches, and to evaluate the short-term and long-term outcomes of these various approaches to teaching medical students and physicians about improving healthcare quality and safety. Each of these approaches is discussed below, including their advantages and disadvantages.

The barriers to change in medical schools include limitations in available time in the medical-school curriculum, difculties in engaging students if they are temporary participants, and medical school atmospheres that are not cooperative, team-oriented, patient-centered, avid for measurement, tolerant of risks, and friendly for learning.
In addition to addressing the barriers cited above, it is essential that medical schools also begin to reward faculty contributions to improving healthcare quality and safety. Lack of academic incentive to

Teaching Physicians About Healthcare Quality and Safety Outside of Their Medical School Education
One approach to educating medical students and physicians concerning quality and safety is to teach healthcare quality and safety through certicate and degree courses in parallel with, or in addition to, what is taught in medical schools. Although this
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does not solve the problem of getting this training to medical students early in their education, it does

One approach to educating medical students and physicians concerning quality and safety is to teach healthcare quality and Voluntary Decisions by Medical Schools to Teach Quality and safety through certicate and Within an Integrated Curriculum degree courses in parallel with, or Safety In order to accomplish the goal of improving in addition to, what is taught in patient safety, it is essential that the medical schools themselves provide much more training medical schools.
offer the opportunity for a dual-degree programs for physicians and other healthcare professionals. This approach also allows for interdisciplinary learning, because students with different backgrounds are taking classes together. Three universities have already begun to offer graduate-level programs and degrees in healthcare quality and safety for both physicians and other healthcare professionals. Thomas Jefferson University School of Population Health18 is offering an online masters degree as well as a doctoral degree for all types of healthcare professionals who want to pursue careers in these areas of quality and safety, as well as a certicate program. In addition, Jefferson is involved in a joint program whereby physicians and some other healthcare professionals can earn a masters degree by combining courses taken through the American College of Physician Executives with online courses given at Jefferson. Northwestern University in Chicago, Illinois19 is offering a master of science degree in healthcare quality and patient safety. This program is designed for both clinical and nonclinical professionals who want to focus their career development on these important areas in healthcare. This is an 18-month, part-time program. In addition, they offer a faculty-development program in healthcare quality and patient safety to prepare faculty to become effective healthcare-quality and patientsafety educators, leaders, and innovators. This is a 12-month, part-time program. They also have a certicate in healthcare quality and patient safety, a 12-month, part-time program. College of Medicine, University of Illinois at Chicago20 offers online programs in patient safety leadership and a graduate certicate in patient safety, error science and full disclosure, created by the College of Medicine, the Institute for Patient Safety Excellence, and other partners at the University of Illinois at Chicago.
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These 3 programs are all quite new, so it is not yet possible to evaluate their effectiveness in teaching skill, both technical and interpersonal. It is clear, however, that these new programs cannot provide the total answer to the problems of teaching medical students all that they need to know.

and knowledge regarding patient safety to medical students, including knowledge of interventions known to be effective in preventing errors, education in technical performance, and information about organizational and team issues. This training should occur early in the training of professionals, preferably

In order to accomplish the goal of improving patient safety, it is essential that the medical schools themselves provide much more training and knowledge regarding patient safety to medical students.
while they are still in school, if there is ever going to be a change the culture of medicine. Several medical schools in the United States have planned, or have already begun, to teach quality and safety as part of an integrated curriculum in their medical-education programs. This type of change is often due to the school having one or more champions who have develop such curricula. One example is from the Greenville Hospital System in Greenville, South Carolina, where Dr. Michael Fuller has been working with his colleagues to develop this type of integrated curriculum.

Cooperation of Outside Agencies Involved and Inuential in Medical Education, Along With Major Payers of Healthcare
Voluntary curriculum development is important, but it is also necessary that changes take place on a larger scale (i.e., a national level). Much work has already gone into formulating a plan for such a change. On October 26, 2009, the Lucian Leape Institute at the National Patient Safety Foundation in Boston, Massachusetts published a white paper titled Unmet Needs: Teaching Physicians to Provide Safe Care.21 The recommendations come from an expert

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Voluntary curriculum development is important, but it is also necessary that changes take place on a larger scale (i.e., a national level).
roundtable composed of Lucian Leape Institute board members and invited experts from the medicaleducation and related elds. This paper addresses the need for medical-education reform, and specically focuses on how to change medical education to improve the safety of the healthcare system in the United States. This paper describes the current system of medical education, and then goes on to propose what medical education should ideally become. Their recommendation are as follows: Medical-school deans and teaching hospital CEOs should be creating learning cultures that emphasize patient safety, teamwork, leadership skills, communication, and performance improvement, and should provide resources and incentives to support these goals. Training in patient safety should be treated as a basic science that spans all of medical education. Training should shift from transmitting facts and information to developing desired behaviors and skills that are of equal importance in developing and preparing a physician. This would include education in problem-solving and also introduce students to faculty from other disciplines. Policies of zero tolerance must be developed for disrespectful, abusive, intimidating, and unethical behaviors by physicians. The selection process for admission to medical school should place greater emphasis on selecting for attributes that reect professionalism and an orientation to patient safety. In addition, the selection process should avoid potential students with serious psychosocial disorders and other undesirable traits. The authors then describe what strategies should be used to leverage the desired changes: The Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties should together articulate and support the need for making patient-safety training an educational priority, and these organizations must develop/expand requirements to support such training.

A system should be developed to monitor compliance with the new requirements, and results should be reported to the public. Financial, academic, and other incentives should be put in place to leverage these desired changes in medical education. State and federal funds should be used to support these changes. The authors acknowledge that this type of educational and cultural reform in medical education will require the buy-in and coordination of a variety of important stakeholders, including organizations responsible for accreditation. In particular, LCME accreditation is required for medical schools to receive federal grants for medical education and to participate in federal loan programs. Also, most state licensure boards require that medical schools be LCME accredited. The authors are recommending that LCME standards should make patient-safety education an explicit curriculum requirement, as well as setting forth competencies. Similarly, the authors are recommending that the Accreditation Council for Graduate Medical Education, the principal evaluator and accreditor of medical residency programs, set up improved institutional requirements and common program requirements. Specic recommendations are made for each organization. The problem, however, is that these changes, although desirable from a rational perspective, involve basic changes in the culture of medical schools and teaching hospitals. Can these large changes be mandated from outside of medical schools and teaching hospitals, in the sense of making the state and federal governments and the accrediting organizations the generators and enforcers of these reforms? This approach would produce a large amount of political opposition from medical schools and teaching hospitals. It will be necessary to rst get the support of the leading medical schools and teaching hospitals. Moreover, the cost of implementing these changes would be very large and constitute an unfunded mandate. Given the present economic problems in the United States, this could be a serious barrier. It should also be noted that at the present time there are very few people who are well trained to develop and teach these classes.

Research Program to Identify and Evaluate Desirable Outcomes of Various Approaches

It is also important to systematically evaluate the effectiveness of these programs, as well as other programs designed to change the ways that
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physicians think about quality and safety. A study by Madigosky and her colleagues looked at students

It is also important to systematically evaluate the effectiveness of these programs, as well as other programs designed to change the ways that physicians think about quality and safety.
who went through a patient-safety curriculum at the University of Missouri-Columbia. They found that The curriculum led to changes in second-year medical students knowledge, skills, and attitudes, but not all of the changes were sustained at one year, were in the desired direction, or were supported by their self-reported behaviors.22

certication to begin to formulate what it would take to develop a plan that the medical schools could accept and support. Activity in this arena has already begun. This planning might include phasing in various curriculum requirements over time. Perhaps working with the major insurers in the United States could result in incentive programs for phasing in various aspects of a quality and safety curriculum, particularly if such programs can be shown to be cost-effective.

Working with the major insurers in the United States could result in incentive programs for phasing in various aspects of a quality and safety curriculum, particularly if such programs can be shown to be cost-effective.
CONCLUSION
Perhaps this article can help to focus on the history, need for change, barriers to change, and some proposals for change in a way that is helpful to physicians and others who are interested in promoting safer and higher-quality healthcare.

WHAT CAN BE DONE NOW?

Despite the problems noted above, it is certainly possible to move forward in changing medical education. Although it is unclear which of the approaches outlined above (separate or dual-degree training or integrated training in the medical-school curriculum) will be more successful in training medical students and physicians in healthcare quality and safety methods and culture, we do know what we want people to learn in terms of both analytical and interpersonal skills. Information about the contents and curricula should be discussed and shared, to the extent that this can be done in a competitive educational environment. Programs can learn from one another, and do not have to reinvent everything. Many good resources are available on Web sites, and many important articles have been and will be written. A central repository for cases, resources, and teaching material should be set up, perhaps by one of the agencies involved in certifying physicians. Eventually, standards can be set for accreditation of quality and safety curricula. This will help to ensure that schools are at least meeting minimum requirements as they develop these programs. As for the changes recommended in the Leape report, some of these actions can and should be implemented as soon as possible. The unfunded mandates are unlikely given the political opposition by medical schools to be told what they must do, the severe economic conditions at this time, and the lack of personnel trained in healthcare quality and safety. Still, this is a good time for the organizations in the leadership in medical education, testing, and
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DISCLOSURES
Potential conict of interest: Nothing to report.

REFERENCES
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7. Sackett, DL, Rosenberg, WMC, Muir Gray, JA, Brian Haynes, R, Scott Richardson, W. Evidence based medicine: what it is and what it isnt. BMJ 1996; 312: 71. 8. Institute for Healthcare Improvement. IHI annual report, 2011. http://www.ihi.org/about/pages/default. aspx. Accessed November, 2010. 9. Blumenthal D, Scheck AC, eds. Improving Clinical Practice: Total Quality Management and the Physician. San Francisco, CA: Jossey-Bass; 1995. 10. McLaughlin CP, Kaluzny AD. Continuous Quality Improvement in Health Care: Theory, Implementation, and Applications. 2nd ed. Gaithersburg, MD: Aspen Publishers; 1999. 11. Graham NO. Quality Assurance in Hospitals: Strategies for Assessment and Implementation. 2nd ed. Gaithersburg, MD: Aspen Publishers; 1990. 12. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 13. Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor s Checklist Can Help Us Change Health Care from the Inside Out. New York, NY: Hudson Street Press; 2010. 14. World Health Organization. WHO Patient Safety Curriculum Guide for Medical Schools. Geneva: World Health Organization; 2009. 15. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med 2010; x: 14251439.

16. Alper A, Rosenberg EI, OBrien KE, et al. Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey. Acad Med 2009; 84: 16721676. 17. Dhalla IA, Detsky AS. Aligning incentives for academic physicians to improve health care quality. JAMA 2011; 305: 932933. 18. Thomas Jefferson University, Jefferson School of Public Health. http://www.jefferson.edu/population_ health. Accessed November, 2010. 19. Northwestern University Feinberg School of Medicine. Institute for Healthcare Studies. http://www. feinberg.northwestern.edu/ihs/index.html. Accessed November, 2010. 20. College of Medicine, University of Illinois at Chicago. Master of Science in Patient Safety Leadership. http://www.uic.edu/orgs/online/programs/master-ofscience-in-patient-safety-leadership/index.shtml. Accessed November, 2010. 21. Lucian Leape Institute Roundtable on Reforming Medical Education. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: Lucian Leape Institute and the National Patient Safety Foundation; 2010. 22. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006; 81: 94101.

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