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Synergistically Improving Resident Education and Rates of Human Papillomavirus Vaccination

      Academic general pediatricians accept the awesome responsibility of seeking to provide superb care to patients while teaching new generations of pediatric residents with methods of the highest quality. What if there is a way to combine both efforts synergistically? An emerging model of training does just that. Experiential and longitudinal quality improvement (QI) activities that engage the resident within a multidisciplinary office-based team can improve care delivery and create a rich learning environment. A focus on improving vaccination rates provides the resident a chance to learn fundamentals about office systems, physician communication, and QI methodology in a setting where the resident desires to best serve his or her own patients. The resident continuity clinic experience uniquely provides progressive autonomy and longitudinal ownership for patient care. Enthusiasm from residents can often serve as a catalyst for the changes necessary to see process improvement. QI done well in the continuity clinic setting is what we all seek: a more effective model of education that fosters the best health outcomes for patients.
      Residents learn practice patterns during their training that impact their future practice.
      • Cabana M.D.
      • Rand C.S.
      • Powe N.R.
      • et al.
      Why don't physicians follow clinical practice guidelines? A framework for improvement.
      Traditional continuity clinic education has been delivered in the form of minilectures, group critique of review articles, or topic-based discussions, in addition to the precepting of clinical visits by attending physicians. While the majority of pediatric residents in a national survey report positive educational experiences, about one-third indicate the QI curricula in their program needed improvement.
      • Craig M.S.
      • Garfunkel L.C.
      • Baldwin C.D.
      • et al.
      Pediatric resident education in quality improvement (QI): a national survey.
      Despite more than 90% reporting the ability to learn the concepts of QI, more than a quarter of residents lacked self-efficacy in conducting or leading future QI activities.
      • Craig M.S.
      • Garfunkel L.C.
      • Baldwin C.D.
      • et al.
      Pediatric resident education in quality improvement (QI): a national survey.
      Guidance for pediatric educators around QI is lacking.

      Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in pediatrics. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_2016.pdf. Accessed January 10, 2017.

      QI curriculum content and design, the amount of hours dedicated, and the quality of experiences are greatly variable across US postgraduate programs. The evaluation of existing curricula is limited.
      • Mann K.J.
      • Craig M.S.
      • Moses J.M.
      Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors.
      While the continuity clinic setting has been a popular site for resident QI projects, these projects have been attempted with variable success. Typical threats to the success of QI projects in this setting include lack of interprofessional support for a project which is often generated by a single resident, lack of buy-in from attending physicians or other office-based clinicians and staff, and lack of awareness of the initiative by all important stakeholders. Perhaps there are flaws in the organization of the QI project, or the topic chosen does not allow for a rich learning opportunity for residents. A resident may experience an unsuccessful improvement plan and develop doubt in the value of QI methods.
      QI around missed opportunities to vaccinate, specifically with the human papillomavirus (HPV) vaccine, offers the chance to meet a current important need for patients in a way that creates a learning opportunity for pediatric residents that can synergistically strengthen both goals. Resident physicians are invested in learning the basics of care delivery and vaccination that is fundamental to every pediatric practice. Physician educators are looking for best ways to address Accreditation Council for Graduate Medical Education (ACGME) Milestone requirements that include systems-based practice and communication with patients and families. All members of the continuity clinic team are typically eager to advocate for health promotion and illness prevention.
      Residents are often motivated by passion for a topic or a gap in care they identify, especially when the patients and families they care for are directly impacted. Improving the rates and timeliness of HPV vaccination is an important national health initiative.
      • Reagan-Steiner S.
      • Yankey D.
      • Jeyarajah J.
      • et al.
      National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2015.
      HPV vaccination QI strategies in the clinical setting include altering office protocols, adding nursing and clinician reminders at all visits, and implementing standing orders to improve patient visit flow. By engaging in these process improvements, residents gain a better understanding of the purpose of vaccination. Skills practiced and learned by the resident include effective counseling of caregivers who are hesitant about vaccination, use of a strong provider recommendation, collaborative communication with other members of the office staff, and adequate electronic medical record documentation of delayed vaccination.
      Modeling best practices and engaging residents in the process for continuous improvement is best accomplished by working together within interprofessional teams including office staff, managers, social workers, advanced practice providers, medical assistants, and nurses. Collaboration that values each person's role is exemplified through active engagement as a team working toward a common goal. The first step in the process is acceptance of the idea that the quality of care provided within the clinical setting can be improved.
      • Fieldston E.S.
      • Hart J.
      Quality improvement in primary care for children: interest and desire, but lack of action.
      Next, an appropriate topic and metric for improvement must be established. Residents often are good sources of topics, as they are intimately involved in the care of patients and can, sometimes more easily than attending physicians, generate buy-in from their resident peers. The rest of the QI team can help modify resident ideas for improvement as they factor in feasibility and prioritize by importance. Then, through careful observation of the systems involved, the team can be guided by QI methodology toward the desired improvements. The active inclusion of residents at all stages of the QI process is important to their learning as well as the success of the project as they accept roles to help identify the problem statement, create the interventions for the Plan–Do–Study–Act (PDSA) cycles, determine outcome metrics, audit charts, and review and present data.
      We have learned through national multisite projects focused on improving HPV vaccination rates that involved residents report several positive outcomes. Residents experientially learn leadership skills through their participation. Residents also appreciate peer leadership of projects which contributes to better buy-in, engagement and more robust learning and care improvement. A resident site lead who participated in a national project commented, “As residents, we are so clinically focused that we do not always step back to look at patient care issues from a systems perspective or appreciate the leadership and advocacy opportunities we have in our role as future pediatricians.” Resident involvement in a longitudinal, experiential QI curriculum has been shown to lead to scholarly activity.
      • Simasek M.
      • Ballard S.L.
      • Phelps P.
      • et al.
      Meeting resident scholarly activity requirements through a longitudinal quality improvement curriculum.
      Faculty pediatricians have an important role in the implementation of an effective QI project. Residents need to be empowered to fulfill the QI team roles that they choose or are assigned whether they are a leader, project team member, or frontline provider. Faculty mentors can help create an environment of accountability for residents so their QI efforts are recognized, as well as noticed if not fulfilled. Other important roles for faculty that lead to a more successful project include navigating the local institutional political climate, aligning projects with other clinic needs, facilitating collaboration with other stakeholders, and addressing feasibility of change suggestions, as well as mentorship or scholarly dissemination. Participation in the presentation of results at local, regional, or national meetings, and dissemination by manuscript publication are best achieved with faculty mentorship and can be enriched by collaboration.
      QI efforts can certainly be developed locally, yet there are some advantages to participation as a site within a regional or national QI collaborative. These include sharing ideas between practices, testing change strategies, including expertise in areas not available locally, mentoring staff at the individual sites, providing a QI educational curriculum, supporting ongoing data analysis, and increasing the sample size of patients involved, which may potentially result in a larger impact across multiple sites. National QI projects have often been vetted through a funding agency, which lends strength to the importance of the chosen topic. The use of multiple sites enhances the sample size and generalizability of results. Each site offers a unique perspective that enhances the implementation of the PDSA cycles. Regular touch points among sites, often by phone call, allow continued contact and assurance that collaborators have deadlines and are making continued progress.
      QI within the academic pediatric clinical setting is not without barriers. Those identified within prior projects have included difficulties with high turnover of clinical staff, administrative barriers to more rapid-cycle changes, challenges in creating a spirit of buy-in and communication due to the large number of staff and providers, limitations of resident presence, and the lack of protected time to devote to QI initiatives. Even when QI work is successful in improving metrics, sustainability can be challenging as residents graduate annually and some faculty work intermittently in this setting.
      Embracing the constant need to evaluate clinical performance and the benefits of including residents in important roles can lead to a culture within a continuity clinic where the QI process is the expectation rather than an occasional project. The focus on improvement of HPV vaccination rates is an example of an important gap that can generate widespread engagement and lead to effective resident education and skill development. This new model of learning environment may help residents to develop the passion to make QI a career-long goal.

      Acknowledgments

      Financial disclosure: Publication of this article was supported by the Centers for Disease Control and Prevention.
      Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

      References

        • Cabana M.D.
        • Rand C.S.
        • Powe N.R.
        • et al.
        Why don't physicians follow clinical practice guidelines? A framework for improvement.
        JAMA. 1999; 282: 1458-1465
        • Craig M.S.
        • Garfunkel L.C.
        • Baldwin C.D.
        • et al.
        Pediatric resident education in quality improvement (QI): a national survey.
        Acad Pediatr. 2014; 14: 54-61
      1. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in pediatrics. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_2016.pdf. Accessed January 10, 2017.

        • Mann K.J.
        • Craig M.S.
        • Moses J.M.
        Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors.
        Acad Pediatr. 2014; 14: 23-28
        • Reagan-Steiner S.
        • Yankey D.
        • Jeyarajah J.
        • et al.
        National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 850-858
        • Fieldston E.S.
        • Hart J.
        Quality improvement in primary care for children: interest and desire, but lack of action.
        Acad Pediatr. 2016; 16: 712-713
        • Simasek M.
        • Ballard S.L.
        • Phelps P.
        • et al.
        Meeting resident scholarly activity requirements through a longitudinal quality improvement curriculum.
        J Grad Med Educ. 2015; 7: 86-90