Quality and Education - Wiley Online Library

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Croskerry et al. • QUALITY AND EDUCATION

Quality and Education Pat Croskerry, MD, PhD, Carey Chisholm, MD, John Vinen, MD, MHP, Debra Perina, MD Abstract Juxtaposing quality with education in emergency medicine (EM) generates two distinct issues: 1) the quality of education in EM, and 2) educating about quality in EM. There is considerable overlap between the two, and neither should be considered without the other. This paper focuses on education about quality in EM, with some

discussion of the quality of EM education. Despite its apparent importance, there is a relative paucity of research on this topic. Key words: graduate medical education; errors; medical practice; quality improvement. ACADEMIC EMERGENCY MEDICINE 2002; 9:1108– 1115.

EDUCATING ABOUT QUALITY IN EMERGENCY MEDICINE

nying the existence of systemic error-provoking weaknesses, and the blind pursuit of the ‘‘wrong type of performance measures.’’3 Further, the tolerance of particular EPCs and VPFs that develops over time, known as ‘‘normalized deviance’’ that exists in many EDs, makes any effort at defining ‘‘quality’’ particularly challenging.8 What are the dimensions of quality in the ED? Without delineating and identifying these, it is impossible to understand the relationship between quality and education. The traditional dimensions of health care (Table 1), described more than 25 years ago, remain relevant today. Characteristics of each of these dimensions have been well described.9,10 In 1980, Donabedian defined high-quality care as that which would be expected to ‘‘. . . maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.’’11 He later acknowledged that there were several possible formulations of quality ‘‘. . . depending on where we are located in the system of care and on what the nature and extent of our responsibilities are.’’12 Given the nature of emergency medicine (EM), these definitions might be particularly appropriate. The uncertainty of the ED milieu suggests a context-dependent approach to quality that acknowledges these unique ED features. Within current frameworks of quality, we would then need to develop ED-specific approaches to the measurement and management of quality. In 1990, the Institute of Medicine (IOM) saw quality as the ‘‘degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.’’13,14 The Academic Emergency Medicine Quality in Emergency Medicine consensus conference participants defined quality as ‘‘the care we (physicians) would want to receive if

The emergency department (ED) has unique operating characteristics that create special challenges on our ability to consistently provide quality.1,2 It is a clinical microsystem that has been described as ‘‘a natural laboratory for the study of error.’’3,4 Few other medical milieus experience the range of errorproducing conditions (EPCs) and violation-producing factors (VPFs) that regularly occur in most EDs.5 An EPC is any condition that increases the probability of failure in a given system. In the ED, these include diagnostic uncertainty, high decision density and cognitive load, time and resource limitations, interruptions, frequent transitions of patient care, and poor feedback.2,6,7 VPFs are associated with individual performance characteristics, having their origins in gender, personality traits, and cultural factors.5 Surge phenomena alone, the rapid changes in volume and acuity that are routinely experienced in many EDs, would be sufficient to compromise quality in any system. The attendant disruptions in provision of quality care give rise to an organizational pathology and the ‘‘vulnerable system syndrome.’’3 This results in attribution of blame to ‘‘frontline’’ individuals, deFrom the Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (PC); the Department of Emergency Medicine, Indiana University, Indianapolis, IN (CC); Emergency Medical Support Services, Royal North Shore Hospital, New South Wales, Australia (JV); and the Department of Emergency Medicine, University of Virginia, Charlottesville, VA (DP). Received July 15, 2002; accepted July 15, 2002. Presented at the AEM Consensus Conference on ‘‘Assuring Quality,’’ May 2002, St. Louis, MO. Address for correspondence and reprints: Pat Croskerry, MD, PhD, Division of Emergency Medicine, Dalhousie University Medical School, 5849 University Avenue, Halifax, Nova Scotia, Canada B3H 4H7.

ACAD EMERG MED • November 2002, Vol. 9, No. 11 • www.aemj.org

TABLE 1. Descriptors of Quality Dimensions Safety Provider competence Acceptability

Accessibility

Efficiency Appropriateness Effectiveness

Awareness of error theory, EPCs, VPFs, and error management Procedural, cognitive, and affective skills in a variety of areas Does the level of care meet patient expectations? Is it also acceptable at other levels (e.g., accreditation)? Patients are able to access the ED, and the ED is able to access ongoing care for patients The right care given at the right time in the right manner Considerations of overuse, underuse, misuse, and waste Demonstrable evidence that the care given achieved the desired effect

EPC = error-producing condition; VPF = violation-producing factor; ED = emergency department.

we got sick,’’15 which may or may not include a consideration of cost. Not surprisingly, many patients see quality at this individual level. In a recent study, process redesign of an academic ED resulted in significant decreases in waiting time intervals and led to dramatic improvements in patient satisfaction.16 Certainly, shorter wait times do result in improved quality of care (e.g., time to administration of antibiotics for pneumonia, pyelonephritis, and cellulitis), but it is unlikely that our patients are aware of these parameters. For many patients shorter ED waiting times will equate with quality, and the sophisticated advances and subtleties of modern medicine will remain largely invisible. Barriers to Quality Care. Many health care providers view barriers (historic and ongoing) as the reason that quality is less than desirable. If we are to teach about quality and understand what quality is in health care, we should understand how these barriers are perceived to have subverted initiatives to new approaches to quality measurement and implementation. Thus, learning about obstacles to quality should be part of establishing quality in education and practice. The barriers can be divided into two broad categories: general impediments to the attainment of quality (Table 2) and those that have focused on physicians (Table 3). Most of the factors listed in Table 3 cluster around Berwick et al.’s four themes: time, territory, tradition, and trust.19 Disproportionate emphasis on historic physician-resistance barriers inappropriately suggests that they alone are responsible for the perceived quality failures in health care delivery. Yet a number of the physician concerns about quality implementation programs are legitimate.

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Quality indicators developed by nonclinicians often are not congruent with what the patient or the physician understands to be quality care. Also, by replacing physicians as leaders in the quality initiative, we are experiencing a leadership vacuum. One of the critical changes at the University of Arizona study involved making an EM physician the administrative director of the ED.16 We do not need to restore a physician-centric culture, but the interdependence of the care team and the multidisciplinary approach to the delivery of EM care mandate leadership. Good teams need good leaders, and EM physicians are well suited to this role. Measuring Quality. In their most recent report, the TABLE 2. General Barriers to Change* 1. Unclear quality improvement goals: a lack of focus, prioritization, direction, vision 2. Unreliable and uncomparable data: failure of providers to benchmark improvements in quality 3. Inadequate information technology: failure of organizations to provide adequate IT support for the new complexity of health care 4. Payment policies: current systems do not provide adequate incentives or rewards for improved quality 5. Lack of organizational and system support for quality: failure to appreciate that quality is a product of the interaction of individual, technical, organizational, regulatory, and economic factors 6. Liability issues: failure to develop no-fault system, persistence of adversarial legal position, barriers to openness, discussion, and examination of error 7. Failure to develop a culture of quality: no move toward a culture of excellence *Based on: Kizer K. Quality in emergency medicine. Plenary address at the AEM Consensus Conference on Quality in Emergency Medicine, St. Louis, MO, 2002.

TABLE 3. Physician Barriers18–21 1. Intrinsic resistance to change 2. Relinquishing of control, autonomy, power, and clinical freedom 3. Quality improvement (QI) not seen as a clinical function 4. Shift of leadership from physician to team, organization, system 5. New accountability—previously physicians saw accountability only to themselves and their professional bodies; now it has nonclinical origins 6. Disagreement with criteria being used for quality; seen to be developed by those without clinical training and insights into patient care 7. Development of new QI initiatives requires an investment of physician time and is seen as an encroachment on clinical time 8. Time spent on QI is seen as an added burden to other administrative duties 9. QI is seen as an opportunity for blame and possibly litigation 10. Absence of physician role models in the new paradigm 11. Suspicions that QI programs are designed to cut costs rather than improve care

1110 IOM defines six domains of quality: care must be safe, efficient, patient-centered, effective, timely, and equitable.22 These are not substantially different from the dimensions listed in Table 1, but they are notable for the addition of equitability.22 Quality assessment occurs through examination of process data and/or outcome data. Process data look at features of the interaction between the health care professional and the patient. Outcome data focus on the result of that interaction. The lower cost and relative ease of data collection and analysis, as well as ‘‘control’’ of the components by care providers, result in disproportionate assessment of process phenomena. Table 4 lists the methods of assessing quality based on process data. The first three use implicit criteria; i.e., the care is evaluated from a standpoint where no previous agreement exists on what constitutes good or bad care. The last two are explicit and more rigorous, in that there is a prior expectation of what constitutes good quality. There is some consensus that we should continue to use process criteria, provided that they are based on good evidence and that there is expert agreement that application does lead to quality improvements.23 Outcome measures are more likely to reflect team performance, rendering this as a better measuring device. Gaming Behavior and Perverse Incentives. One of the unintended consequences of quality improvement programs is that behaviors sometimes result that have little to do with quality. Due to the interconnection of system components, introduced changes on one level may result in unanticipated and untoward events on another. Efforts focusing entirely on numerical goals can result in compromised clinical performance. For example, the drive to reduce door-to-needle time can occasionally result in disproportionate focus toward the obvious (anchoring), and a patient with pericarditis or a dissecting aorta may inadvertently receive thrombolytics with adverse outcomes.24 Speed, while easily targeted in process data studies, may not reflect the TABLE 4. Methods of Assessing Quality* 1. Determination of adequacy of process of care from data source (e.g., medical record) 2. Could better care have improved the outcome? 3. Considering process and outcome, was overall quality of care acceptable? 4. What proportion of accepted process criteria was met in the care provided? 5. Are the observed results of care consistent with explicit, validated expectations? *Based on: Brook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2: measuring quality of care. N Engl J Med. 1996; 335:966–70.


occasional poor outcome data created by such a simplistic focus. Similarly, developing ‘‘league-tables’’ (‘‘quality’’ hierarchies based on morbidity and mortality statistics) for surgeons may lead to a tendency not to operate on difficult cases because poorer outcomes will tarnish the surgeon’s profile. There should be eternal vigilance for performance indicators that have not been fully examined clinically and/or are driven more by process statistics or charges. Further, we should be aware of the pitfalls behind the mentality ‘‘If it can’t be counted, it doesn’t count.’’ The parameters of good quality are not always obvious, but absence of proof is not proof of absence. We should be wary, too, of reacting to pseudoindicators of quality. Occasionally, the media seizes upon catastrophic events that become inflated beyond the overall context of health care delivery. One of the best examples is the impact of New York State’s Bell Commission regulatory statutes on graduate medical education following the death of Libby Zion in 1984. The ramifications of these statutes continue to have profound effects on teaching hospitals, without attendant evidence of improved outcomes. This might lead to fiscal and other efforts’ being misdirected at relatively insignificant system weaknesses, or the wrong target entirely. The relative merits of individual components of a quality improvement program need to be examined in the broad picture, and we need to be aware of initiatives that are tailored to the squeakiest wheel. The Teaching of Quality. Once there is a consensus of what quality means in EM, an accepted lexicon and a core content embracing new paradigms of quality will be required (Table 5). Teaching methodologies must then be developed such as the REACT approach (Table 6). It emphasizes the connection between acquired knowledge and the context in which it will be used. It offers strategies for optimal ways in which the concepts of quality might be inculcated into the EM culture of learning. Relating. Acquired core content knowledge needs to be applied in the ED. Educators should illustrate how routine function, events, and the varying work environment of the ED impact quality. For example, students and residents need to be aware of conditions under which resource availability (RA) and continuous quality improvement (CQI) begin to trade-off (TO), and which may lead to the vulnerable system syndrome. Resource availability–continuous quality improvement trade-off (RACQITO) typically applies to surge conditions and is a useful concept in educating about quality in EM.25 It is one


TABLE 5. Core Content for Quality in Emergency Medicine (EM) 1. Educating about quality in EM Basic principles of quality theory Lexicon of quality terms Unique operating characteristics of the emergency department that affect quality Barriers to change Vulnerable system syndrome/RACQITO* Process and outcome approaches/gaming behavior 2. Quality of education in EM Contextual learning emphasis Medical error and safety theory Early critical thinking skills training Cognitive bias detection training in clinical decision making Training in transference of learning theory Training in skill maintenance theory Assessment tools for acquisition of lifelong improvement skills *RACQITO = resource availability–continuous quality improvement trade-off.

TABLE 6. Five Features of Learning about Quality in Emergency Medicine* • • • • •

Relating Experiencing Applying Cooperating Transferring

*Developed by the Centre for Occupational Research and Development ([email protected]).

thing to understand the essential components of quality, but quite another to deliver them in environments where the resources are limited. The relation of quality theory to practice can be usefully supplemented in the problem-based learning (PBL) format with re-told clinical cases (war stories), video vignettes, simulation, and other aids.26 Experiencing. There is no substitute for experience, and any learning in the classroom is passive compared with the active learning that takes place in the ED. As soon as the core material has been acquired, it must be actively manipulated in the ED. Clinical bedside teaching should incorporate and integrate quality concepts. Experience should also embrace ED settings other than those of the academic setting. One option is to provide training opportunities outside of the academic ED, or conversely, focus on issues that are routinely encountered at a community practice setting but rarely discussed in an academic setting (transfer of patients, responding to critically ill patients outside of the ED, unavailable diagnostic testing). Applying. Students must show that they can apply

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the concepts that have been taught at the core content level and in PBL. This might be accomplished through an ongoing relationship with a clinical mentor trained in quality issues. The student should be able to demonstrate how quality theory and practice are translated into a variety of other ED settings, as well as at an organizational level. Cooperating. The importance of teamwork in the ED has received considerable emphasis recently.27 The introduction of small-group PBL into many medical schools has provided an exceptional opportunity for students to work cooperatively in smaller size groups, and to experience the beginnings of teamwork. The shared and cooperative learning that occurs in this format is not only superior to that which occurs in the traditional, didactic class lecture, it also introduces the student to the team approach so valued in the ED. Teamworking also allows physicians to get away from the traditional paradigm that emphasized autonomy but encouraged isolation. The principles of teamwork (delegation, observation, suggestion, discussion) and an appreciation of the interdependencies inherent in health care are a recommendation of the IOM.22 Transferring. The ability to take what is learned in one context and transfer it to another is the hallmark of a successful educational program. This is especially important as much of core competency learning is ‘‘situation-dependent’’ (see below). When the principles of quality health care have been learned effectively, they will be applicable in novel contexts. Further, the process of transfer itself amplifies, reinforces, and refines acquired knowledge. Confidence grows from being able to build on what has already been learned.

OVERALL APPROACH TO TEACHING ABOUT QUALITY IN EM The new ‘‘tight–loose–tight’’ deployment strategy that characterises successful organizations28 might provide an effective approach to teaching about quality in EM. In the initial tight phase, the basic principles of continuous quality improvement, as well as the most meaningful and measurable performance indicators and outcome measures, are agreed upon at a discipline level. There should result a clear vision of what is meant by quality EM, and how to measure and achieve it. The core content of EM then incorporates these quality components. The loose phase refers to the local development of programs and initiatives to deliver the core con-

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tent. This occurs under the leadership of senior EM faculty at the teaching institution. It will provide the flexibility to allow for what can and cannot be done with local resources and personnel. Some programs will have different strengths in different parts of the program compared with others. The final tight phase brings accountability through accreditation or certification by governance at the discipline level (e.g., the American Board of Emergency Medicine, ABEM), or at an umbrella organization level such as the American Board of Medical Specialties (ABMS), the Accreditation Council for Graduate Medical Education (ACGME), or the American Association of Medical Colleges (AAMC).

QUALITY OF EDUCATION IN EM The quality of education provided to learners needs continuous monitoring and occasional revision to respond to the ongoing changes in knowledge. The seven dimensions of quality (Table 1), to which should be added equitability, apply equally to the process of EM education. The goal is teaching information in EM that fulfils acceptable and validated criteria. The dimensions are considered in turn below: 1. Safety. While safety has always been considered an essential feature of quality of care, it is only relatively recently that the full significance of its relationship to quality has been realized. The IOM proposed addressing patient safety issues in educational curricula.22 An agenda and curriculum for teaching about patient safety and error in EM have been proposed,26 as well as a system for analyzing medical errors to improve graduate medical education (GME) curricula and programs.29 Preliminary curricula proposals have recently been developed.30–32 While some of these course materials may need to be formally introduced into the curriculum, many of the ideas and concepts around patient safety should be incorporated into existing teaching avenues (e.g., bedside clinical teaching, teaching moments, morbidity and mortality rounds), preferably using narrative and case-based material rather than less-effective didactic approaches. 2. Provider Competence. There are a number of issues around provider competence that are critical in quality of education. Emergency medicine educators must determine what the content of competency should be, the optimal ways of teaching it, and what steps are necessary to maintain it. Traditionally, the ACGME, as the entity responsible for setting standards and accrediting GME programs,

has based accreditation decisions on a residency’s substantial compliance with established program requirements in a prescriptive review fashion. In part in response to the IOM report, the ACGME, together with the ABMS, developed six new core competencies to be incorporated into all GME programs by July 2002. These core competencies are listed in Table 7. By 2006, programs are expected to put into place assessment methods to collect outcomes of the educational content and to ensure that trainees are acquiring the core competencies. This ongoing assessment of both trainees and the program will provide a nidus for quality improvement of the educational program itself. This represents a frame-shift by the ACGME in accreditation requirements to one of outcomes assessment rather than simply process measurement against an educational requirement. Still, the basic core competencies have several limitations. First, an emerging concern in medical education in recent years has been the lack of emphasis on thinking strategies (problem solving, clinical decision making) and critical thinking skills (e.g., bias detection). Much of medical education is aimed at acquisition rather than application of knowledge.25 It is somewhat disconcerting that up to 20% of undergraduates may not have achieved sufficient cognitive maturation to be able to think at the conceptual level required for problem solv-

TABLE 7. Accreditation Council for Graduate Medical Education (ACGME) Core Competencies* a. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health b. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care c. Practice-Based Learning and Improvement that involves investigation and evaluation of the learners’ own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care d. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals e. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population f. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value *Used with permission of the Accreditation Council for Graduate Medical Education. 䊚 ACGME, 2002.


ing.33 The impact of this might be considerable in EM, where clinical problem skills and the ability to detect cognitive bias in decision making are so critical.34 However, it appears that these skills can be acquired through specific teaching methods based on cognitive learning theory.35 Recognizing this, some medical educators have introduced clinical problem solving at the outset of medical undergraduate training.36 Because a significant proportion of beginning residents lack this level of critical thinking, some will need closer supervision into later stages of training. Supervision practices of EDs should reflect this caution. We should recognize that EM is a discipline that places considerable reliance on critical thinking and problem solving in a unique practice context. This should be emphasized at the outset of residency training. Given the prevalence of heuristic thinking, the overwhelming tendency in the ED to take cognitive shortcuts, and the vulnerability to cognitive bias in EM, it is especially important to encourage the development of ‘‘metacognition,’’ the ability for reflection and introspection about one’s thinking.25,37 This is especially important at a time when many areas of EM are being increasingly (judiciously) driven by clinical decision rules. There will be an increased need for metacognitive thinking styles in EM that allow the practitioner to step back from protocol and rule-driven decision making and accommodate the unusual, exceptional, atypical, or esoteric clinical presentations. We should be mindful, too, that mimicry forms a significant part of learning. Learners will mimic and incorporate system values and behavior modeled by their clinical teachers. If the ED does not emphasize a quality approach, then the learners cannot be expected to value it. Faculty in large teaching centers often work in bureaucratic systems that are notoriously cumbersome to change. Despite these imperfections, it is important that they serve as role-models for residents in developing quality-seeking behaviors, lest their learners develop a nihilistic attitude toward systems change and quality medical care delivery. Second, the structured learning that does take place in satisfying the formal requirements of ‘‘competence’’ is highly situation-dependent. Often, the learning experience provided in an academic setting varies dramatically from the eventual practice environment. Upper-level EM residents often serve as ‘‘flow supervisors’’ or ‘‘pit bosses’’ of more junior residents and students. It is unclear how this skill set translates into the multitasking skills required in a busy community setting in which the only physician present to ‘‘manage’’ is the solo ED practitioner.

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Another example is trauma management. In the academic setting, which is usually a Level 1 trauma center, there is an abundance of personnel from a variety of levels of training, disciplines, and professions. Both human and technical resources will usually be plentiful, and care is often rote and protocol-driven. Crowd control and an appreciation of authority gradients may be two of the more important skills to be learned. But it is unclear whether this skill set translates into the community setting where the EM physician must simultaneously provide both the cognitive and the technical components of the trauma resuscitation with far fewer resources. These two distinct components (cognitive and technical skills) of a trauma resuscitation are usually separated in the training center. In addition, transfer decisions and mechanics suddenly become critical, yet the training center rarely reflects this experience. Similar situation-dependent learning occurs in other settings: the ten deliveries required for competence in obstetrics are usually spontaneous vaginal deliveries in a setting where protocol, routine equipment, and abundant expertise are at hand. Emergency medicine residents’ will usually be denied any difficult deliveries, and receive close supervision from seasoned nurses and more experienced practitioners. Again, the experience is likely to be quite different from that in the graduate’s first job. The American Board of Emergency Medicine’s move to a life-long self-assessment acknowledges the potential cognitive degradation over time. However, this incompletely addresses cognitive degradation and does not include the concept that being technically skillful in a particular procedure requires both an acquisition and a maintenance phase. It is a certainty that all skills that are not maintained will decay over time, yet unlike other high-technology occupations such as aviation, there is no mandatory requirement in critical skill areas known to be vulnerable to decay. Given the recent advances in high-fidelity simulation, it should be possible to design ‘‘maintenance’’ courses in critical skill areas for practicing clinicians, and avoid any attendant discomfort that might result from re-joining residents in clinical training. Paradoxically, faculty at teaching centers may be the most vulnerable to technical skill degradation. 3. Acceptability. If the care provided by the ED health care teams meets the expectations of patients, and the overall performance of the ED meets the needs of the community, then the health care provided can be said to be acceptable. Acceptability says less about the process of care than it does

1114 about outcome. It is defined mostly by how it is perceived from without rather than within. Thus, some parameters of care (e.g., attitude and demeanor of care providers, patient wait times) may be disproportionately weighted as an index of satisfaction by patients. The historic yardsticks of acceptability are patient satisfaction surveys (never validated from the ED patient population), proportion of patients who left without being seen (LWBS), accreditation, and other institutional or organizational endorsements. 4. Accessibility (and Equitability). The ease with which patients can access the services of the ED reflects accessibility. It refers to access not only to the services and capability of the ED, but also to the various services that patients believe can be accessed through the ED. These are often influenced by the quality of support services and the resources of the hospital. Importantly, accessibility should be available to all; i.e., it should be equitable. Paradoxically, the types of patients most vulnerable to poor-quality care (ethnic minorities, the impoverished, the uninsured) access the health care system through the ED. Again, patient satisfaction surveys, and other indices of resource utilization within the hospital (occupancy rates, wait lists, etc.), provide a crude measure of accessibility. 5. Efficiency. The provision of an excellent service with a minimum of effort, expense, and waste reflects the efficiency of the ED. High efficiency translates directly into high-quality care. It will be reflected in patient satisfaction, but also in more objective measures of performance such as budget performance, workload measurement, utilization data, complaints, turnaround times, LWBS rates, and wait times. 6. Appropriateness. If the ED is not providing the correct and proper things in its delivery of care, then the care is inappropriate. The correctness and appropriateness of care are largely determined by evidence-based medicine, which, in turn, influences the development of clinical practice guidelines and clinical pathways. Certain algorithms (e.g., Advanced Cardiac Life Support, Advanced Trauma Life Support) and guidelines (e.g., Ottawa Ankle Rules, Canadian C-spine Rules) are widely disseminated and accepted, but many proven guidelines and pathways are not consistently implemented. Given the amount of clinical expertise and resources of the modern ED, it could also be considered inappropriate to provide care that would be better delivered in a family physician’s office. Appropriateness can be assessed through case reviews


at morbidity and mortality (M&M) conferences rounds, chart audits, compliance with clinical practice guidelines and clinical pathways, etc. 7. Effectiveness. There is considerable overlap between efficiency and effectiveness, but the latter refers more to doing the right things right, and using meaningful and appropriate outcome measures to demonstrate it. Effectiveness can be assessed again though M&M conferences rounds, external review of the department, clinical appraisal, and outcome data (e.g., the appropriate thrombolytic in an appropriate time).

RECOMMENDATIONS Teaching Quality in EM. 1.

2.

3.

Consensus should be reached on reliable and meaningful definitions of quality in EM, and on the best ways to measure it. A core content in quality should be developed for EM. It would include the general principles of continuous quality improvement as it applies within the special context of EM. A basic lexicon of terms should also be developed to facilitate communication. The core content would include a review of the principal dimensions of quality, and their application in EM. There should be an understanding of how quality can be reliably and meaningfully assessed. The content should also provide some insight into the barriers to quality in health care. Specific strategies should be adopted to teach quality in effective and meaningful ways. The optimum method should be problem-based learning in the small-group tutorial format. The approach should stress contextual learning, the applicability of quality concepts in the ED, and the special operating characteristics of the ED. The problem of situation-dependent learning should be recognized and a strong effort made to include ‘‘field’’ experience in settings outside the teaching center. The teaching approach should optimize the likelihood of transfer capability once formal training is complete.

Quality of Education in EM. 1.

2.

3.

The quality of education in EM should be examined against the principal dimensions of quality of health care. Undergraduate and postgraduate curricula must address safety issues. All teaching venues should inculcate a culture of safety. The core competencies should include Safety and Quality.


4.

5.

6.

The teaching of problem solving, critical thinking skills, clinical decision making, and, especially, cognitive bias detection should begin as early as possible in the undergraduate program. Emergency medicine residents should have special coaching in these skills throughout their training. The situation-dependent nature of GME must be recognized. Training should be more comprehensive, so that graduates will be more likely to function optimally in the wide variety of workplace settings encountered after completion of formal training. There must be recognition that particular skills, including key procedures, once acquired, need ongoing maintenance. Critical skills should be reassessed on a regular basis throughout a practicing clinician’s career.

15. 16.

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The administrative support of Sherri Lamont at the Dartmouth General Hospital is gratefully acknowledged.

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References

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