Perspectives Viewpoints•Residents should be involved in structured case review.•Resident participation in root cause analysis allows them to serve as frontline system experts.•Resident participation in root cause analysis dovetails with a culture of safety. •Residents should be involved in structured case review.•Resident participation in root cause analysis allows them to serve as frontline system experts.•Resident participation in root cause analysis dovetails with a culture of safety. Adverse event review using root cause analysis is a cornerstone of the peer review process. As stated in the landmark Institute of Medicine publication To Err is Human, “Adequate attention and resources must be devoted to analyzing reports and taking appropriate follow-up action to hold health care organizations accountable … Sufficient attention must be devoted to analyzing and understanding the causes of errors in order to make improvements.”1Kohn L.T. Corrigan J.M. Donaldson M.S. To Err is Human: Building a Safer Health System. National Academy Press, Washington, DC2000Google Scholar In response to this call to action and to state regulatory requirements, hospitals have established internal processes to collect events, analyze them, and report findings as they occur. Given that residents and fellows are integral members of academic medical centers, the Accreditation Council for Graduate Medical Education (ACGME) has emphasized the importance of training the future workforce in safety science as well. Originally, this was codified indirectly within the framework of 6 core competencies and within milestone reporting.2Accreditation Council for Graduate Medical Education (ACGME). ACGME common program requirements. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Accessed August 11, 2015.Google Scholar Through the Clinical Learning Environment Review program, institutions are now also being asked to provide opportunities for trainees to participate in hands-on investigation of events.3Accreditation Council for Graduate Medical Education (ACGME). Clinical learning environment review program. Available at: http://www.acgme.org/acgmeweb/tabid/436/ProgramandInstitutionalAccreditation/NextAccreditationSystem/ClinicalLearningEnvironmentReviewProgram.aspx. Accessed August 11, 2015.Google Scholar, 4Weiss K.B. Wagner R. Nasca T.J. Development, testing, and implementation of the ACGME clinical learning environment review (CLER) program.J Grad Med Educ. 2012; 4: 396-398Crossref PubMed Google Scholar, 5Nasca T.J. Weiss K.B. Bagian J.P. Improving clinical learning environments for tomorrow's physicians.N Engl J Med. 2014; 370: 991-993Crossref PubMed Scopus (73) Google Scholar Despite these increased requirements for safety training, most published work in quality improvement and safety education tend to focus on resident integration into quality improvement work and medical morbidity conferences rather than event review or root cause analysis.6Oyler J. Vinci L. Johnson J.K. Arora V.M. Teaching internal medicine residents to sustain their improvement through the quality assessment and improved curriculum.J Gen Intern Med. 2010; 26: 221-225Crossref PubMed Scopus (27) Google Scholar, 7Diaz V.A. Carek P.J. Dickerson L.M. Steyer T.E. Teaching quality improvement in a primary care residency.Jt Comm J Qual Improv. 2010; 36: 454-460Google Scholar, 8Kim C.S. Lukela M.P. Parekh V.I. et al.Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.Am J Med Qual. 2010; 25: 211-217Crossref PubMed Scopus (51) Google Scholar, 9Daniel D.M. Casey D.E. Levine J.L. et al.Taking a unified approach to teaching an implementing quality improvements across multiple residency programs: the Atlantic Health experience.Acad Med. 2009; 84: 1788-1795Crossref PubMed Scopus (22) Google Scholar, 10Tomolo A.M. Lawrence R.H. Watts B. et al.Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills.J Grad Med Educ. 2011; 3: 49-58Crossref PubMed Google Scholar, 11Reardon C.L. Ogrinc G. Walaszek A. A didactic and experiential quality improvement curriculum for psychiatry residents.J Grad Med Educ. 2011; 3: 562-565Crossref PubMed Google Scholar, 12Stueven J. Sklar D.P. Kaloostian P. et al.A resident-led institutional patient safety and quality improvement process.Am J Med Qual. 2012; 27: 369-376Crossref PubMed Scopus (13) Google Scholar, 13Rosenfeld J.C. Using the morbidity and mortality conference to teach and assess the ACGME general competencies.Curr Surg. 2005; 62: 664-669Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 14Falcone J.L. Lee K.K.W. Billiar T.R. Hamad G.G. Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.J Surg Educ. 2012; 69: 385-392Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 15Kauffmann R.M. Landman M.P. Shelton J. et al.The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies.J Surg Educ. 2011; 68: 303-308Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Few describe resident involvement in the peer review process itself.16Smith K.L. Ashburn S. Rule E. Jervis R. Residents contributing to inpatient quality: blending learning and improvement.J Hosp Med. 2012; 7: 148-153Crossref PubMed Scopus (13) Google Scholar In this paper we describe the structured approach to event review by residents in our Department of Medicine and share descriptive outcomes over the past several years. The Department of Medicine at Beth Israel Deaconess Medical Center (BIDMC) has had a longstanding commitment to quality, including resident training related to quality improvement and patient safety.17Aronson M.D. Neeman N. Carbo A.R. et al.A model for quality improvement programs in academic departments of medicine.Am J Med. 2008; 121: 922-929Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The Stoneman Elective in Quality Improvement at BIDMC started in 2001 as a pilot program to teach residents core principles and concepts of patient safety and quality improvement in an experiential format. The Department of Healthcare Quality (HCQ) and the residency program in the Department of Medicine together developed a 3-week elective rotation that would allow residents to perform a review of a recent adverse event and participate in a quality improvement project within the hospital.18Weingart S.N. Tess A. Driver J. et al.Creating a quality improvement elective for medical house officers.J Gen Intern Med. 2004; 19: 861-867Crossref PubMed Scopus (60) Google Scholar In 2006, our residency program entered into the Education Innovation Project within Internal Medicine. In this project, we focused on outcome measures of training and not on typical process measures. Training all of our residents in quality and safety became a cornerstone of our residency. Residents spend 3 weeks on this rotation in groups of 4 and are paired with a member of our Patient Safety Core Faculty, who serves as the case review mentor.19Tess A.V. Yang J.J. Smith C.C. et al.Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine.Acad Med. 2009; 84: 326-334Crossref PubMed Scopus (37) Google Scholar As residents took on this larger role within the formal departmental process for peer review, we recognized the need to implement a more structured approach to case identification and review. From the perspective of the Departments of Medicine and Healthcare Quality, we needed to ensure a standardized systems approach with appropriate supervision, accommodating the large number of trainees. From the educators' perspective, our process needed to support explicit learning objectives and specify clear expectations of the learners. Given that patient safety education is a relatively recent development, most house officers have little background in adverse event review.20Jagsi R. Kitch B.T. Weinstein D.F. et al.Residents report on adverse events and their causes.Arch Intern Med. 2005; 165: 2607-2613Crossref PubMed Scopus (173) Google Scholar In order to provide this background, our review process begins with a faculty-led didactic session on root cause analysis and online modules on systems theory.18Weingart S.N. Tess A. Driver J. et al.Creating a quality improvement elective for medical house officers.J Gen Intern Med. 2004; 19: 861-867Crossref PubMed Scopus (60) Google Scholar Cases for review are gathered via the usual departmental process. Cases originate from many different sources, including online event review and incident reporting systems, code reviews, death reports, and patient complaints. A subcommittee of the Medical Peer Review Committee (MPRC), including representatives from the Department of Medicine (AC, MA) and the Department of Healthcare Quality (CT) select cases appropriate for presentation at MPRC. Cases with emphasis on process of care are selected for residents to broaden their perspective on systems-based thinking. Each resident is assigned his or her own case at the beginning of the 3-week rotation (Figure 1). Residents meet with the Department of Healthcare Quality patient safety coordinator to review the process of event review, to strategize around how to approach cases involving faculty members, and to learn to minimize the negative impact on “second victims.”21Wu A.W. Medical error: the second victim.BMJ. 2000; 320: 726-727Crossref PubMed Scopus (832) Google Scholar The patient safety coordinator provides the residents with a scripted e-mail to use in approaching providers for interview to further minimize this impact. She then meets individually with each resident to review the original adverse event report for their specific case. After receiving the case and reviewing the medical record, each resident meets with their faculty mentor to identify key facts and a list of persons to interview in the peer review process. As they complete the chart review and interview providers, residents complete an online database that walks them through a root cause analysis. This assists in the identification of contributing factors, which now makes use of the Eindhoven classification scheme.22van Vuuren W, Shea CE, van der Schaaf TW. The development of an incident analysis tool for the medical field. Eindhoven, the Netherlands: Report EUT/BDK, Eindhoven University of Technology, Department of Industrial Engineering and Management Science; 1997. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.519.8706&rep=rep1&type=pdf. Accessed January 3, 2015.Google Scholar This structured approach fosters independent assessment and analysis by the resident. Residents subsequently meet with the faculty advisor to review their findings and contributing factors. Each resident then generates an action plan, meeting with hospital clinical and administrative representatives, while guided by their faculty mentor and the HCQ patient safety coordinator. Residents complete their report, including contributing factors and action plan, in an online event reporting system. Residents present their findings and make suggestions for improvement at the departmental MPRC. This committee is a multidisciplinary interprofessional committee with membership from our generalist and subspecialty faculty, as well as leadership from nursing, pharmacy, and information technology. Cases may then proceed to further internal review or external reporting, depending on the nature and severity of the case, state regulation, and accreditation agency requirements. Residents “close the loop” by providing feedback to the providers in the case, including action plans that have resulted from the case review (Figure 2). One recurring barrier to resident presentations at MPRC arose from residents' 3-week rotation schedules; in comparison, the peer review committee met monthly. Occasionally, residents would not have an opportunity to present their cases at the MPRC. Committee members recognized that the peer review was less valuable when residents were unable to share their work directly. As a result, the Department of Medicine matched the peer review committee meeting with the resident schedule, now meeting every 3 weeks instead of every 4. From 2007 to 2014, residents were responsible for 357 of 614 departmental case reviews that underwent peer review analysis. This represents 58% of all cases reviewed during this time frame. Of the 357 cases reviewed by residents, 320 (90%) were presented by residents at the departmental peer review committee; this represents 52% of all presentations over this timeframe. Since mid-2011, when the committee schedule was adjusted to accommodate resident rotations, the percentage of cases reviewed and subsequently presented by the residents at the peer review committee has been 99.4% (166 presented of 167 cases reviewed). Of the 357 cases reviewed, 341 (96%) involved processes of care. Residents reviewed only 16 (4%) procedure-related events, which tend to have less emphasis on global contributing factors. Residents were involved actively in the generation of an action plan for each case, under faculty supervision. Of the cases reviewed, many were presented subsequently in other venues: 72% were referred to additional departmental and extra-departmental meetings, 19% were presented at Morbidity and Mortality conferences, and 7% were reported to local, state, and federal agencies. In addition, 20% resulted in revision of existing policies or formation of new policies, 12% resulted in changes to the computerized provider order entry system, 2% resulted in the acquisition of new products/devices, and 2% resulting in the hiring of new/additional staff (Table).TableSummary of Resident and Committee Suggestions for ActionReferred for presentation at M&M62/328 (19%)Reported to local, stage & fed agencies22/328 (7%)Revision of existing policies or formation of new policies64/328 (20)%Changes to cPOE39/328 (12%)Acquisition of new products/devices5/328 (2%)Hiring of new/additional staff6/328 (2%)cPOE = computerized physician order entry; M&M = Morbidity and Mortality conference. Open table in a new tab cPOE = computerized physician order entry; M&M = Morbidity and Mortality conference. The model described here is the first example of which we are aware of resident involvement in hands-on case review with full integration into the Department of Medicine peer review process. We provide a structured approach to the process, collaborate with the patient safety coordinator in the Department of Healthcare Quality, and actively involve residents in the process. This provides residents with key knowledge and skills in this arena, and allows them to provide insights into the processes of care at the departmental level. This is a true win-win situation for all parties involved. Participation in adverse event review is now an expectation within the residency program, and our program has worked to standardize this process for medical residents. This dovetails nicely with the culture of safety at the hospital, which has pushed to incorporate patient safety and quality improvement efforts at departmental and global levels over the last decade.17Aronson M.D. Neeman N. Carbo A.R. et al.A model for quality improvement programs in academic departments of medicine.Am J Med. 2008; 121: 922-929Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Our program successfully integrates a large group of trainees into the safety architecture in the Department of Medicine. Over the past 14 years, we trained over 350 residents in root cause analysis. We found that the participation of residents has had a meaningful impact on the committee and that members look to the rotating residents as frontline experts in hospital operations. Our experience highlights several factors that facilitate integration of residents into the peer review structure. A collaborative relationship between the Department of Medicine and the Department of Healthcare Quality, at both leadership and the front line levels, is essential. Access to fresh cases is also critical if residents are to perform timely, meaningful, hands-on work. The Vice-Chair for Quality of the Department of Medicine and the Senior Vice President of Healthcare Quality both recognize the advantages of this partnership, which reconciles the educational mission of the Department of Medicine, the requirement for review in the Department of HCQ, and the expertise of resident physician as direct caregivers. On the front lines, medical residents, faculty mentors, and Department of Healthcare Quality patient safety coordinator work in concert to achieve similar aims. An explicit process with close oversight is also necessary. Although it is simple to assign a case to a resident and schedule him or her to present at a committee meeting, the detailed structure of the assignment ensures high-quality reviews and fulfillment of educational objectives. The standardized template, paired with direct check-ins with a faculty mentor, allowed residents to complete a full root cause analysis in approximately 2 weeks. Faculty mentors can also bring institutional memory and perspective to development of potential action plans. This prevents prior solutions that didn't work or solutions that are not feasible or timely from being brought back to the committee repeatedly. Early in the evolution of this rotation, some providers felt ambushed by phone calls for the review, and this made it harder for residents to approach staff at higher levels in the institution for interviews. We recognized the need to minimize these impacts on frontline providers in the cases selected for resident review. Our templated e-mail that the residents use to approach providers allows the practitioner to select a convenient and private time to be called; by including the faculty mentor on the e-mail, residents feel supported as they approach faculty members and those higher up in the hierarchy for interviews. This became easier as residents understood that both the reporting and review of cases were done in a nonpunitive manner and that the emphasis was truly on quality improvement. This has become embedded in the culture of this residency program. Recognizing the need to align schedules to support resident presentations was an important eureka moment for us and speaks to the importance of creating structures that support resident involvement. Whether scheduling logistics, computer access to the error reporting system, access to system leaders, or giving residents dedicated time to work on the cases, making it easier for residents to participate allows for more engagement. Partnering with our Department of Healthcare Quality to open doors and change the way things are done again speaks to the importance of a collaborative relationship. Safety work is by nature interprofessional work. We have found that one critical element has been to incorporate our patient safety coordinator, who is a nurse, in a training role in the program. The residents interview nurses and other allied health professionals in the majority of the reviews, and nursing leadership plays a large role in the peer review committee. Active conversations with other professions allow residents to see clinical care from multiple perspectives. It is an explicit way to demonstrate to our trainees the importance of interprofessional interactions in safety work. Although our process has evolved over time, several challenges remain. We rely on various methods to capture cases, but the majority of process-related cases are self-reported, rather than via mortality reports, patient complaints, or the other usual avenues for case detection. As such, there are a large number of case submissions, but it is sometimes difficult to find 3-4 new process-related cases every 3 weeks that are suitable for resident review. This is usually overcome with requests to the core faculty to identify additional cases. In addition, while we have become adept at triaging cases for review and performing root cause analysis, we are often limited in the scope of the action plans that can be implemented by residents after review. Resident reviews generate suggestions as to how to modify the care in the hospital. We assign a level of importance to the issue raised with quality improvement leaders carrying forth the suggestions. Given the nature of residents rotating responsibilities, the same resident may not be involved in the action plans. However, we attempt to provide feedback and “close the loop” by sharing implemented solutions at resident and departmental venues such as Morbidity and Mortality and educational conferences. Limitations include funding for precepting faculty, currently budgeted at 0.6 full-time equivalents in total. In addition, the BIDMC institutional culture supports a linkage between the Department of Medicine and the Department of Healthcare Quality; we recognize that these may not be present in every institution. Despite these limitations, there are numerous features in this program that can be generalized to other hospitals. Patient safety is a core competence of the well-trained clinician. The model described here offers one approach to develop that competency in a way that provides value to learner, to the hospital, and ultimately, to the patient.