Organizational success in quality improvement depends on a well-functioning QI system and the ability to focus on prioritized goals. Health care organizations often set broad QI objectives and let their workforce (as well as their residents and fellows) identify specific goals that are meaningful at the local level. Residents and fellows should be encouraged to design and implement interprofessional QI efforts that align with the CLE's overall goals. This will increase the chance of attracting organizational resources and enhance the probability of sustained improvement.

If residents and fellows are to learn to improve the health of the populations they serve, they need to be aware of quality goals such as those set by regulators, payers, and others outside the CLE (e.g., use of universal protocol, or reducing central line-associated blood stream infections, catheter-associated urinary tract infections, or potentially avoidable 30-day readmissions). They also must learn to critically evaluate the CLE's own processes of patient care and how those affect patient outcomes.

Didactic approaches are helpful but insufficient, and data from the CLER site visits suggests that residents and fellows' exposure to quality improvement is often fragmented. Learners rarely have the opportunity to work through the full scope of an improvement effort. Instead, they may plan an intervention they never get to test, or implement a change with limited knowledge of the background evidence and no opportunity for follow-up evaluation. Experiential training in all phases of QI is necessary to develop the skills essential to improving health care quality.

Optimal QI strategies should include formal, reliable, and regular structural links between the efforts generated by the residents, fellows, and faculty members and the CLE's staff-led efforts to improve care. Coordinating the resident and fellow QI efforts with those of the organization would benefit patients, tap into a rich resource of innovation, and provide the foundation for life-long QI success.

Disparities

There are differences in health care and health outcomes among various populations and sub-populations within the US.8 Residents and fellows should be aware of these disparities and participate in efforts to eliminate them.

While access to care—limited by financial constraints, workforce shortages, and geographic challenges—is an important contributing factor to health care disparities, it is not the only factor. There are many socio-cultural and economic barriers that affect patient care. The CLER site visits found that few CLEs have a well-defined or easily articulated formal strategy to routinely monitor and address health care disparities among their patients. As a result, residents and fellows may not learn how to best manage these issues in their later careers.

CLEs need to assure that their residents and fellows learn to recognize health care disparities and strive for optimal outcomes for all patients, especially those in potentially vulnerable populations. As front-line caregivers, residents and fellows are a valuable resource for formulating strategy on these matters. They can assist the CLEs in addressing not only low income populations, but also those that experience differences in access or outcome based on gender, race, ethnicity, sexual orientation, health literacy, primary language, disability, geography, and other factors.

The diverse, often vulnerable, patient populations served by CLEs also provide an important opportunity for teaching residents and fellows to be respectful of patient cultural differences and beliefs, and the social determinants of health. In learning cultural competence, residents and fellows would benefit from moving beyond one-time educational activities to a more formal, longitudinal curricular-based program of progressive educational activities that continues throughout training. Similarly, they may benefit from experiential learning within a community context for some of the culturally unique groups in the local environment. That would prepare them not only to address the disparities they face today but other unknown challenges that will arise in their future careers.

2016 CLER National Report of Findings

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