SOJ Surgery

Objective: To propose a new framework to design and implement quality improvement within research projects.

Backgrounds: The design and implementation of resident-driven clinical research quality improvement projects has become increasingly complex.

Methods: We propose using the AHRQ systematic seven-step model to guide research projects and the SMART question method to conceive the clinical research questions Results.

Conclusion: Our model provides a practical approach to guiding mentors and residents in their pursuit of quality improvement projects.

Keywords: Quality improvement; clinical research; S.M.A.R.T; AHRQ

Quality improvement projects fulfill an essential core competency in general surgical training. Historically, these projects followed an apprenticeship model, in which the project mentor identified the important clinical questions, resources, personnel, and networking, while the residents carried out the specified tasks. The landscape of the healthcare system continues to evolve, bringing forward several fold challenges to maintaining this competency [1]. First, the clinical questions are growing more complex, rendering the “low hanging fruit” type of projects less frequent. Second, the mounting clinical, didactic, and administrative duties further limits the time and resources allocated to such projects. Third, the healthcare environment has become more technologically driven, heavily regulated, and multidisciplinary which requires the need to work with providers from various specialties.

The role of mentorship has become crucial to the success of trainee residents as they navigate this complex sphere and attempt to meet the benchmarks set by the ACGME for completion of their residency programs. Unfortunately, due to the Good Evening Julie,
It was great to see you in San Francisco. Sorry for causing any confusion but I am not a member of SAGES.

I wanted to request you to be a speaker on SSAT Healthcare and Quality Panel in early May 2020 in Chicago. The panel topic is Relationship between Cost and Surgical Quality and was hoping that you will share your expertise as CEO on hospital mergers. There will be three other speakers followed by panel discussion.

I sincerely hope you will accept the invitation and the Committee accepted with high ratings. Again, I apologize for not asking your permission prior to submitting your name.

Hope you have a fun vacation planned in April. Best, Vanita above-mentioned increasing demands not only on residents but also on their potential mentors, the mentors are often not equipped with the skill set to coach the residents and bring their projects to fruition. In this paper, a seven-step model is adapted from the AHRQ model and proposed to train the trainer on how to approach these projects [2]. Of note, this model should serve as a flexible approach and be viewed as a “research learning spiral” in which the team, led by the trainer, revisits and modifies each step as deemed necessary to help propel the project forward. In other words, insight gained from recurrent evaluation of every step in this motif continues to advance the aim of the project and in the process, enhance the learning experience of the residents [3].

Step 1: identify the clinical question (feasible, tangible outcome, institutional barriers)
Step 2: collect data (electronic, paper)
Step 3: analyze data (HIPAA compliance)
Step 4: develop strategy and know resources (improvement/ intervention plan)
Step 5: implement the strategy (feasibility, barriers to implementation)
Step 6: reassess implementation (compliance, utilization, pitfalls)
Step 7: modify strategy (additional changes, feedback loop)

Evidently, the first step is the most crucial to the success of the project, where the mentor’s role is of the utmost importance. The SMART framework that was used was originally described by Doran et al. In this model, the clinical question should be Specific, Measurable, Attainable, Relevant, and Time based (SMART). There are several caveats to keep in mind when devising these projects. First and foremost, the clinical question must be of relevance to the stakeholders. In the field of general surgery, the American College of Surgeons- National Safety and Quality Improvement Project (ACS-NSQIP) is a common resource used by many healthcare institutions to judge their performance against peer institutions; this resource aids in highlighting areas of deficiency that present an attractive opportunity for quality improvement interventions. More importantly, these areas of deficiency usually intersect with the interests of other stakeholders (e.g. hospital administration, public relations, hospital ranking, reimbursement…etc).

The second point is to ask if the outcome is quantifiable. The data for these projects should be readily available and its collection should ideally lie somewhere along the continuum between case reports/series and the time-intensive meta-analyses. It is important to identify the size of difference, the sample size, and the number of patients needed to reach a satisfactory answer to the posed question. Taking these factors into consideration early on avoids futile efforts and ensuing frustration.

The question of relevance to stakeholders is probably the most crucial to maintaining the project and securing sources of support. Alignment of the project with the division, department, and hospital goals is more likely to secure funding, personnel, and resources. A stakeholder analysis is therefore of the essence.

Finally, can the project be completed within a reasonable time frame? One must take into consideration the delays imposed by the proposed interventions, implementation, compliance, and data entry/processing, IRB approval…etc. In our experience, selecting a project in which such elements can be accomplished within weeks to months is more practical than long-term followup studies that take a span of several years. One must recognize that unforeseen changes in the institutional leadership, financial structure, and goals can create a major hindrance to these projects. Again, a stakeholder analysis that includes identification of the collaborators, resources, and barriers to implementation cannot be overemphasized.

Deficiencies in surgical research have been identified and examined previously and the need for a formal research curriculum has been raised [4]. Lack or limitation of resources was consistently identified as a barrier to progress in research mentoring programs [5]. In response to the challenges discussed above, one of the new models advocated lateral mentorship in which the residents continue to rely on the project mentor but also other peers involved in research [6]. While this model has merit, it does not obviate the clinical acumen, experience, and networking skills of the clinical mentor to quality improvement projects.

Our spiral research model seeks to take all these challenges into consideration and adapt the best available resources to maximize the positive outcomes for both our residents and patients.

1. Sambunjak D, Straus SE, Marusic A. A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine. J Gen Intern Med. 2010;25(1):72-78. doi: 10.1007/s11606-009-1165-8
2. Section 4: Ways to Approach the Quality Improvement Process. Content last reviewed July 2017. Agency for Healthcare Research and Quality R, MD. http://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html
3. Doran GT. There’s a SMART way to write management’s goals and objectives. Management Review. 1981;70(11):35.
4. Suliburk JW, Kao LS, Kozar RA, Mercer DW. Training future surgical scientists: realities and recommendations. Ann Surg. 2008;247(5):741-749. doi: 10.1097/SLA.0b013e318163d27d
5. Kashiwagi DT, Varkey P, Cook DA. Mentoring programs for physicians in academic medicine: a systematic review. Acad Med.2013;88(7):1029-1037. doi: 10.1097/ACM.0b013e318294f368
6. Chiu AS, Pei KY, Jean RA. Mentoring Sideways-A Model of Resident-to-Resident Research Mentorship. J Surg Educ. 2019;76(1):1-3. doi: 10.1016/j.jsurg.2018.05.016