Advocate Lutheran General Hospital, Park Ridge, IL
Process Improvement and the ACGME Annual Program Evaluation: Teaching the Teachers

Abstract

Background: Process improvement science (PIS) is relatively new to healthcare, and the Advocate Lutheran team identified the need for instruction and incorporation of PIS at the GME level. This study was designed to share knowledge and develop skills in PIS by having residency program directors (PDs) and associate program directors (APDs) complete an educational program on PIS and use these concepts and tools to prepare the required ACGME annual program evaluations (APE).

Methods: Investigators developed a pre- and postintervention survey to measure 18 participating PDs' and APDs' knowledge of and attitudes toward PIS application in evaluation and curriculum programs. The team conducted 4 education sessions, and trained, independent reviewers analyzed the APEs from the 2 years prior to the intervention (2010 and 2011) and the year following (2012).

Results: The survey revealed subjects reported either an increase in using or no knowledge of PIS practices, including PDSA models, fishbone diagrams, and process-mapping techniques. Not all subjects completed the pretest and/or attended the education sessions, which may be a factor in the PIS knowledge result. APE metrics revealed the content and format of data provided on APEs varied and some content was copied and pasted year to year. Little evidence of dynamic or process improvement existed in APEs over 3 years. The 2012 APEs did not reflect an impact from the educational sessions.

Conclusions: The study confirmed the need for education on PIS through a program that can serve those with a variety of skill levels and busy schedules. The team will next revise the APE instructions and integrate APEs into performance reviews. The PDs and faculty will continue to help develop PIS knowledge and skill programs.