The QI-CPD Matrix: Battling Burnout Through Professional Development in Quality Improvement:  A Primary Care Experience

Column Editor:  Natalie Sanfratello, MPH

By Mallika Sabharwal, MD

Fatigue, emotional exhaustion, depersonalization–I felt these characteristic signs of burnout upon completion of family medicine residency at Boston Medical Center (BMC) in 2022. The COVID pandemic marked my intern year. I navigated unimaginable time restrictions when seeing clinic patients and realized electronic health record inbox management had become a second job. These experiences made me hesitant to become a full-time primary care physician. Luckily at the time I was about to sign on at a Federally Qualified Health Center (FQHC), BMC had an open position in the preventive medicine residency program. Prior to medical school, I worked at a local health department and learned about preventive medicine as a specialty through my supervisor.  I took advantage of the opportunity and pursued the program.

The American College of Preventive Medicine (ACPM) describes preventive medicine physicians as those who work with governments, business, health systems, and other organizations to understand the needs of their communities and develop policy and population health practices to prevent disease.¹ The training program prepares residents for board certification through various clinical, governmental, and academic rotations.² At BMC, preventive medicine trainees are required to complete a quality improvement rotation which includes modules through the Institute for Healthcare Improvement (IHI) Open School and meeting QI leaders.

Given my focus in maternal and child health equity, I met with the Director of Quality Improvement for the Department of Obstetrics and Gynecology at BMC. He highlighted the department’s priority to reduce the rate of anemia on admission to labor and delivery. Iron deficiency anemia is common during pregnancy due to physiological changes, however if it is not treated it can lead to maternal and neonatal morbidity, like hemorrhage, blood transfusions, or small for gestational age.³ Due to systemic factors, Black birthing people are most impacted by iron deficiency anemia and its morbidity.⁴     

Around the same time, the Resident and Fellow Quality Improvement Council released a request for proposals for a project that addresses patient safety, decreases harm, and measurably improves performance. With our QI Director’s support I applied for the grant and received the award. From there, I was connected to the QI Project Specialist for the OBGYN department who had just started working in the role. We met regularly and applied knowledge from the IHI modules, defining outcome measures and reviewing run charts. However, our meetings felt incomplete and the task of decreasing rates of anemia on admission to labor and delivery among Black birthing people felt like an impossible task.   At this point, I decided to participate in the Improvement Leadership Academy offered by the institution to give me with the additional knowledge and support to proceed with this study. 

The Improvement Leadership Academy (ILA) is an experiential, interdisciplinary, interprofessional capacity building program provided by the Boston University Chobanian & Avedisian School of Medicine, Center for Continuing Education and sponsored through collaboration with BMC Quality and Patient Safety guiding healthcare professionals through an improvement project by providing skills, tools, and support to conduct QI work within one’s organization by utilizing the Institute for Healthcare Improvement’s Model for Improvement. The Fall 2023 cohort started meeting in October with monthly sessions up until March 2024. Each session had a topic, like current state assessment (CSA) or PDSA and human factors, with relevant deliverables due before the next class. Everyone received thorough feedback on their deliverables from the program manager, who maintained communication and guidance throughout the six months of the program. The ILA is offered twice a year for a 6-month period. Sessions include a day-long kickoff and monthly half day sessions. Prospective participants or participant teams apply for the program with support from their supervisor and executive sponsor with an improvement project idea in their department. Preference is given to those applications that address health system quality priorities and those projects that can be best implemented through a quality improvement framework. The addendum includes more information on the program.

As I developed my project through ILA, I discovered the time-intensive nature of the current state assessment (CSA) or a comprehensive analysis of how a process is currently functioning. In our prenatal anemia study that is the diagnosis of iron deficiency anemia during pregnancy. We convened a group of prenatal care providers that included midwives, obstetricians, and family medicine providers to create a driver diagram and identify the primary and secondary causes of increased rates of anemia on admission to labor and delivery but that was only half the story. Including the perspective of patients who were diagnosed with anemia during the pregnancy was equally important to the CSA.

To get patient input, we held focus groups in both English and Haitian Creole to learn from them their experience regarding iron supplementation and nutrition to manage iron deficiency anemia. From the patient focus groups, we learned that patients had a stronger preference for receiving health information online or electronically and were visual learners. More importantly, we learned how housing is a major barrier since living in a hotel or shelter restricted people from having the food or tools needed to manage iron deficiency anemia. One patient recalled, “I am anemic because I live in a hotel. I can’t cook and I don’t eat like I’m supposed to.” Another patient noted that “we know how to find the food, but we can’t cook it because of the shelter.”

In addition to constructive support from ILA staff, we were also paired with a mentor who had extensive experience in QI work at BMC. My mentor, a board-certified geriatrician, had completed considerable work on sepsis management throughout the hospital, among other quality projects. I met with her once a month and received feedback on my prenatal anemia project, including identifying process measures and how to navigate data collection through IT support.  The importance of mentoring as a part of the structured curriculum is a valuable point for those considering establishing their own QI academy. Various frameworks exist to employ when undergoing a QI initiative, and teams generally see more success in their initiatives if they also receive coaching from someone with experience in QI (Norman et. al., 2015). Furthermore, clinics that have received QI coaching were more likely to adopt evidence-based guidelines than those that did not (Leeman et. al., 2020). Here, coaching can be defined as tailored facilitation of a QI initiative involving problem solving and support that is sensitive to the context in which the QI is occurring. (Leeman et. al., 2020). Since QI work is so context-specific and related to the psychology of change, an experienced coach can help a team to navigate the nuances of both the interpersonal relationships of stakeholders as well as the technical skills of data collection and analysis (Leeman et. al., 2020).

The ILA helped me distinguish between QI work and research in patient care. QI work aims to improve processes or outcomes for patients, while research seeks to answer questions with generalizable results. Patient support and input is imperative in both. With the support of the Department of Obstetrics and Gynecology and the ILA, we were able to implement three PDSA cycles to affect anemia rates on admission to labor and delivery, two of which directly impact patients by providing resources and educational materials through the prenatal clinic. Data monitoring will continue over the summer and into the fall to assess improvement.  Additional funding is being pursued by the Department of Obstetrics and Gynecology to specifically address the nutritional needs of pregnant people with insufficient housing because of the focus group participants.

Now, as the preventive medicine fellowship comes to an end, my time to work as a full-time primary care physician has arrived. Having negotiated time to work in quality improvement at the FQHC, I will have the dual benefits of providing both clinical care to the community, as well as applying the QI tools learned in the ILA experience. Ultimately, I hope to contribute to the improvement of health outcomes in the community. This combined work experience of ‘care plus quality’ will also help me to effectively deal with a potential burnout situation in the future.   

References

¹American College of Preventive Medicine. About ACPM. https://www.acpm.org/about-acpm/

²American College of Preventive Medicine. What is preventive medicine? https://www.acpm.org/about-acpm/what-is-preventive-medicine/

³Smith C, Teng F, Branch E, Chu S, Joseph KS. Maternal and Perinatal Morbidity and Mortality Associated With Anemia in Pregnancy. Obstet Gynecol. 2019;134(6):1234-1244. doi:10.1097/AOG.0000000000003557

⁴Tang GH, Sholzberg M. Iron deficiency anemia among women: An issue of health equity. Blood Rev. 2024;64:101159. doi:10.1016/j.blre.2023.101159

Leeman, J., Petermann, V., Heisler-MacKinnon, J., Bjork, A., Brewer, N.T., Grabert, B.K., & Gilkey, M.B. (2020). Quality improvement coaching for human papillomavirus vaccination coverage: A process evaluation in 3 states, 2018-2019. Preventing Chronic Disease, 17(E120). DOI: https:// doi.org/10.5888/pcd17.190410

Norman, A., Fritzen, L., & Gare, B.A. (2015). Pedagogical approaches in quality improvementcoaching in healthcare: A Swedish case study of how improvement coaches approach learning in a contemporary healthcare system. Nordic Journal of Studies in Educational Policy, 2015(3). https://doi.org/10.3402/nstep.v1.30178

Mallika Sabharwal, MD, MS is a Family Medicine Physician at DotHouse Health and Preventive Medicine Faculty at Boston Medical Center. 

Natalie Sanfratello, MPH, CHCP is Senior Program Manager of Quality Improvement, Educational Programs, and Contracts, Barry M. Manuel Center for Continuing Education, the Boston University Chobanian & Avedisian School of Medicine

Addendum

Improvement Leadership Academy

The Boston University Chobanian & Avedisian School of Medicine

The Boston University Chobanian & Avedisian School of Medicine has been working with the Boston Medical Center Quality and Patient Safety Office since 2015 to support QI projects through the QI Hub. The QI Hub leverages continuing professional development education to drive improved performance and to further develop a culture of QI at the organization. We lend our expertise in QI techniques, project management, data collection and analysis, and process documentation. Under the QI Hub, we manage our ABMS Portfolio program. Our team leads and teaches in the BMC Improvement Leadership Academy which train cohorts of BMC clinicians and managers each year in QI skills. The participants in these trainings and projects include physicians, nurse practitioners (NPs), physician assistants/associates (PAs), behavioral health specialists, nurses, pharmacists, as well as medical students, residents, patient health advocates, and educators.

The Academy curriculum covers the following topics using the IHI Model for Improvement as our framework:

• Overview of the IHI model and why QI is important
• Psychology of Change
• Stakeholder Identification and Analysis
• Aim Statements and Measurement Framework
• Current State Assessment and Prioritization of Change Ideas
• Plan-Do-Study-Act Cycles and Intervention Implementation
• Run Charts and Control Charts
• Reporting
• Human Factors and Design Thinking
• Cost of Quality and Return on Investment
• Sustainability
• Poster preparation and Publication

Aim of the Program 

• To guide learners through an improvement project and provide them with the skills, tools and agency to become improvement champions in their local work areas. 
• Improvement Leadership Academy graduates will become effective leaders and facilitators who can organize teams and achieve sustainable improvements according to the goals of their department and the organization. 

Program Objectives

• Apply improvement science principles to mitigate a local gap in care delivery
• Apply skills of data collection, analysis, and interpretation to understand and improve clinical processes
• Develop leadership and communications skills required to drive meaningful change and function within interprofessional teams in order to solve clinical process challenges
• Distinguish financial analyses for improvement

Target Audience

All clinical and non-clinical mid-level managers, nurse and physician leaders, fellows and residents in training at Boston Medical Center Health System.
Sample Course Format for Fall, 2024:

• Day One Kick Off (Date: 9/13/24 from 8:30 a.m. – 4:00 p.m.): The course will kick-off with an introductory in-person meeting where we will review course expectations and key improvement concepts. Breakfast and lunch will be provided.
• Learning Blocks: Following the introduction, we will transition to 5 learning blocks from October – February. Learning blocks will be 2-3 hours in length depending on topics provided. These blocks will take place on 10/10/24, 11/8/24, 12/13/24, 1/17/25 and 2/14/25 beginning at 9am. 
• Hybrid Format: The course will be hybrid, with select sessions in-person, and other sessions on Zoom. In-person sessions will NOT be available on Zoom.  
• Graduation: Learners  will develop and present posters Quality Week 2025.

Attendance, Participation and Expectations:

• Each learner will enter the course with an idea for an improvement project that will provide an opportunity to apply the methods learned during the course.
  • This project should be strategically important to your department, with preference for projects that impact BMC’s organizational goals. You should be sure that your Supervisor and Executive Champion endorse the chosen project. 
  • Learners should maintain an open channel of communication with their supervisors to ensure they are kept abreast of project developments and are able to provide feedback to be incorporated into the project plan.
• Learners can expect to dedicate 5-10 hours to their improvement project each month.
• Learners will submit evaluation surveys and project deliverables, culminating in a final poster.
  • Project deliverables we will ask you to report in on and discuss may include your project aim statement, stakeholders, current state assessment, measures and eventually data (run or control chart).
  • Learners should expect to perform at least 1 PDSA cycle before the course ends in February 2025.
• Learners will attend 80% of sessions. If the learner must miss a session, they will review the previously recorded session.

For more information, contact Natalie Sanfratello, MPH, CHCP at nsanfrat@bu.edu.

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