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View from the top: Leadership perspectives on the use of practice improvement modules (PIMs) in residency programs.

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Bernabeo EC, Hood SC, Iobst WF, Holmboe ES. — American Board of Internal Medicine

Caverzagie K. — Henry Ford Hospital

Presented: Asia Pacific Medical Education Conference, January 2011

Background: Internal medicine training programs in the U.S. are charged with teaching and evaluating quality improvement (QI) as part of the Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP) competencies. The American Board of Internal Medicine (ABIM) approved the use of ABIM PIMs Practice Improvement Modules® in internal medicine residency and fellowship programs as part of their PBLI/SBP curriculum. PIMs are Web-based tools that combine medical record audit, patient experience surveys, and an assessment of office systems to guide a comprehensive self-evaluation of practice performance. Preliminary research in training has suggested PIMs are variable in terms of ease of use and value in this setting. This study sought to deepen understanding of the PIM experience as part of the QI curriculum in residency and fellowship programs from the perspective of the PIM faculty leader.

Methods: A total of 43/59 (73%) of programs responded to a Web-based survey assessing the experience and impact of a PIM in training. The Program Director (PD) or Associate PD was the leader of the PIM process in 30 of the 43 programs (70%), citing prior interest in QI, responsibility to program, and/or because “no one else was available to do it” as primary reasons for assuming the leadership role.

Results: Trainees’ degree of involvement was highly variable between programs, and several PIM leaders felt that residents and fellows were not engaged enough at a deep level, or with enough consistency. The most common QI activity for trainee involvement was data collection, largely through patient surveys or chart review. These activities were typically completed during clinic or research time, with only 17 of the 43 programs (40%) having protected time to complete the work. Few trainees were given leadership roles within the PIM process, or participated in higher level activities such as data analysis, problem solving or identification for areas of improvement.

Despite these modest roles, the majority of leaders felt that the completion of the PIM helped trainees learn basic principles of QI (36/41; 88%), develop competence in PBLI and SBP (34/41; 83%) and prepare them for MOC (30/41; 73%). Leaders further reported that completing the PIM improved the program’s ability to understand and develop QI initiatives (31/41; 76%) and frequently resulted in program-level (25/41; 61%) or institutional (26/41; 63%) enhancements to care systems or processes. Most described a sustainable improvement in process or outcome measures of patient care, such as increased screening rates for preventive services (30/41; 73%). The majority of leaders (36/43; 84%) reported that the effort to complete the PIM was worth the outcome.

Conclusion: Leaders report PIMs to be a valuable but underutilized educational experience for trainees as well as training programs. Generally, PIM projects led to the development and implementation of meaningful QI activities and sustainable improvements. However, training programs should encourage greater faculty and trainee involvement, especially in QI projects. Future research should address the experience and impact of the PIM from the resident and fellow perspective, to better understand how trainee participation, learning and engagement in QI can be optimized.

For more information about this presentation, please contact Research@abim.org.