Leadership in health care now requires an understanding of how health information technology (HIT) can help to deliver safe, high-quality care. In recent years, policymakers, educators, and health care leaders have seen a need to change educational models in order to synthesize HIT concepts with ongoing quality and safety efforts. In response to this growing need for a shift in the educational paradigm, the Safety, Quality, Informatics and Leadership (SQIL) program was conceived at Harvard Medical School (HMS), with a target audience of current and emerging health care leaders. The conceptual framework anchoring the SQIL program is the Learning Health System, which combines information technology (IT), data, and a culture of continuous improvement to enable health care organizations to evolve into true learning systems.
What Does the HMS SQIL Program Look Like?
What makes the HMS SQIL program unique is the international student body and the blended learning format, which combines face-to-face learning with online learning. The SQIL program comprises modules in patient safety, quality of care, informatics, and leadership, with subthemes of policy and research woven throughout the curriculum. Three face-to-face workshops, held in London (UK), Dubai (UAE), and Boston (USA), anchor a year-long master’s-level certificate program.
The workshops focus on active adult learning and involve medical simulation scenarios, case-based exercises from Harvard Business School (focusing on, for example, such cases as “The 2010 Chilean Mining Crisis Rescue,” “Paul Levy: Taking Charge of the Beth Israel Deaconess Medical Center,” and “The Dana-Farber Cancer Institute”), and robust discussions and small-group exercises led by national and international thought leaders. Between the in-person workshops, students join online modules, participate in interactive faculty webinars, complete and present team assignments with their peers, and undertake a final individual capstone project. This blended learning format involving an international, multidisciplinary student body creates a global community of learning.
The Macro, Meso, and Micro Levels of Learning
The SQIL program showcases the challenges of patient safety, quality, and informatics at three levels: (1) macro (focusing on national and international considerations), (2) meso (focusing on organizational considerations), and (3) micro (focusing on an individual or small team). At the macro level, the three workshops mentioned above present strategic overviews of major regional health care challenges. National leaders, such as Sir Liam Donaldson in London and Dr. David Blumenthal in Boston, provide a rich yet frank commentary on the merits and drawbacks of nationalized health care and electronic health record (EHR) adoption. In Dubai, Dr. Sameen Siddiqi from the World Health Organization elaborates on a different set of challenges for low- and middle-income countries, such as the catastrophic collapse of health care infrastructure as the result of war and the rising prevalence of non-communicable diseases.
At the meso and micro levels, concepts such as value in health care and optimizing the delivery of primary care are discussed with Dr. Thomas Lee. The valuable repertoire of shared knowledge and skills that participants acquire during the in-person workshops are potentially transferrable when these individuals return to their local health care settings.
What Types of Participants Does the SQIL Program Attract?
Potential students complete an online application and submit a CV and letter of recommendation, all of which are reviewed by the SQIL program directors and staff. In our first year, we had 73 participants representing 14 different countries, with some scholarship support offered to participants from low- and middle-income countries; in our second year, we have 52 participants.
The majority of our student body consists of health professionals, mostly physicians; however, our program also includes students who are non-clinical health care administrators, as well as leaders from the private sector. In our first year, for example, physicians, nurses, and other health professionals worked side-by-side with a Chief Information Security Officer, a Head of Quality and Manager Operations, a Quality Improvement Facilitator, and an Operation and Training Director for a helicopter company. As leadership positions in health care are not solely within the purview of physicians, we find that participants with skills in finance, business administration, computer science, and change management provide valuable contributions during classroom and team learning.
Although much of the educational content is delivered from the perspective of a clinician, participants with a non-clinical background have much to offer and much to gain. During our Dubai workshop, students learn by spending a full afternoon participating in three medical simulation scenarios: emergency department disaster triage, crisis resource management, and unstable patient evaluation. Each scenario is followed by a facilitated debriefing session to deconstruct the event. The goals of the simulation exercises are to provide a safe adult learning environment with active participation and to teach practical lessons in quality and patient safety, with a focus on building individual and small-group leadership skills.
We have found that, in some simulation scenarios, participants with a clinical background often take the lead but are so focused on the clinical facets of the case that key elements of teamwork and communication are not executed well. In the debriefing sessions, non-clinical participants often provide significant insights into team leadership, conflict resolution, collaboration, and closed-loop communication. The diverse clinical and non-clinical perspectives on the simulation exercises provide a rich opportunity for group learning.
The Capstone Project
All participants are required to complete a final six-page capstone project, with the top three projects being presented at our third workshop at HMS in Boston. We encourage participants to weave the major strands of learning on quality, safety, informatics, and leadership into their capstone projects. Each proposal covers the same basic elements (Background, Problem, Aims, and Measurement) but also addresses potential challenges, risk-mitigation strategies, and approaches to ensuring sustainability and scalability. The breadth of the proposals that we have received has reflected the learning that has occurred during the program.
We have found that participants may implement their capstone projects locally during the course of the program. For instance, one of our top-3 capstone projects from Year 1 focused on improving patient safety through reduced time to follow-up after receiving an abnormal test result in the ambulatory setting. The multifaceted intervention consisted of (1) an electronic alert flag within the patient’s chart that was visible to all clinicians, coupled with an electronic referral functionality to expedite appropriate care based on the abnormal result, (2) dual notifications of the abnormal result through both an SMS text message sent directly to the patient and a separate message sent via the patient portal, and (3) a simplified physician workflow to ensure review of and action on the abnormal result. This project deploys several innovative features, such as using EHR data to identify at-risk patients and directly involving patients in the follow-up on abnormal test results. If this capstone project is successful, the concepts behind the EHR functionality, patient SMS platform, and physician workflow potentially can be implemented by SQIL participants in other countries.
Another successful top-3 capstone project from Year 1 involved an initiative to standardize the use of appropriate antibiotic prophylaxis in elective orthopedic surgery cases. A retrospective audit was conducted to identify whether compliance with infection-control guidelines was occurring. The audit demonstrated that the surgery case-booking process was problematic in that it did not leave enough time for an adequate preoperative assessment, resulting in a potential for precautionary overprescription of antibiotics. An intervention was developed to convert from paper to electronic booking in order to allocate appropriate time for patient screening. Rather than attempting to integrate new complex software, the participants chose to implement a simpler electronic calendar management tool for electronic booking. The identified challenges included the need to modify surgeon behavior and the lack of adequate IT support, barriers that are encountered in many quality and safety initiatives. These challenges were successfully overcome through regular data sharing combined with physician and staff education, which engendered a commitment to use the new electronic booking system. The initial four months of pilot data from 2015 showed a decrease in inappropriate antibiotic use. As this project has identified opportunities for increasing operating room efficiency while simultaneously improving quality and safety, there may be opportunities to scale this model to other units of the hospital.
Highlights and Challenges of SQIL
Working with a global cohort presents a number of challenges. For instance, teams comprising students from Canada to China need to communicate effectively, but not all commercially available communication tools and platforms are universally supported and available, which can impact timelines. Some students face challenges with visa requirements and limits on the frequency with which they can travel abroad in any given year, making attendance at some of the workshops difficult. In our second year, we have modified our program by creating smaller teams and by holding an additional workshop in China. However, despite these challenges, participants report that the diversity in terms of roles, cultures, and experience is one of the major strengths of the SQIL program.
As HIT is implemented and adopted worldwide, skills in leadership, continuous improvement cycles, and a quality and safety perspective will be requisite for those working in health care. For instance, EHR implementation varies significantly among the countries and organizations represented by our students. The SQIL program can promote learning between countries by sharing lessons in (1) how to move from paper-based records to EHRs and (2) how to optimize EHRs to support clinical workflows that promote quality and safety. In this respect, having a global network can be invaluable in that it can help others to avoid the pitfalls and learn from the successes experienced in early-adopter countries.
We hope that others will be able to build on the insights that we have gained and create a dedicated, skilled, and networked cohort of leaders who can help lead the transformation of health care systems globally. We are evolving our educational approaches and redesigning our curriculum to meet the needs of adult learners by moving away from lecture-based sessions to group exercises, active classroom discussion, and online distance learning. The HMS SQIL program is an ambitious first step toward a more novel approach to global postgraduate education in health care.
Acknowledgements: We acknowledge the current and former Co-Program Directors for the Harvard Medical School (HMS) Safety, Quality, Informatics and Leadership (SQIL) Program: Dr. Ajay Singh, Associate Dean for Global and Continuing Education and Associate Professor, HMS; Dr. Charles Safran, Chief of the Division of Clinical Informatics at Beth Israel Deaconess Medical Center and Professor of Medicine, HMS; and Dr. Charles Friedman, Chair, Department of Learning Health Sciences and Professor of Information and Public Health, University of Michigan. We thank Mr. Robin Wheatley, Director of Administration, Ms. Crystal Chang, HMS SQIL Education Manager, and the entire HMS Office of Graduate Medical Education team.
This article originally appeared in NEJM Catalyst on November 16, 2016.