The 2016 project on documentation of disease-activity measures for rheumatoid arthritis … led to a 38% increase in provider-documented use of RAPID3 scores in decision making.
In 2015, the curriculum was led by another faculty member who simultaneously completed the Teaching for Quality program through the Association of American Medical Colleges.6
That year the fellows chose to incorporate RAPID3 (routine assessment of patient index data 3) into our clinic, an effort that resulted in 93% RAPID3 completion clinicwide, a goal that has been sustained over several years.
In 2016, the program director taught the monthly course again, designating one fellow as the project leader based on her ongoing enrollment in the Duke graduate medical education concentration in patient safety and quality improvement and serving as the training program’s representative to the Duke Patient Safety Council. The fellows chose to focus on treat to target and barriers to achieving remission using RAPID3 as a measure.
In 2017, we evolved the fellow-as-project-leader concept even further, and one of the second-year fellows (note: Ryan Jessee, now a faculty member) with an interest in QI was invited to not only lead the project, but teach the didactic curriculum with the program director’s supervision and guidance. The fellow project that year focused on implementing hydroxychloroquine dosing guidelines.
QI sessions were scheduled monthly starting in July to allow more time for data collection. With monthly meetings, we expanded the content of didactic sessions to include creating and submitting an institutional review board protocol and creating a REDCap database (a secure web application for building and managing surveys). Once PDSA cycles were underway, didactic sessions included such topics as patient safety, morbidity and mortality review, and SQUIRE (standards for quality improvement reporting excellence) guidelines for QI reporting.7 We also included in-person collaborative data analysis and dedicated sessions to co-write the abstract for submission to the ACR/ARP Annual Meeting.
Additionally, fellows present their QI project several times each year in Rheumatology Grand Rounds to gain divisional buy-in and keep members abreast of project progression. We incorporated time at the end of each QI session to discuss potential improvements to the fellowship program in general, capitalizing on a time when fellows felt empowered to drive change.
Curriculum Evaluation & Results
This curriculum has successfully produced positive outcomes. Several fellows have developed expertise in QI, with one fellow each year from 2014–17 completing the Duke Patient Safety and Quality Improvement GME Concentration program (the certificate program ended after 2017). Subsequent fellows from 2017, 2018 and 2019 have completed the Duke Learning Health Systems Training Program.
The curriculum has given every fellow an opportunity to complete a project that includes scientific writing and presentations. Every year since 2015, our fellows’ project abstracts have been accepted for presentation at the ACR/ARP Annual Meeting; one project was published as a full manuscript (see sidebar, left).8
In informal graduate surveys, at least three former fellows are leading QI projects in their current practice. A 2016 graduate served on the ACR’s Quality Measures Subcommittee to the Committee on Quality Care and implemented the RISE (Rheumatology Informatics System for Effectiveness) registry in her practice.
Physician fellows are not the only ones who have benefited from this participatory curriculum: In 2016, a medical assistant who participated in the curriculum presented her own clinical QI project at a national ACR nursing meeting. One of Duke’s nurse practitioners who participated in the QI curriculum during her training completed a clinical QI project using team-based methods to ensure rheumatology clinics adhered to North Carolina law for prescribing and monitoring opioid analgesic prescriptions; she has subsequently obtained institutional grant funding for this project, which she is implementing across the Duke Health system.9