The UCSF Family & Community Medicine Residency program is based at Zuckerberg San Francisco General Hospital (ZSFG), a publicly funded hospital. Their continuity clinic, the Family Health Center (FHC), exclusively serves uninsured or publicly insured individuals and provides over 50,000 patient visits a year. Over 20 languages are spoken at the FHC and this large, complex clinic is staffed by nearly 100 staff and providers.
The UCSF Family & Community Medicine Residency program had a robust 2-year long Continuous Quality Improvement (CQI) curriculum in which residents were each expected to develop a quality improvement project using the FOCUS-PDSA. In the R2 year, 48 hours were devoted to the curriculum, with a focus on didactics and early project development. R3s had another 48 hours, most of which were set aside for project implementation and analysis. When the residency implemented the UCSF Double Helix Practice Transformation curriculum in July 2016, they:
1) Added 2 hours to R1 year to teach the basic principles of the 10 Building Block model,
2) Integrated practice transformation concepts into the R1 and R2 clinic orientation sessions,
3) Utilized the materials on this website to integrate teaching about Practice Transformation into the R2 CQI curriculum,
4) Deliberately alluded regularly to the concepts throughout the CQI curriculum, and
5) Focused on increasing integration of resident CQI projects into ongoing clinic transformation efforts.
Tips from the Residency Program
Most, if not all residencies, now have QI time in their curriculum as well as introductory months. There are good places to embed some of this material when you are trying to use the time you already have and do not necessarily have to create more time to teach it. Another place to consider embedding is into pre-clinic teaching sessions (30-45min sessions, shorter sessions) such as the reviewing the importance of team based care. Also at clinic meetings, some of this material can be extrapolated for the whole team.
Going through the 10+3 Building Block Assessment for your clinic can be helpful to assess what areas your clinic may have some gaps in, and as a residency and clinical team decide to strategize to focus on those areas. Then you can focus your teaching on these areas that will then be synergistic to the clinical areas that are identified. Additionally, just laying out the different threads (change management, care team, population management, and access) and seeing what your current residency curriculum already teaches and seeing what curricular gaps exist can be another way to identify areas to teach.
Much of the 4 bottom building blocks – engaged leadership, data driven improvement, empanelment, and team based care are foundational topics that can be really helpful to teach in PGY-1 and early in PGY-2 year so the residents are aware of who the clinical and residency leaders are, how to think about data and improvement, make sense of their panels, and work closely with their teams. I also think that during 3rd year residents can really then focus on completing projects related to practice transformation and quality improvement.
- Time can be a significant challenge – where to fit these topics and how to best fit them. And that’s where a critical assessment of the curricular gaps and clinical areas of growth are helpful to know what would be best to teach.
- Training other faculty to teach the material – this can be a challenge because often there are 1-2 faculty that are leading the way, but there’s a lot of material to cover. So I think the options are – 1 or 2 faculty members have protected time to teach this material, or several (3-5) faculty members have agreed to spread the material among them so it doesn’t depend on one person.
- Engaging the clinic – I think there does need to be buy from the clinical leaders and management team that the curriculum the residents are learning is aligned with clinical goals as well. Integrating the clinic and team leaders into these primary care transformation sessions is helpful.
In general I think residents really appreciate active and engaging teaching sessions, so the workshops and exercises have been very successful. When I make the PowerPoint focused and engaging that helps, as well as when I ensure that each didactic portion has an exercise or workshop associated with it.
For us it’s worked really well to focus on knowledge and skills during the PGY-1 and PGY-2 years and much of the material that we are teaching in primary care transformation has been focused during these 2 years. Focusing on ensuring that the foundational educational material is taught during these 2 years uniformly has allowed us to do the following:
- Allotting project time for residents during PGY-3 year to be able to really devote to building a quality improvement project alongside clinic team members, and do rapid PDSA cycles.
- Bring “real world” quality improvement and primary care transformation leaders to share their experiences and journey with the residents. This is both educational and preparation for their future careers.
- Allot project time for residents to build scholarly work. For example, we have dedicated time during PGY-3 year for residents to learn how to put together an abstract for a conference and our Vice-Chair for research meets with our residents to see if anyone wants to take their projects to the research level.
