|Year : 2012 | Volume
| Issue : 3 | Page : 208-210
To Improve Postgraduate Training: Medical Residents' Input in Residency Quality Improvement
Alfredo Eymann, Eduardo Durante, Silvia Carrió, Marcelo Figari
Department of Teaching and Research, Hospital Italiano de Buenos Aires, Argentina
|Date of Web Publication||29-Mar-2013|
Departamento de Docencia e Investigación. Hospital Italiano de Buenos Aires, Gascón 450, Buenos Aires
Source of Support: None, Conflict of Interest: None
Introduction: The "Open Space Technology" (OST) is an innovative group process introduced by Harrison Owen in 1997. There is some evidence for its effectiveness in education quality improvement. However, its application in higher education has not been reported. Our objective was to apply a modified OST as a quality improvement tool in a postgraduate training quality improvement program at a university hospital in Argentina. Methods: OST is a method in which a program's participants propose and discuss topics of their interest with an aim that had been defined for them by coordinators. After proposing and writing down themes important to improving the quality of their postgraduate training, residents were divided into small groups to discuss the suggested topics for 90 minutes. They then reconvened in the large group and presented the conclusions of their small group discussions. Results: Thirty-six percent of residents (75/208) participated in one of the two OST sessions. Topics suggested by participants were similar in both sessions: (1) work hours, (2) work conditions, (3) residency curriculum, (4) residents' duties, (5) salaries, (6) professional burnout, (7) patient care load, and (8) interdisciplinary activities. Discussion: In only four hours, residents were able to share their concerns and proposals for improving the quality of their residencies with their faculty. Most of the topics they suggested were subsequently included in the program's quality improvement agenda.
Keywords: Education, graduate, internship, quality improvement, residency
|How to cite this article:|
Eymann A, Durante E, Carrió S, Figari M. To Improve Postgraduate Training: Medical Residents' Input in Residency Quality Improvement. Educ Health 2012;25:208-10
| Introduction|| |
The literature mentions various tools for gathering information from people within complex systems as part of the process for improving quality, such as brain storming, affinity networks, Ishikawa fishbone, and focus groups.  Approaches to collecting information from a large number of medical residents have rarely been described. The Open Space Technology  (OST) is a possible resource to meet this goal.
OST, a group process introduced in business environments, has proven valuable in motivating and stimulating discussion among participants in large groups. It has been shown to be particularly effective managing complex and/or conflictive situations. OST organizers do not need to have a prearranged agenda, as issues and leadership emerge from the participants. Philosophically, the notion is to set forth a minimum structure and then let ideas and discussion flow freely from the group. The minimal structure for OST is built around four basic principles: (1) whoever comes are the right people; (2) whatever happens is the only thing that could have; (3) whenever it starts is the right time, and (4) when it is over, it is over. There is also one law: the Law of Mobility.  The Law of Mobility is the Law of Two Feet, which states that, if during the course of data gathering, a participant finds they are neither learning nor contributing, they may use their two feet and go somewhere they can be more productive.
Within the OST process, after few instructions participants are instructed to agree on topics to be discussed, assemble into smaller groups for these discussions, assign roles to group members (speaker, recorder, etc.), come to their own conclusions on their topic and then share them with the wider group of participants. Time invested in OST can vary from a few hours to two or more days.
Several studies have involved residents in quality improvement programs in clinical areas, but we have seen no study to have engaged residents in quality improvement efforts around the content and environment of their postgraduate training through participatory methods. To our knowledge, this is the first time OST has been implemented in residency quality improvement.
Our aim was to apply a modified OST to collect residents' opinions of their training programs and their issues to engage them in the educational quality improvement process.
| Methods|| |
The study was carried out at a large university hospital in Buenos Aires. The Department of Teaching and Research organizes postgraduate educational activities and has the responsibility for the internal quality improvement of postgraduate education. National agencies have recently begun to evaluate for minimum standards of quality in residency training in Argentina.
In October 2009, through the Hospital Intranet, the Department of Teaching and Research e-mailed to all residents an invitation to volunteer to participate in a meeting to last approximately four hours. They were told that the aim was to discuss the current state and education within their residency programs and the future of their programs. Two dates were set to help allow residents of all specialties/programs to attend one of the meetings. Similar group processes were applied on both occasions.
A general coordinator was appointed to lead the meetings. The general coordinator was an educational psychologist with training in higher education quality improvement. She was known by some of the residents as a member of the staff of the Department of Teaching and Research.
The general coordinator explained the OST process to participants, including its four principles and one law. She stated that the aim of the activity was to include medical residents' input into quality improvement activities, taking into account problem areas within their residencies and possible solutions. Chairs were arranged in a circle and participants were asked to sit. The coordinator solicited topics related to residency programs that participants considered were important or needed improvement. Participants were asked to write down their choice of topics on a sheet of paper with their names on it and to post each suggestion in a box in a grid on a board that already had other, similar topics posted. The purpose of the grid (unknown by the participants) was to organize the topics to be addressed by each small group and to set the timetable. In the end, each cell in the grid displayed a topic and the time allotted for discussion. Those who had first proposed a topic were encouraged to coordinate the group that would discuss that topic. The large group was then divided into small groups. Participants were free to choose any of the groups according to their interest in the topic to be discussed, and to stay or leave for a different group at any time. Participation in the groups was voluntary, following the Four Principles and the Law of OST. Each group coordinator recorded the main ideas and opinions expressed in order to later inform the larger group in the reconvening session. Faculty from various specialties took on the role of facilitators during the activities carried out in each session, following the principles advocated by Owen.  Snacks and beverages were provided throughout the meeting.
After 90-minute small group discussions, the larger group reconvened. Speakers from each group presented the group's conclusions. The general coordinator recorded these points as they were reported to the group. There was no further discussion of each point by the large group, because general consensus and large group discussion are not part of the OST process.
| Results|| |
Thirty-six percent of the hospital's residents (75/208) participated in one of the two OST sessions: 40 residents attended the first meeting and 35 attended the second. Participants were from 21 out of the hospital's 29 residency programs. Sixty percent of participants were female, similar to their proportion within the hospital's general resident population. No residents attended both meetings. There were no significant differences in attendance rates across specialties.
Topics spontaneously suggested by participants were similar in both sessions. The main identified topics were:
- Work hours, related to the regulation of working hours such as consecutive hours and hours per day permitted, shift schedules, and time-off after duty.
- Work conditions, related to facilities available to residents when they were on duty food catering and meeting rooms.
- Residency curricula, related to its adequacy to current teaching conditions, supervision quality and continuity, residents΄ autonomy, and the accomplishment or lack of accomplishment of clinical, teaching, and research activities as defined in the curriculum.
- Resident income, related to the need for periodic income increase in a national inflationary economy.
- Professional burnout, both in residents and faculty, related to the concern about the possibility of work overload with patients, emotional exhaustion, and depersonalization.
- Interdisciplinary activities, related to the scarce number of such activities among medical residencies.
| Discussion|| |
Since resident education is all about people learning, quality improvement needs to address the quality of residents΄ experience as primary stakeholders. Fortunately, the social, cultural, and scientific development of medicine's organizations have become more democratic. Consequently, direct channels of communication among members of medical institutions need to be created. This evolution from top-down to bottom-up in organizations facilitates the creation of a "quality" culture.
Group process techniques in social organizations have been studied since the 1930s.  Still, new methods for involving organization's various actors in quality improvement are needed. OST has become a valuable resource to overcome the passive attitude found in top-down organizations and promote commitment among all stakeholders and a sense of self management. 
The fact that members from 21 out of 29 residency programs in our school participated on a voluntary basis in this activity shows their commitment and interest in improving the training process. Since residents freely shared their perceptions of work conditions with their peers, they could realize that many of their experiences and concerns were common among their colleagues in other residency programs, perhaps thereby creating the notion of a "community" of residents.
Residents' raising topics they found important generally resulted in practical action. A significant increase in residents' salary was specified by hospital authorities and implemented in the 6 months following the OST. Improvement in residents' lodging area was planned and executed by the authorities of the Teaching and Research Department and the Hospital Board over the 18 months following the OST session. Suggestions for residents' self-management of their work schedule were strongly recommended by the Teaching and Research Department to the hospital's residency program directors; subsequently, enhancements in interdisciplinary activities among residencies were introduced, including clinical rounds and courses on research.
Among project limitations, we recognize that faculty facilitating and coordinating the OST could have hampered the unbiased flow of information and opinions, as social desirability is a well-recognized bias.  Including "peer" facilitators would have been an option to mitigate this bias.
| Conclusions|| |
The application of OST to a residency quality improvement program was effective in our hospital. In just four hours, residents were able to share their concerns about their programs with their faculty as well as proposals for addressing these concerns. Most of the topics raised by residents during these meetings were subsequently included in the Department of Teaching and Research's quality improvement agenda.
| References|| |
|1.||Sallis E. Total Quality Management in Education. 2 nd ed. London: Kogan Page Limited; 1996. |
|2.||Owen, H. Open Space Technology. A User's Guide. San Francisco: Berret-Koehler Publishers; 1997. |
|3.||Corey G. Theory and practice of group counseling. Part III action group. Different perspective. Belmont: Wadsworth Inc; 1995. |
|4.||Streiner DL, Norman GR. Health Measurement Scales: a practical guide to their development and use. 2 nd ed. Great Britain: Oxford Medical Publication; 1995. |