This post was authored by Chittur A. Sivaram, MD, FACC, chair of the ACC Fellowship Training and Workforce Committee, and chair of the ABIM Competency-Based Pilot in Cardiology-Internal Medicine.

Many new hot button issues concerning the delivery of cardiovascular care are slowly finding their way into the curriculum for future cardiovascular professionals. This is inevitable since academic programs and their curriculum need to adapt to the changing health care needs and priorities of the populations they serve.  One such emerging area of emphasis in graduate medical education is training in areas of quality, safety and cost-effective care.

The call for enhanced focus on quality and safety began with two important publications: “To Err is Human” and “The Quality Chasm,” both from the Institute of Medicine (IOM). The Accreditation Council on Graduate Medical Education (ACGME) subsequently incorporated specific expectations regarding quality and safety education and competencies in their institutional as well as program-specific requirements.  These requirements apply both to internal medicine residency as well as cardiovascular fellowships.  Fellowship training is now required to prepare a cardiovascular specialist to advocate for quality, work within inter-professional teams, ensure safety in patient care, identify system errors and engage in effective transitions of care. In addition, ACGME’s annual fellow and faculty surveys now include questions related to education in the areas of safety, quality and inter-professional team based care. Compliance with such requirements is essential for continued accreditation of fellowship programs.

These new changes have placed unique responsibilities on cardiovascular fellowship training programs, and the programs are responding slowly, but deliberately. Two potential pathways exist for educating fellows in the areas of quality and safety. One option is experiential learning through actual participation by fellows in their own medical centers’ quality and safety operations. Many training programs are modeling processes of cardiovascular operations after the safety checklist principles already adopted in the surgical suites. Such checklists can be easily implemented with robust involvement by the fellows in many areas where patient care is delivered e.g. cardiac catheterization lab, echocardiography lab and EP lab. In my institution, such checklists have also incorporated another highly topical item – appropriate use criteria (AUC) for procedures. Moreover, the checklists are called out with the collaboration from nursing and other ancillary laboratory staff, thus allowing the fellows the experience of harmonious functioning within an inter-professional team. Fellowship training programs are also adapting their morbidity-mortality conferences to serve as opportunities for fellows to identify and resolve systems issues. Participation in ACC’s registries such as the PINNACLE Registry® also allows fellows to engage in practice-based learning and improvement.

The second option is formal instruction in quality and safety. Several training programs are slowly starting to make use of online resources such as the Institute for Healthcare Improvement (IHI) Open School, a free service that offers several training modules. The superiority of experiential learning over formal instruction alone cannot be overemphasized.

Now more than ever is the time to focus on quality and safety since cardiovascular training programs are rapidly aligning their structure to prepare our fellows to deliver patient care as defined by the IOM – safely, effectively, timely, equitably and efficiently with a patient-centered focus.

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