House officer education and organizational obstacles to quality improvement

Background: House officers are physicians-in-training who provide the bulk of direct medical care for patients in teaching hospitals. Because of their intimate, ongoing role in patient care, they occupy a particularly advantageous position in the health care system for identifying and solving common organizational problems that undermine the quality and increase the cost of care. Yet most house officers are inadequately prepared to address problems in organizational and technical support systems which undermine the delivery of health care. In fact, house officers' strategies for coping with the demands of residency training often perpetuate problems. Cases: Cases describing prescription errors, lost laboratory data, and inappropriate beeper-related interruptions in care illustrate how house officers contribute unwittingly to poor quality and costly care. Recommendations: Department chairs, residency program directors, and senior clinicians should create opportunities for house officers to participate in interdisciplinary problem-solving teams. Medical faculty should instruct house officers in the principles and practice of quality improvement, integrating this material into existing teaching conferences and other educational activities. Instruction should be case based, data intensive, and jargon free, modeled by clinicians with training and experience in quality management and related disciplines. Senior clinicians and department officials should endorse organizational problem solving as a legitimate, appropriate, and valuable activity for every well-trained physician.