Back to Bedside: Defining Success
Introduction
In May 2016, the Accreditation Council for Graduate Medical Education (ACGME) Council of Review Committee Residents (CRCR) participated in an appreciative inquiry exercise to explore how to enhance meaning in trainee work, inspired by When Breath Becomes Air by Paul Kalanithi.1 The residents were motivated to find solutions to combat and reduce burnout. Through these discussions, the Back to Bedside initiative was born. In its first iteration, Back to Bedside is a competitive funding opportunity that encourages residents and fellows to foster meaning in their work by creating and leading innovative projects. Thirty projects—representing 15 specialties across 16 states—were selected for funding starting in January 2018.
Throughout the funding cycle, project teams convened at the ACGME headquarters for 2 days of collaborative meetings. October 2017 marked the first Back to Bedside meeting, during which teams had the opportunity to present their projects, participate in small group discussions, and build connections among teams facing similar challenges. The second meeting in August 2018 focused on feedback and defining success at specific time points within a funded project cycle, and beyond. This review focuses on the activities of the second meeting (figure).
Citation: Journal of Graduate Medical Education 11, 1; 10.4300/JGME-D-19-00012.1
Project teams were randomly assigned to groups. During the first part of the meeting, each team presented a poster of its current progress, including accomplishments, SWOB (strengths, weaknesses, opportunities, barriers) analysis, timeline, budget, and solicited advice. Following poster presentations, each team was given time to discuss strategies for overcoming barriers related to recruitment, survey tools, and data analysis. The second portion of the meeting focused on team success, defined by specific time points, and envisioning successful collaborative efforts between teams.
Methods
Each team member was given a sheet with the prompt, “What does success look like for your project?” Underneath, we identified 3 specific time points for each member and team to consider: the 2019 ACGME Annual Educational Conference (AEC; during which project teams will participate in a preconference and present preliminary results of their work), the end of second-year funding (January 2020), and 2023. Another prompt asked teams to consider, “What would a successful collaboration with another Back to Bedside team look like?” After reflecting on the prompts, teams were placed into groups to discuss and summarize their definitions of success. Each group described their collaborative thoughts on defining success at each time point as well as broader thoughts on what working with another Back to Bedside team would entail.
For this review, the transcriptions from each group underwent thematic analysis, which is summarized below.
Envisioning Success at Time Points
Annual Educational Conference
Looking ahead to March 2019, the time of the ACGME AEC, many groups hoped to work out the remaining logistical challenges of their projects; several projects anticipated completing Plan-Do-Study-Act (PDSA) cycles by March, and others sought to have full implementation of their initiatives by this time. Many groups even aimed to have their first sets of data collected and analyzed, with the intention of sharing their “interim conclusions” at the AEC.
To determine what success would look like, a major theme identified by residents and fellows was the importance of reengaging stakeholders. The teams identified the months leading up to the AEC as a crucial time to renew conversations with important project collaborators and supporters, including program leadership, co-residents, and ancillary hospital staff such as child life specialists. Echoing ideas that were shared at the October 2017 meeting, the groups reinforced the importance of having both the residency program and hospital support their projects. Reengaging these stakeholders was a necessary step toward maintaining this support.
Similarly, with many Back to Bedside team members approaching graduation from residency training, the teams recognized the importance of establishing a transition plan for their projects. By March 2019, the groups aim to have recruited first- and second-year residents who would take over their projects. In the spirit of collaboration, the current teams hope to involve newly recruited members in the discussions regarding what their projects would look like in year 2 and beyond.
End of Second-Year Funding (January 2020)
By January 2020, at the end of the second year of Back to Bedside funding, groups anticipated having substantial results from their data collection. They hoped that their research would show reduced burnout as a result of their programs, with the “exportable recommendations” beginning to be disseminated through publications and presentations.
At the outset of this ACGME initiative, the groups recognized a goal greater than their individual projects; these projects were the initial steps in bringing the Back to Bedside philosophy to their programs. By January 2020, the teams look forward to seeing the beginning of a culture shift that would define the ultimate success and legacy of their projects. Integration of their projects into the daily routines of residents and fellows was a common theme. Acknowledging the larger aims of the initiative, the teams were optimistic that by 2020, the Back to Bedside movement would be adopted by other groups within the hospital.
In discussing their goals for January 2020, the resident and fellow teams cited the need to create a concrete plan for sustainability of their projects. Integrating the interventions within already existing wellness committees was proposed as an idea to accomplish this, with several groups anticipating the creation of a “playbook” or “toolkit” that would help solidify the infrastructure of their projects. Successful leadership transitions, along with continued support from hospital leadership and other stakeholders, were identified as key factors that would allow for long-term success.
In 2023
Envisioning success in 2023, more than 5 years after the first call for Back to Bedside proposals, the resident and fellow groups focused on 2 major themes: continued expansion of the Back to Bedside concept and deeper culture change. The groups not only anticipated to have continued buy-in and support from their own programs, but also hoped that their projects would be rolled out by programs throughout the country. By perfecting a sustainable model for their projects over several years, the teams foresaw the development of “pearls” that could be spread to programs, and even integrated into the resources that ACGME provides for its residents and fellows.
By 2023, the groups anticipated their projects being a “defining feature” within their residency programs, one that would become a “highlight during recruitment.” They hoped that the residents and fellows would become self-motivated to have deeper, more meaningful interactions with their patients, with continued focus on wellness within residency programs. Several groups discussed their projects leading to Back to Bedside focused residency committees, such as a “Meaning in Work Committee.” Major success in 2023 would ultimately see the changing of daily practice as a result of the Back to Bedside projects.
Team Collaboration
Residents involved with Back to Bedside projects had opportunities to establish collaboration between teams through the October 2017 and August 2018 meetings. During each meeting, residents worked together to discuss struggles, difficulties, and roadblocks to their projects and to come up with solutions to address these difficulties. At the October 2017 meeting, teams presented ideas for interventions and the general directions they wanted to take their projects, and received feedback from other Back to Bedside participants on how to convert these ideas and themes into attainable, measurable, and achievable project elements. During the second collaborative meeting in August 2018, project representatives met again to present barriers their group had encountered during development and early implementation of their projects, share ideas that had worked well, and devise solutions to challenges they faced. At the end of the second meeting, teams discussed themes of what successful collaboration among future Back to Bedside teams would look like.
Responses clustered around collaboration between teams, adoption of components from other teams, and projects spanning multiple centers. Groups envisioned collaboration as providing longitudinal feedback to ensure projects' success in both the short- and long-term, consulting with similar project teams to address difficulties encountered while implementing interventions, utilizing experiences of current and previous teams to anticipate potential barriers, and continued communication between project teams to provide third-party input for troubleshooting.
Many residents discovered that critical evaluation from other Back to Bedside teams provided alternative solutions to barriers or creative ways to address difficulties they had encountered. Common difficulties included resident or clinical staff engagement, institutional review board approval, maintaining resident and clinical staff buy-in, and balancing the work required for project success with a busy resident schedule. Along the theme of adoption, responses included integrating applicable aspects and successful components of other projects. When discussing collaborative projects, responses included a desire to implement Back to Bedside initiatives with common project themes or outcomes across multiple centers to increase the power of the study, demonstrate reproducibility across multiple centers, and perform joint analysis of combined project data.
Conclusion
The Back to Bedside initiative began simply with residents' inquiries into how to create more meaning in work. This evolved into ACGME sponsorship of 30 projects, well into their first year of funding. The Back to Bedside project teams and work and advisory group have met twice to present the projects and receive feedback. The second meeting focused on defining what successful projects would look like. Several important themes emerged, including maintaining support by reengaging stakeholders, establishing a transition plan to sustain projects as residents graduate, and producing results that demonstrate these projects help reduce burnout and add meaning in their work. Ultimately, residents and other project participants want to see a cultural shift, in which the themes from the projects would be adopted by other groups, both within their health system and across the country.
Visual Abstract (designed by LCDR Dinchen A. Jardine, MD, MS)
Author Notes
