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Sneak Peek: The Hospital Leader blog

Is QI really a dirty word for residents and physicians?


Editor’s note: First published on The Hospital Leader blog under the title, “How I Realized QI Could Be a Dirty Word.”

With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace: Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?”

Chris Moriates, MD, SFHM

Dr. Chris Moriates

Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first four years of my postresidency career at the University of California, San Francisco, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons; I would hear on occasion the off-hand snide remark from a cardiology attending, but by and large, QI was not controversial at UCSF. It is what we do. As residents, we led QI projects and contributed to QI projects from our colleagues. As a hospitalist faculty member, I led my own QI-related projects and mentored residents and other faculty who led their own QI projects.

Imagine the hard reality that hit me when I read this quote from a resident: “Truly, the first thing I think of when I hear [QI] is going to make more work for residents.”

Wait – is QI actually a dirty word for other residents and physicians?

The quote comes from an Academic Medicine study titled “ ‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” I read on, and it got worse.

“This hasn’t really made any difference to the patients. Like this checklist we do on rounds, like I don’t know. Maybe it has.”

And, by far, most concerning: “There’s like the central line protocols … If you suspect that anybody has any type of bacteremia, you don’t do a blood culture; you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.”


That is some harsh truth about unintended consequences right there. (Also, apparently us kids of the 1990s still say “like” a lot, which is, like, not very professional and also like kinda grating.)

The residents in this study were from the University of Utah, Salt Lake City – an institution I frequently– and publicly – admire for their incredible progress on systematically introducing value improvement into their practice.

What can we do?

Read the full post at

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