Thursday, November 21, 2013

The Structure of an Innovation Academy within a Medical Residency Program

We are at the beginning of a historic era for innovation in health care delivery in the US due to the convergence of payment reform and the proliferation of mobile technology. Academic medical centers (AMCs) have the potential to be leaders in this era of delivery reform, but most have yet to display a commitment to delivery innovation on par with their commitment to basic research. [Ackerly et al] This discrepancy is not due to lack of talent or innovative spirit in AMCs, but rather because of a paucity of training in designing and implementing end-user validated interventions and a lack of established pathways for career advancement in clinical innovation outside of research, among other barriers.

A group of medical residents in the Boston Combined Residency Program (BCRP) have come together to explore how changes in the medical training experience can help cultivate leaders in efficient, patient-centered, and commercially sustainable healthcare delivery innovation. Below is a draft overview of the themes and structure of an Innovation Academy for a medical residency training program.

What is an Innovation Academy?
The innovation academy is a career development, networking, and idea incubation program for creating healthcare delivery innovations by trainees in medical residencies.

Why an Innovation Academy?
The innovation academy is needed in order to equip future healthcare leaders with skills necessary to usher AMCs and health systems more broadly through the immense change that is happening because of health care reform. The missions of most AMCs include thought leadership, creation of generalizable knowledge, training future leaders in healthcare, and providing care to patients. Until recently, the business models of AMCs supported these missions with volume-driven reimbursement for patient care and NIH-funded research as the largest revenue generators for AMCs. With shrinking NIH budgets and hospitals facing 10-15% decreases in reimbursement over the next several years, the traditional missions of AMCs may no longer be aligned with their current business models.

Furthermore, the skills being taught to trainees today, namely clinical and research skills, are only a fraction of the skills that will be requisite for clinicians to thrive or even survive in the delivery systems of the future. The innovation academy can help equip residents with the skills and network that will enable them to effectively contribute to achievement of the Triple Aim and to find or create jobs as clinician-innovators when they complete their training.

The Pillars of the Innovation Academy
To be aligned with the spirit of innovation, the Innovation Academy should adhere to a core principle of design thinking which is creating an experience with the end user in mind. In that vein, prescribing a fixed set of “pillars” can limit the necessary out-of-the-box thinking that may be needed for residents to learn how to create truly innovative system redesigns. So the pillars should be used as a guide rather a fixed construct.

The pillars include technology, policy, entrepreneurship, system redesign, and quality improvement. Each of these realms can overlap with one another. But each pillar also encompasses sufficient unique skill sets and career paths that warrant their own designation.

The Curriculum
The innovation academy curriculum should be based on the currency of clinical innovation which is value-added to patients. That value may be direct or indirect, but that value must have immediate effect. So the goal of the innovation academy curriculum should be to enable residents to create a deliverable that is validated by some end user. Given the time constraints on residents to obtain clinical training, the expectation for deliverables should be modest. Examples of deliverables may include:

-Technology: prototype software

-Policy: written legislation

-Entrepreneurship: creation of a business plan

-System Redesign: completion of a management project for the hospital

-QI: completion of a microsystem improvement

Although the incentive structure of the innovation academy should be based on value-adding deliverables, scholarly activity is still important for dissemination of knowledge as well as reinforcing and solidifying lessons learned through writing. To enable maximum flexibility and still encourage writing, the innovation academy should require all participating residents to submit at least 2 blog posts per year. The blog would enable an informal peer-review process without the time-consuming obligations of writing, submission, and revision for a formal peer-reviewed publication.

In addition to learning by doing, the innovation academy would provide expert speakers and mentors to provide structured bursts of wisdom through noon time talks and afternoon skills sessions. We propose including 1 residency-wide lunch time talk by experts each quarter.

Speakers should reflect the skills necessary to excel in each of the pillars of the innovation academy. Some of those skills should include:


-articulating value of personal skills and project (elevator pitch)

-using mentors



-Lean Startup Thinking

-Design Thinking


In addition to group didactic learning opportunities, we strongly support the role of mentors in identifying individual goals. Coaches can assist with achievement of personal life goals, “here and now” career goals, and longer term career arc goals. Residents will outgrow mentors over time, so having a robust mentorship program is essential. Mentors should be internal and external to the home institution. Mentors should also be internal and external to the healthcare industry altogether. Furthermore, mentors can and should be peers as well as faculty-level. The goal of using faculty-level mentors is to help the resident answer the questions that they now they don’t know. The goal of peer-mentors is to help think through what they don’t know that they don’t know.

The orientation to the innovation academy should occur during the first few weeks of residency. The goal of the orientation is to expose residents to the need for and purpose of the innovation academy, sample careers, and key concepts/skills. Examples of career paths and examples of how to find a job “doing innovation” include Dr. Clay Ackerly (Assistant Director of Population Health at Partners Health Care, Dr. Daniel Stein (Director Medical and Clinical Services of Walmart), Dr. Patrick Conway (Director of Centers for Medicare and Medicaid Innovation - CMMI), Dr. Joshua Sharfstein (Former Deputy Director of FDA, Current Health Director of Maryland), Dr. Rushika Fernandapulle (Founder, CEO Iora Health), Dr. Wen Dombrowski (Chief Medical Information Officer VNA Health Group).

Intern Year
The goal of the innovation academy for interns is introduce them to projects and people that represent various approaches to achieving their vision for impacting health. Another goal is to help them find mentors. Additionally, the innovation academy can help interns start exploring interesting projects through their Keystone experience.

Junior Year
The goal of the innovation academy for juniors is to identify the approach the resident will take to achieve the vision they clarified during intern year. With strong mentor guidance, residents should be able to leverage the internal and external network of the innovation academy to identify a project to work on as a senior during the 3 month academic development block (ADB). 1-2 months of “research” elective can be used as a dry run working with a team that may be the home of the innovation project during senior year.

Senior Year
The goal of the innovation academy for seniors is to provide the mentorship and incubation of project ideas during their ADB. By the end of senior year, residents should have a deliverable completed. Part of creating the deliverable should be creating the connections and demonstration of capacity to create or find a job in clinical innovation.

The goal of the innovation academy for recent graduates is to serve as a job pipeline for clinicians with hard skills and experience in the various pillars of innovation. The job-pipeline would be aligned with formal or informal pathways to organizations that are leading health delivery innovation and redesign including CMMI, Insitute for Healthcare Improvement (IHI), Management and Policy Fellowship at MGH, Kauffman Fellowship in entrepreneurship, Clinician-in-residence at a startup incubator such as Startup Health, among others.

Executing an innovation academy requires leadership at three levels. First, senior program leadership has to fully support the vision, mission, and culture of the innovation academy. Second, resident leaders need to own the innovation academy, it’s goals, and it’s activities, supported by faculty mentors. And third, resident leaders including current and future chief residents should be involved to preserve institutional memory and serve as a bridge and/or buffer between residents and faculty.

Future Work
Many interesting avenues of future work are possible around the innovation academy and innovation in medical training. One particularly interesting project would be to create a “Myer’s Briggs” personality test to predict the type of clinical innovation career that best reflects the resident’s strengths and interests. This could be done by retrospectively looking at successful clinician innovators and project to when they were interns. Furthermore, the efficacy of such a program will need to be evaluated. But before studying this approach, we will first prototype!

For more information and public discussion of this topic, please come to the panel on "Hacking Medical Training" at SXSW in March 2014.

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