The Healthcare Improvement and Innovation in Quality (THINQ) Collaborative: A Novel Quality Improvement Training Program for Undergraduate and Postgraduate Students

Setting

The THINQ Collaborative was founded within the Department of Medicine (DoM) at the University of California, Los Angeles (UCLA). UCLA has more than 30,000 undergraduate students and a top-ranking medical school. Nearly a third of undergraduates earning a degree are the first generation in their families to graduate from a 4-year college or university. The main medical center of UCLA Health is located on the university campus in a metropolitan city. The health system’s mission is to provide state-of-the-art patient care, generate research discoveries leading to new treatments and diagnoses, and train future generations of health care professionals. The UCLA DoM quality program provides faculty and administrative support for the THINQ Collaborative and aligns all projects with the department’s vision and mission.

Training

The THINQ Collaborative comprises approximately 30 current undergraduate and postgraduate students from various majors, backgrounds, and professional goals each academic year. Ten to 15 new members are selected each year based on space availability, and they are considered “Interns” for the first 3 months of their training, which happens every year during the summer. New members must be current UCLA students (undergraduate or recent graduates) and are selected through a written application and interview process before formal credentialing through the health center’s volunteer office. As there is a mix of students at various levels in their education, we strive to create a curriculum in the internship that is appropriate for all levels. Evaluations from previous cohorts and faculty leadership help optimize the program each year.

New members complete a 12-week summer internship that introduces them to the basic principles of QI and fosters essential research skills (ie, PubMed searching, integrative reviews, and presentations) in place of the single Lean methodology workshop previously used for training.³ Once the summer internship is completed, THINQ Interns become THINQ Fellows and embark on a research fellowship that applies the skills learned to clinical research and outreach projects. They are also placed in 1 of 4 committees for the academic year, and each committee is assigned to lead 2 general meetings per year. The committees include: (1) Journal Club for students to become familiar with reading and analyzing academic literature, (2) Social Justice to understand factors beyond medicine that impact patients, (3) Leadership Development to prepare them to create and lead QI projects, and (4) THINQ Tanks that host internal competitions modeled after the show Shark Tank where students pitch their solutions on improving health care specific issues, to practice specific and efficient problem-solving. THINQ remains the only undergraduate organization dedicated to QI, a topic of health care usually introduced at the graduate level.

Research Initiatives

THINQ Fellows gain hands-on experience in clinical research that directly impacts ambulatory and inpatient processes and outcomes. Projects align with the priorities of the UCLA DoM quality program and the health system. Projects can vary in duration (from 1 month to several years), level and type of work involved (data analysis, study design, literature reviews), and overall goal (presentation, intervention implementation, publication), providing students with a variety of experiences to choose from. For example, to optimize teamwork and communication in the hospital, THINQ research from 2019 to 2023 focused on interdisciplinary bedside rounding. THINQ Fellows surveyed medicine residents and nurses to gain their perspectives on interdisciplinary rounding and areas of improvement and conducted an observational study of over 1000 patient encounters during internal medicine morning rounds to characterize structures and behaviors that promote effective communication.⁴ THINQ Fellows have also been involved in critical projects concerning other aspects of clinical care, such as investigating the efficacy of medical scribes in mitigating physician burnout and establishing Sepsis Patient and Family Advisory Councils (PFACs) to improve sepsis management.

Outreach Initiatives

A strong focus has been placed on impacting the university campus and beyond, and these efforts have become a crucial component of THINQ’s mission. Fundraisings occur annually to benefit important communities that align with the mission and vision of the organization. THINQ Fellows assist with community service and education by participating in initiatives such as colorectal cancer prevention. They also actively contribute to the THINQ About It blog, which provides them with the opportunity to explore health care from a writing perspective while educating the public on important issues in health care across 3 domains: (1) Intersectionality and Social Justice that examines the intersectionality of health and society, (2) Procedural Issues that discusses issues with procedure and treatment in medicine, and (3) Internal Issues that examines how health care and the medical environment impact quality of care. In 2023, the blog garnered over 5700 views and 3300 reads.

The Pre-Health Guidebook, updated by THINQ, is an accessible collection of all university prehealth organizations and their missions to allow students to find activities that best fit their interests. The interdisciplinary experience is also fostered through collaborations with other student organizations on campus and guest speakers from the medical, research, technology, and business sectors. The annual Case Competition, a more long-term form of the THINQ Tank activity, also serves as a way for students in and out of THINQ to gain insight into QI and network with physicians and staff members from the health system.

Leadership and Sustainability

As a primarily student-run organization, the THINQ Executive Board consists of THINQ Fellows who have completed at least 1 year with the program and are responsible for the leadership and management of THINQ activities (Figure 1). Current Board positions include executive director, associate director, director of logistics, research and shadowing coordinators (2 positions), director of marketing, and director of finance. Additionally, project leads, selected by the Board after an application process, each direct an individual research or outreach project. Faculty advisors within the UCLA DoM quality team assist with research development and provide overarching guidance to the Board.

Recruitment for the Summer Internship begins every academic year in March and is primarily managed by the associate director, allowing them to shape their vision for THINQ within the new cohort itself. At the end of the academic year, the associate director is promoted to executive director, and the remaining Board positions are filled again through an application and interview process. Incoming Board members and project leads are trained extensively by their outgoing counterparts, ensuring a seamless transition from year to year.

Shifting priorities for the program is one challenge faced by the Executive Board changes every year. Every new Executive Board has its own ideas and approach for developing THINQ, which could lead to inconsistency and interruptions in projects and shifts in policies and initiatives. However, making the associate director-executive director role a 2-year position ensures some level of continuity in ideas and initiatives while allowing for more sufficient time for training.

Leadership responsibilities are allocated between Board members to provide strategic oversight and ensure team collaboration. The executive director is responsible for providing leadership and direction to the club organization and overseeing the logistics, cohort, and program curriculum. They also serve as the liaison between THINQ and faculty advisors within UCLA DoM. The associate director assists the executive director with their duties and oversees external platforms such as the THINQ Program admissions cycle and Case Competition. The director of logistics manages the internal platforms, including cohort socials and the mentorship program. Research and shadowing coordinators organize research projects and work with the chief residents of the UCLA DoM to coordinate shadowing opportunities. The director of finance manages the yearly budget, and funding sources include programming funds from the UCLA Undergraduate Students Association Council, UCLA DoM, and fundraisers. Fundings, including grants and programming fees from UCLA Undergraduate Students Association Council and DoM, are used for research publications, conference fees, outreach events, and internal programming for THINQ Fellows. Money raised from fundraising is primarily used for nonprofit donations, with a portion allocated to use for social activities and merchandise. THINQ Fellows themselves are not compensated and work on a volunteer basis. THINQ’s Director of Marketing manages active pages on Instagram, Facebook, and LinkedIn and uses the platforms to update the audience on what the THINQ fellowship is conducting throughout the academic year, as well as any additional recruitment updates. Social media has become increasingly important in showcasing programming and encouraging other students to get involved.

THINQ maintains a strong presence within the prehealth community of the larger undergraduate campus by regularly collaborating with other student-led prehealth organizations through seminars and workshops. Within the organization, students enjoy quarterly socials and opportunities to build community with each other in an informal setting. By inviting students from a variety of backgrounds, THINQ is able to encourage a more comprehensive understanding of the diverse experiences found in health care. In addition, having a blend of undergraduate and postgraduate students in the program and on various research projects promotes learning and opportunities for engagement through collaboration and discussion of individual experiences. While there may be differences in approaches, experiences, and exposures to QI, providing formal structures and processes to promote a collaborative environment between the students has been instrumental in advancing the goals of THINQ.

Program Evaluation

Regular evaluation of research outcomes and member satisfaction is integral to the quality, productivity, and sustainability of the THINQ Program. Research and outreach project performances are evaluated weekly or biweekly by the research and shadowing coordinators for adequate progression, giving project leads the opportunity to troubleshoot any issues. Formal evaluation of the curriculum and leadership by THINQ Interns and Fellows occurs at the midpoint (6-week mark), the end of the Summer Internship, and every quarter throughout the academic year. For the THINQ Interns, the formal evaluation usually consists of the executive and associate director examining the intern’s attendance record, overall participation, and behavior during each benchmark to ensure all interns are engaged with THINQ activities. For the THINQ Fellows, surveys are sent out at least once during the academic year to learn about their experiences and ideas for program improvement. Feedback has been integrated into the curriculum and organization by focusing on areas for improvement. Examples of feedback integration include improving cohort bonding, increasing training on research methodology, and networking with health professionals. The executive and associate director oversees feedback survey administration and subsequent implementation of any organizational changes. THINQ Fellows are also encouraged to pitch ideas and areas of improvement to the executive board at general meetings or via Slack, and this method of informal feedback has led to the creation of projects such as Patient Feedback, Pre-Health Guidebook, and Intersectionality.

Impact on Clinical Care

THINQ Fellows have been involved with inpatient and outpatient improvement efforts and contributed to process and system improvements throughout the health system. THINQ research has produced tangible results that have shaped hospital policy and emphasized administrative practices and operations that shape patient care for the broader health care community. Publications have included Physician Behaviors Associated With Increased Physician and Nurse Communication During Bedside Interdisciplinary Rounds;⁴ Using Decisional Conflict to Evaluate Patient Engagement During Hospital Discharge;⁵ Leveraging Lean Principles in Creating a Comprehensive Quality Program;⁶ and the Impact of an Enhanced Transition Process on Patient Readiness for Discharge.⁷

Using data from the physician–nurse communication study, THINQ Fellows created multiple poster and podium presentations discussing how various factors impact interdisciplinary discussions at morning rounds. The posters have been presented at the National Collegiate Research Conference at Harvard University (2021) and the UCLA DoM’s Research Day (2022). Additionally, multiple manuscripts on physician–nurse communication are in different stages of publication (published, under review, in preparation) and focus on the nursing perspective, medical team perspective, and factors that promote or obstruct effective physician–nurse communication.

Results from a survey administered to nursing staff as part of the Discharge and Care Transitions project were incorporated into an abstract titled “Educating Patients at Discharge: Perceived Responsibilities Among Nurses and Residents at an Academic Medical Center” that was presented at the Society of General Internal Medicine Annual Meeting (2023). The research group has submitted a manuscript (in review) on common challenges nurses face at discharge, such as (1) lack of communication between inpatient and outpatient providers, (2) changes in the medication list not being clearly communicated, (3) patients not being adequately prepared for discharge, (4) the disconnect between provider-information giving and patient understanding, and (5) the primary team physician not effectively communicating discharge planning and evidence-based interventions that can be used to tackle each of these challenges.

Another research group conducted a scoping review on the role of intersectionality (ie, social identities) in physician–nurse relations. The study assessed how social identities such as age, gender, race/ethnicity, specialty, and other factors impact communication between health care staff. They presented their process and results at the UCLA DoM’s Research Day (2022) and the UCLA Nursing Science and Innovation Conference (2023). Findings from the study show that younger age, female gender, certain specialties, and ethnic background were factors that impacted nurse and physician interactions. In addition, years of experience, spoken language, and work culture were additional variables that influenced physician–nurse relations. The group is currently finalizing a manuscript for submission.

The first-ever Sepsis PFAC was launched in the health system in April 2022. The research group for the Sepsis PFAC project presented a poster at UCLA DoM’s Research Day (2022) describing the steps in setting up the PFAC in the health system. The group is currently working on patient and clinician recruitment by contacting various providers responsible for sepsis care to assist in recruiting patients most affected by sepsis. The goal of the project is to create a space of collaboration between hospital administrators and patients to create real change in sepsis care through various platforms (ie, education, research, and media).

Impact on Members

Of 109 individuals contacted, 35 completed the survey (response rate of 32%). Respondents graduated from the university between 2014 and 2022. They joined THINQ as part of the summer internship cohorts from 2014 to 2022 and spent a mean number of 2.0 years as THINQ Fellows (standard deviation = 0.94). As Fellows, 77.14% of respondents participated in project groups, 57.14% were part of poster presentations or authored abstracts and/or publications, and 42.86% served on the THINQ Board. Demographic information of the survey respondents is further summarized in Table 1.

After graduation, popular education and employment ventures for the respondents included employment in health care (ie, medical assistant, medical scribe), graduate or professional school, and paid research positions (ie, research associate/assistant, laboratory technician). Most respondents (77.14%) have experienced a career or education change since graduation, and at least 54.29% of respondents are pursuing careers in the health care industry, either through professional training or in paid positions.

Respondents showed a broad range of learnings from THINQ (Table 2). For example, several noted that their involvement in THINQ was their first exposure to QI, and they learned how it “can be applied to improve patient outcomes and health care delivery.” Many appreciated the opportunity to learn about and brainstorm solutions to tackling health disparities through THINQ Tanks and Case Competition. THINQ also provided invaluable experience in conducting and presenting research, as well as avenues to develop leadership project planning, critical thinking, and problem-solving skills. Journal Club discussions, shadowing, and other activities helped encourage THINQ Fellows to think about health care from an interdisciplinary lens, ensuring that the perspective of every member of a care team is acknowledged and incorporated into solutions and plans.

After gaining early exposure to the field of QI, many respondents were pursuing careers that allowed them to continue this work, 14.29% of respondents were involved in QI in some way, while an additional 28.57% were strongly interested in working in the field as part of their education or career. Through THINQ, Fellows gained valuable clinical exposure and learned about various health care careers they may not have previously considered. The health care issues discussed in meetings and projects they worked on inspired them to work in areas such as research, social justice, and public health. When asked to describe their THINQ experience in 5 words, the most common were “fun,” “collaborative,” “educational,” “inspiring,” and “unique” (Figure 2).

As part of the program evaluation and QI process, feedback was garnered from the THINQ Fellows about areas of opportunity for growth of the program. The major themes from the feedback included improvements in shadowing access, research and presentation options, and leadership development and networking events. Specific steps have been taken to address the issues raised in the survey, and these potential avenues for growth are outlined in Table 3.