And they said, let’s start with family medicine residencies. And pointedly, we wanted to start with clinical care issues, improving the care of diabetes, which was a hot issue at that time. And we chose congestive heart failure also.

And then we put together basically an IHI style breakthrough collaborative. And what we were able to demonstrate, we got funding from local philanthropists, we were able to demonstrate really impressive improvement in the numbers, including a 47% reduction in hospitalization, later mortality for CHF. And we got to the stage where the residencies all got to NCQA standards for diabetes in terms of process cares.

So once that started, we discovered that they really liked it. Basically, faculty and residents and increasingly staff came for our regular meetings. Since PCMH was now in operation, we moved to Triple Aim and so on. But that’s the story. What is exciting to me is that people really enjoyed it.

We called it I3, because we thought it was important to say that we’re talking about improvement. And the most important improvement is in the care of the patients. But we also care about the improvement that residents make in their practices. And we think the cubic part is the faculty who also begin to go out. And we made it exponential. So that means every paper I’ve written and presentation, you have to correct and make it an exponent. I3 is an I cubed, at any rate. And so that’s where it went on. And it ended up, we sort of learned the methodology.

Actually, I think methodology is important. By the end, it was twice a year. The second phase, we expanded to Virginia. We included internal medicine and pediatrics, getting us to a core of between 25 and 30. At every phase, we asked people: are you in? What do you want to talk about? And then once we chose a topic, they got to be in. The methodology was a little bit different with each of the phases.

But in the end, our collaborative was about 25 to 30 residencies. And as you can appreciate, the numbers of patients you get at that stage are 700,000 to 800,000 patients. Over half are uninsured or Medicaid or they’re underserved patients, because that’s the people that residencies serve.

So you can estimate your impact based on what you’ve changed, the practice. Obviously, a secondary goal concerns the residents. We know that residencies are actually important, and we must pay attention to the clinical practice in residency.

Jeremy, you and I have had discussions about various aspects of residency education. The biggest issue for me was: are we going to focus on education or clinical practice? And the answer is yes. But in our specialty, I’d argue that we really first need to deal with clinical practice and improving clinical practice. Education is a secondary part of that, but first attention must be directed to the transformation of clinical practices. But the group wanted to develop a kind of academic collaborative. One of our conditions for going in was that everybody had to have a scholarly project. In the end, we had a large number of papers and scores of presentations, so it was successful from that point of view.