Resident/faculty collaboration for systems-based quality improvement

A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts?

BACKGROUND

With the integration of quality improvement (QI) into competency-based models of physician training, there is an increasing requirement for medical students and residents to demonstrate competence in QI. There may be factors that commonly facilitate or inhibit the desired outcomes of QI curricula in undergraduate and postgraduate medical education. The purpose of this review was to synthesise attributes of QI curricula in undergraduate and postgraduate medical education associated with curricular outcomes.

METHODS

A realist synthesis of peer-reviewed and grey literature was conducted to identify the common contexts, mechanisms, and outcomes of QI curricula in undergraduate and postgraduate medical education in order to develop a programme theory to articulate what works, for whom, and in what contexts.

RESULTS

18854 records underwent title and abstract screening, full texts of 609 records were appraised for eligibility, data were extracted from 358 studies, and 218 studies were included in the development and refinement of the final programme theory. Contexts included curricular strategies, levels of training, clinical settings, and organisational culture. Mechanisms were identified within the overall QI curricula itself (eg, clear expectations and deliverables, and protected time), in the didactic components (ie, content delivery strategies), and within the experiential components (eg, topic selection strategies, working with others, and mentorship). Mechanisms were often associated with certain contexts to promote educational and clinical outcomes.

CONCLUSION

This research describes the various pedagogical strategies for teaching QI to medical learners and highlights the contexts and mechanisms that could potentially account for differences in educational and clinical outcomes of QI curricula. Educators may benefit from considering these contexts and mechanisms in the design and implementation of QI curricula to optimise the outcomes of training in this competency area.

Meeting ACGME and ABMS Quality Improvement Requirements in a Sleep Medicine Fellowship Program

STUDY OBJECTIVES

To describe a sustainable program of teaching and implementing quality improvement (QI) in a 12-month sleep medicine fellowship.

METHODS

We created a QI curriculum based on Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialty (ABMS) Part IV Maintenance of Certification (MOC) requirements for QI. Two program faculty with prior QI training volunteered to mentor fellows. Our institution's central QI office houses QI experts who teach QI across the health system. One of these experts, referred to as the "QI consultant," helped us adapt QI teaching materials to include 4 online modules and 5 group sessions. Fellows worked in teams to complete 2 data-guided QI cycles.

RESULTS

The curriculum required 29 hours for fellows, 18 hours for faculty, and 55 hours for the QI consultant; now that teaching materials have been created, the QI consultant's involvement will decrease over time. Post-curriculum surveys showed that fellows' knowledge of QI concepts increased, as did their confidence performing QI activities. Fellows' QI projects objectively improved timeliness and quality of care for patients. Sleep medicine fellows and QI faculty mentors evaluated the curriculum positively. The curriculum met ACGME requirements for QI, and fellows and mentoring faculty received ABMS Part IV MOC credit upon completion of the curriculum.

CONCLUSIONS

A QI curriculum can successfully be implemented into a 12-month sleep medicine fellowship to increase sleep medicine fellows' QI knowledge and confidence, meet ACGME and MOC requirements, and contribute to care of patients with sleep disorders.

Development of a Quality Improvement/Patient Safety Curriculum to Increase Emergency Medicine Resident Scholarly Activity

CONTEXT

There currently is no standard method for teaching Quality Improvement/Patient Safety (QIPS) content to prepare resident physicians planning QIPS projects. As part of the 2015-2016 MSU Statewide Campus System Teach for Quality (Te4Q) learner cohort, the first two authors from the McLaren Oakland Hospital Emergency Medicine (EM) residency program developed a structured multi-phase QIPS curriculum. The curriculum was developed to help a cohort of seven second-year EM residents feel more confident to design and conduct their own QIPS projects.

METHODS

After institutional review board project approval was obtained, the first two authors evaluated both the pre and post-curriculum confidence survey scores of enrolled EM residents during May, 2016 as part of their Te4Q program participation.

RESULTS

Residents completed a 15-item QIPS confidence survey before and after completing the QIPS curriculum. The mean pre-curriculum score was 3.00 (SD 1.53) on a scale from 0 to 10, indicating that the average sample respondent felt a lower level of comfort concerning their ability to design and conduct a prospective QIPS project. The mean post-curriculum confidence score from residents increased to 6.71 (SD 1.25) on a 0 to 10 scale, over double an increase from the pre-workshop score on this item. Using a series of non-parametric Wilcoxon Matched Pairs Signed Rank Test procedures suitable for smaller samples, statistically significant increases in pre- to post-curriculum differences were shown for composite confidence scores (Z = 2.207, p = 0.027), as well as for five of the 12 individual confidence items (p-values ranged from 0.023 to 0.046).

CONCLUSIONS

These initial results certainly indicate that a structured ongoing QIPS curriculum may have the potential to improve EM residents' confidence levels to design and implement QIPS projects with faculty. The impact of these types of curricula for EM and other types of residents needs to be more rigorously examined in more tightly controlled GME settings with larger samples to gauge what types of resident learners will more likely benefit from such educational offerings across the nation.

Quality improvement in resident education: a pilot project to mitigate metabolic side effects from atypical antipsychotic medications in youth

This resident physician-led quality improvement project was conducted with aims to improve the health of youth prescribed atypical antipsychotic medications by increasing physician monitoring for metabolic side effects, while simultaneously educating trainees in quality improvement methodology.

The plan, do, study, act quality improvement framework was utilized. Baseline metabolic monitoring rates of patients prescribed atypical antipsychotic medications in the two psychiatry resident outpatient clinics were obtained. Rates were stratified based on time on medication (<1 year, ≥1 year) and parameter monitored. Metabolic monitoring rates subsequent to targeted changes were obtained. Problem solving with residents revealed barriers to monitoring, such as limited awareness of specific guideline recommendations and lack of convenient access to medical equipment (calibrated scales). Residents received education about atypical antipsychotic monitoring guidelines and side effect treatment. Residents were provided with calibrated scales. Atypical antipsychotic monitoring templates were introduced. Online surveys using were conducted to determine self-reported baseline-monitoring rates and comfort with guidelines following targeted change.

The baseline metabolic monitoring rates of patients prescribed atypical antipsychotic medications was 9% (range: 0 to 17.6%) for youth in their first year taking an atypical antipsychotic medication and 58.9% (range: 29% to 100%) in subsequent years on medication. The results of relatively easy changes resulted in modest improvement in monitoring rates. The metabolic monitoring rate of a patient initiated on an atypical antipsychotic medication was 29% after targeted quality improvement measures were employed. Following quality improvement changes, residents reported increased knowledge about guidelines and increased monitoring for side effects. Use of a standardized data collection instrument to track monitoring of patients increased from 0% to 70% (range: 30% to 90%).

Quality improvement projects provide an avenue with which to improve atypical antipsychotic monitoring rates. Through active participation in quality improvement projects, psychiatry residents may be taught to employ quality improvement methodology.