Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors

Teaching Quality Improvement: The Use of Education Theories Across the Medical Education Spectrum

It is well recognized that the principles and practices of patient safety and quality improvement (QI) need to be included in medical education. The implementation of patient safety and QI learning experiences at the undergraduate medical education (UME) and graduate medical education (GME) levels has been variable. Consistent teaching of QI across the UME-GME-continuing medical education (CME) spectrum may result in a systemic change of improved patient care and patient safety in clinical practice. We propose using education theories to frame the development of QI curricula for a longitudinal integration in medical education and clinical practice. The basic principles of four education theories, namely, reflective practice, deliberate practice, social constructivism, and organizational learning, are briefly described, and examples of their applications to QI teaching are discussed. The incorporation of education theory into the design and implementation of a longitudinal QI curriculum threaded across the UME-GME-CME spectrum may empower learners with a comprehensive and lasting understanding of QI principles and training in patient safety practice, which are essential prerequisites for the formation of a physician workforce capable of creating sustainable change in patient care.

Achieving Entrustable Professional Activities During Fellowship

BACKGROUND AND OBJECTIVES

Entrustable Professional Activities (EPAs) were developed to assess pediatric fellows. We previously showed that fellowship program directors (FPDs) may graduate fellows who still require supervision. How this compares with their expectations for entrustment of practicing subspecialists is unknown.

METHODS

We surveyed US FPDs in 14 pediatric subspecialties through the Subspecialty Pediatrics Investigator Network between April and August 2017. For each of 7 common pediatric subspecialty EPAs, we compared the minimum level of supervision that FPDs required for graduation with the level they expected of subspecialists for safe and effective practice using the Friedman rank sum test and paired t test. We compared differences between subspecialties using linear regression.

RESULTS

We collected data from 660 FPDs (response rate 82%). For all EPAs, FPDs did not require fellows to reach the level of entrustment for graduation that they expected of subspecialists to practice (P < .001). FPDs expected the least amount of supervision for the EPAs consultation and handovers. Mean differences between supervision levels for graduation and practice were smaller for clinical EPAs (consultation, handovers, lead a team) when compared with nonclinical EPAs (quality improvement, management, lead the profession and scholarship; P = .001) and were similar across nearly all subspecialties.

CONCLUSIONS

Fellowship graduates may need continued development of clinical and nonclinical skills in their early practice period, underscoring a need for continued assessment and mentoring. Graduation readiness must be based on clear requirements, with alignment of FPD expectations and regulatory standards, to ensure quality care for patients.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis

INTRODUCTION

Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement.

METHODS

We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey.

RESULTS

The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague.

DISCUSSION

A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.

Quality Improvement Amid a Global Pandemic: A Virtual Curriculum for Medical Students in the Time of COVID-19

INTRODUCTION

The COVID-19 pandemic in March of 2020 necessitated the removal of medical students from direct patient care activities to prevent disease spread and to conserve personal protective equipment. In order for medical student education to continue, virtual and online electives were designed and implemented expeditiously. We created a virtual curriculum that taught quality improvement (QI) skills within the context of the global pandemic.

METHODS

This 4-week curriculum enrolled 16 students. Students completed the revised QI knowledge application tool (QIKAT-R) before and after the course to assess QI knowledge. Students completed prereading, online modules, and received lectures on QI and incident command systems. Each group designed their own QI project related to our hospital system's response to the pandemic. Finally, groups presented their projects at a peer symposium and completed peer evaluations.

RESULTS

Students' QIKAT-R scores improved throughout the course from a mean of 5.5 (SD = 1.3) to a mean of 7.5 (SD = 1.1; p < 0.001). Students reported that the virtual learning experience delivered the material effectively, and all students agreed that they would participate in QI work in the future.

DISCUSSION

Patient safety and QI topics are content areas for multiple medical licensing examinations. Virtual learning is an effective way to deliver QI content to medical students and residents, especially when projects are trainee-led, QI-trained faculty serve as mentors, and the projects harmonize with institutional goals. Our virtual pandemic-focused curriculum has demonstrated efficacy in increasing medical student QI knowledge.

Pediatric Quality Improvement (QI) Virtual Practicum: Adapting a QI Simulator

INTRODUCTION

Pediatric residencies are expected to arm trainees with skills in quality improvement (QI) that allow trainees to systematically enhance their own practice. Simulation has been shown to be effective in teaching QI, but there are no published QI simulation tools that target pediatric learners.

METHODS

We adapted a previously developed QI simulation to include a case relevant for pediatric residents. Participants devised interventions using basic QI principles with iterative feedback from facilitators with knowledge of QI methodology. Changes in resident knowledge, attitudes about the curriculum, and depth of engagement in QI were assessed using pre- and posttests, surveys, and assessment of independent QI activities performed prior to graduation, respectively.

RESULTS

Eighty-two residents completed the simulation. Of the 76 residents who completed both the pre- and posttests, which each had a total possible score of 28 points, 68% had improved posttest scores, with an average score increase of 2.6 points (SD = 0.6, p < .001). Improvements were most pronounced for residents that scored in the lowest quartile on the pretest. After the simulation, residents reported greater confidence in and likelihood of completing a QI initiative. There was no difference in the level of involvement in future independent QI activities completed by residents who were simulation participants compared with nonparticipants.

DISCUSSION

Adapting a previously published QI simulation for pediatric residents was feasible and effective, and the QI simulation was well-liked by learners. Those with lower baseline QI knowledge may have the most to gain from this simulation.

Assessing the current state of quality improvement training in urology in the UK: Findings from the General Medical Council 2018 trainee survey

Objective:

The General Medical Council (GMC) of the UK has identified the need to support doctors through education in safety and quality improvement (QI) methods. This study reports findings from the GMC annual survey of 2018 from urology trainees regarding the state of QI training and their training needs.

Material and methods:

We designed a set of four questions to assess how QI methods are being taught nationally, and inserted them in the 2018 annual GMC trainee survey for urology. This is a cross-sectional study assessing the current state of QI training and mentoring received by trainees, and their self-assessed ability and confidence in completing a QI project as part of training requirements. Data were statistically analysed in Stata 15 stratified by Local Education Training Boards (LETBs)/Deanery and by specialty trainee level (ST3–7).

Results:

In total, 270 responses were received from urology trainees. Data showed significant variation across the country. Responses from ST3–7 trainees ranged from 5–20% on completing more than three QI projects, while 7–58% replied that they had done none. Across all ST grades, 40% of trainees stated they had not undertaken QI, whereas 0–27% reported they had not received any mentoring on QI to date. There was significant variation across training regions too: 11–74% of trainees answered that they have received training in QI methods, and 58–100% responded that they were confident in undertaking QI projects. Across all LETBs, 1–3% responded that they uploaded projects on national websites for dissemination; finally, a range of 0–18% stated they had completed more than three projects.

Conclusion:

This is the first national snapshot of QI training for the entire urology specialty in the UK. The study demonstrates wide variation in QI training and activity undertaken by trainees, and shows a lack of systematic implementation of QI education across training regions.

Level of evidence:

2c

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

Education Research: A novel resident-driven neurology quality improvement curriculum

OBJECTIVE

To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.

METHODS

We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.

RESULTS

Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.

CONCLUSIONS

Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

How Successful Are Residents and Fellows at Quality Improvement?

BACKGROUND

Nationally, there is an expectation that residents and fellows participate in quality improvement (QI), preferably interprofessionally. Hospitals and educators invest time and resources in projects, but little is known about success rates or what fosters success.

PURPOSE

To understand what proportion of trainee QI projects were successful and whether there were predictors of success.

METHODS

We examined resident and fellow QI projects in an integrated healthcare system that supports diverse training programs in multiple hospitals over 2 years. All projects were reviewed to determine whether they represented actual QI. Projects determined as QI were considered completed or successful based on QI project sponsor self-report. Multiple characteristics were compared between successful and unsuccessful projects.

RESULTS

Trainees submitted 258 proposals, of which 106 (41.1%) represented actual QI. Non-QI projects predominantly represented needs assessments or retrospective data analyses. Seventy-six percent (81/106) of study sponsors completed surveys about their projects. Less than 25% of projects (59/258) represented actual QI and were successful. Project category was predictive of success, specifically those aimed at preventive care or education.

CONCLUSION

Less than a quarter of trainee QI projects represent successful QI.

IMPLICATIONS

Hospitals and training programs should identify interventions to improve trainee QI experience.

Look Who's Talking: A Survey of Pediatric Program Directors on Communication Skills Education in Pediatric Residency Programs

OBJECTIVE

To determine current practices for communication skills curriculum and assessment in pediatric residency programs and to identify programs' greatest needs regarding communication curricula and assessment.

METHODS

We surveyed pediatric residency program directors about their programs' approach to teaching and assessing residents' communication skills and how satisfied they were with their curricula and assessment of competence. Respondents were asked about their programs' greatest needs for teaching and assessing communication skills.

RESULTS

Response rate was 41% (82/202). Most programs did teach communication skills to residents; only 14% provided no formal training. Programs identified various 1) educational formats for teaching communication skills, 2) curricular content, and 3) assessment methods for determining competence. Many programs were less than satisfied with their curriculum and the accuracy of their assessments. The greatest programmatic need regarding curricula was time, while the greatest need for assessment was a tool.

CONCLUSIONS

While teaching and assessment of communication skills is common in pediatric residency programs, it is inconsistent and variable, and many programs are not satisfied with their current communication training. There is need for development of and access to appropriate and useful curricula as well as a practical tool for assessment which has been evaluated for validity evidence.

Multilevel Quality Improvement Teams: An Alternative Approach for Surgical Academic Training Programs to Meet ACGME Core Competency Milestones

BACKGROUND

Quality improvement (QI) activities are an integral part of residency training. We started the process to implement team-based, multilevel QI project streams within our academic surgical residency by studying resident perceptions.

OBJECTIVE

Our residency carried out 6 QI projects in line with the American Council for Graduate Medical Education competencies. A resident survey was completed in 2016 to measure resident perceptions of an individual versus team-based QI project approach.

METHODS

This was a descriptive study looking at resident's preference for team projects and ongoing projects within the training program. We started in 2014 utilizing Wait's Team Action Projects in surgery paradigm to conduct 6 QI projects. After initiation of projects, we allotted 2 full years to pass prior to assessing resident perceptions via a 12-item survey.

RESULTS

Notably, this was a descriptive study aiming to capture resident perceptions on team-based QI and the foundational elements necessary to create and sustain such projects by integrating into our curriculum from the intern year. In 2016, 40 residents completed surveys (72.7% response rate), all (100%) opined that they preferred team-based approaches over individual ones, and 75% were on board to move forward with only a team-based approach in the future.

CONCLUSIONS

This was a pivotal start to adopting a team-based QI project strategy in the future and laid a solid foundation to build upon. We found residents in our program desire to work within teams early on to develop effective solutions to clinical problems. Residents perceived that the team-based model resulted in an improved resident experience with the QI process and improved patient care. We hope to publish a series of articles updating our progress as we move forward in this endeavor.

Pediatric Residents' Reports of Quality Improvement Training and Experiences: Time for an Improvement Cycle?

OBJECTIVE

Explore pediatric residents' experiences and confidence with quality improvement (QI).

METHODS

Pediatric residents were surveyed nationally in July 2017 about their demographic characteristics, experiences with QI projects over the previous year, and confidence with QI skills. Descriptive statistics and distributions of each individual demographic and QI variable, as well as training program size, were calculated for each variable. QI question responses were compared to demographic characteristics of the respondents, and chi-square statistics were calculated.

RESULTS

In total, 11,137 out of 11,304 (98.5%) residents completed the survey. Half of residents had participated in a QI project over the previous academic year, and 78% of third-year residents reported having done so. However, few of these residents self-reported moderate or high confidence in their ability to design a QI project (28.9%), use QI tools (23.1%), use QI methodologies (24.0%), or use data to track changes in their personal practice over time (28.9%). Residents in small or medium programs were statistically more likely to rate their confidence in certain QI abilities higher than those in large programs.

CONCLUSIONS

Although recent pediatric residents appear to be participating in QI activities during training, their self-perception of their QI skills development remains low. Residents in small and medium programs provide more favorable reports.

A National Survey of Quality Improvement Education in Physician Assistant Programs

PURPOSE

Quality improvement (QI) is emerging as a leadership and career track for physician assistants (PAs). Information on how PA programs teach QI is sparse. This study aimed to define how PA programs are providing education in QI through a national program survey.

METHODS

Curriculum survey questions were deployed as a part of the 2014-2015 Physician Assistant Education Association program survey. Questions were grouped into 4 categories: QI champion, pedagogy, integration strategy, and curriculum content. Differences between groups were analyzed, and logistic regression models were built to explore associations.

RESULTS

All 194 (100%) PA programs responded to the survey. There were 137 (70.6%) programs that were teaching QI. The median number of total instructional hours was 12 (interquartile range = 16, overall range = 109). There were 37 (27%) programs that were categorized as having a "mature curriculum." Mature curricula were significantly associated with a QI champion who is an expert from an outside department/institution (odds ratio [OR], 5.05; 95% confidence interval [CI], 1.14-22.33) and with programs that have a QI capstone or thesis project (OR, 3.66; 95% CI, 1.14-11.72) whose educational hours correlated more with experiential learning (r = 0.51, P < .01), small group sessions (r = 0.42, P = .01), and web-based modules (r = 0.36, P = .03).

CONCLUSION

Quality improvement is an important skill set for PAs, but nearly one-third of PA programs do not have a QI curriculum. Mature curricula were associated with more experiential learning and project-based learning (including capstone/thesis). This study captured many elements of QI education for PAs, which can be used by programs to develop and improve their curricula.

Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice

BACKGROUND

The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown.

OBJECTIVE

To determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate.

METHODS

Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis.

RESULTS

The response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21-2.71) and professionalization (2.37; 95% CI, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions.

CONCLUSIONS

Most PDs have not established program minimum Milestones, but would vary such expectations according to competency.

A Project-Based, Resident-Led Quality Improvement Curriculum Within a Pediatric Continuity Clinic

Introduction

Participation in quality improvement (QI) projects is required of pediatric residents, and evidence-based medicine has highlighted the importance of providing residents with experiential practice in this realm. Embedding QI projects within a continuity clinic provides residents an opportunity for meaningful involvement in QI efforts.

Methods

A QI curriculum was implemented within a pediatric residency program that included an introductory lecture on QI principles and participation in resident-led, team-based QI projects at an outpatient clinic. Residents designed, implemented, and analyzed projects beginning in their intern year. Projects operated on an accelerated, 6-month time frame, allowing residents to complete multiple projects over the course of their residency. Resident QI knowledge was assessed before and after an introductory lecture with the Quality Improvement Knowledge Application Tool (QIKAT). Resident feedback was solicited 1 year following curriculum implementation via anonymous online surveys.

Results

Residents completed four QI projects that produced meaningful improvements in clinic processes and patient care. QIKAT scores significantly increased after the introductory lecture. Residents reported that the curriculum afforded them increased confidence to implement plan-do-study-act cycles and improve patient care in their future practices. Qualitative feedback highlighted the team-based structure, participation in multiple projects, and visible direct impacts on patient care as strengths of the curriculum. Increased involvement of clinic staff, scheduling concerns, and improved communication were areas for improvement.

Discussion

Our model for integrating resident-led QI projects into an ambulatory clinic rotation is feasible and has been well received by residents and impactful on clinic processes and care.

Are Graduating Residents Trained and Prepared to Engage in Medical Home Activities in Practice?

A national, random sample of 1000 graduating pediatric residents was surveyed in 2014 on receipt of training in medical home activities and preparedness to engage in same in practice. Of 602 survey respondents (60% response), 71.8% reported being very/fairly knowledgeable about medical homes. Most residents (70.0% to 91.3%) reported they received training in 6 medical home activities; more than one fourth wished for more training in 4 of 6 activities. The majority (62.5% to 77.3%) reported very good/excellent perceived preparedness. Residents with continuity clinic experiences at 2 or more sites and with continuity clinic experience at a community health center were more likely to report very good/excellent preparedness in multiple medical home activities. Overall, residents feel knowledgeable, trained, and prepared to engage in medical home activities as they are leaving residency. Opportunities exist to further explore the influence of additional training in specific activities and the number and type of training site experiences on perceived preparedness.

Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness

PURPOSE

To describe clinical skills progression during pediatric residency using the distribution of pediatric milestone assessments by subcompetency and year of training and to determine reasonable milestone expectations at time of graduation.

METHOD

Multi-institutional cohort study of the milestones reported to the Accreditation Council for Graduate Medical Education for all 21 pediatric subcompetencies. Most subcompetencies were measured using five milestone levels (1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, 5 = master); 3 subcompetencies had only four levels defined.

RESULTS

Milestone assessments for 2,030 pediatric residents in 47 programs during academic year 2013-2014 were obtained. There was significant variation in end-of-year milestone ratings for residents within each level of training, which decreased as training level increased. Most (78.9%; 434/550) graduating third-year pediatric residents received a milestone rating of ≥ 3 in all 21 subcompetencies; fewer (21.1%; 116/550) received a rating of ≥ 4 in all subcompetencies. Across all training levels, professionalism and interpersonal communication skills were rated highest; quality improvement was rated lowest.

CONCLUSIONS

Trainees entered residency with a wide range of skills. As they advanced, skill variability within a training level decreased. Most graduating pediatric residents were still advancing on the milestone continuum toward proficiency and mastery, and an expectation of milestone ratings ≥ 4 in all categories upon graduation is unrealistic; milestone ratings ≥ 3 upon graduation may be more realistic. Understanding current pediatric residents' and graduates' skills can help to identify key areas that should be specifically targeted during training.

Impact of a Longitudinal Quality Improvement and Patient Safety Curriculum on Pediatric Residents

Introduction:

The effectiveness of longitudinal quality/safety resident curricula is uncertain. We developed and tested our longitudinal quality improvement (QI) and patient safety (PS) curriculum (QIPSC) to improve resident competence in QI/PS knowledge, skills, and attitudes.

Methods:

Using core features of adult education theory and QI/PS methodology, we developed QIPSC that includes self-paced online modules, an interactive conference series, and mentored projects. Curriculum evaluation included knowledge and attitude assessments at 3 points in time (pre- and posttest in year 1 and end of curriculum [EOC] survey in year 3 upon completion of all curricular elements) and skill assessment at the EOC.

Results:

Of 57 eligible residents in cohort 1, variable numbers of residents completed knowledge (n = 42, 20, and 31) and attitude (n = 11, 13, and 37) assessments in 3 points in time; 37 residents completed the EOC skills assessment. For knowledge assessments, there were significant differences between pre- and posttest and pretest and EOC scores, however, not between the posttest and EOC scores. In the EOC self-assessment, residents’ attitudes and skills improved for all areas evaluated. Additional outcomes from project work included dissemination of QI projects to hospital-wide quality/safety initiatives and in peer-reviewed national conferences.

Conclusions:

Successful implementation of a QIPSC must be responsive to a number of learners, faculties, and institutional needs and integrate adult learning theory and QI/PS methodology. QIPSC is an initial effort to address this need; follow-up results from subsequent learner cohorts will be necessary to measure the true impact of this curriculum: behavior change and practice improvements.

Engaging Learners Through Modules in Quality Improvement and Patient Safety

INTRODUCTION

Residents are on the front lines of medical care in academic institutions. Their daily interactions are crucial to the quality of care received by patients in these settings, and thus, knowledge of patient safety and quality improvement is essential. The Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs as part of their residency training. To meet this need, we developed a curriculum in patient safety and quality improvement for pediatric residents.

METHODS

This curriculum describes four short modules focused on quality improvement, patient safety, evidence-based practice, and other quality improvement-related topics. These modules can be given during one rotation, throughout residency, or partnered with a practical application, such as a project. A 17-question quality improvement and patient safety knowledge test was developed after an extensive literature review to reflect module goals and objectives. A validated, 12-question attitudes survey was administered before and after the modules.

RESULTS

Of the 57 eligible residents, 42 completed the knowledge pretest, and 20 completed the posttest. Mean posttest results (M = 91.00 [± 9.12]) were considerably higher than mean pretest scores (M = 75.24 [± 11.74]) when utilizing the independent t test (p &lt; .001). Of the 57 eligible residents, 11 completed the attitude presurvey, and 13 completed the attitude postsurvey. Median responses from the survey mostly fell within the 2-3 range of slightly to moderately comfortable. Significant differences showing improvement between presurvey and postsurvey time frames were found in identifying and comparing best practices (p = .02), using the PDSA model (p = .002), and identifying how data are linked (p = .001).

DISCUSSION

Knowledge and perception surveys suggest that resident knowledge and attitudes statistically improved, and faculty and residents participated in even more quality improvement initiatives after completing the curriculum.

Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment

This needs assessment survey of physical medicine and rehabilitation (PM&R) program directors (PDs) from Accreditation Council for Graduate Medical Education-accredited programs aimed to (1) describe current quality improvement (QI) training, (2) characterize PDs' perceptions of their own and their faculty's QI knowledge and skill, and (3) determine PDs' opinions of optimal QI training to inform the development of a future QI curriculum. Descriptive statistics were used for data analysis. Forty-five percent of PDs (35/78) responded. All programs had QI education and required QI project participation; however, the quantity and types of learning experiences varied greatly. PDs assessed their ability as less than proficient to teach QI (67%) and lead a project (57%), and rated 60% of their faculty as having novice or advanced beginner QI skills. PDs reported 31% of graduating residents had less than competent QI skills. Almost all PDs were interested in a standardized QI curriculum.

Change in Residents' Experience in Continuity Clinic After Patient-Focused Primary Care Redesign

OBJECTIVE

Evaluation of efforts to redesign primary care has primarily focused on clinical services, with limited assessment of the effect on learners. This study evaluated the change in pediatric residents' perception of training, teamwork, and patient care in 2 different continuity clinic settings that were implementing patient-focused primary care redesign.

METHODS

Continuity clinic residents at 2 large urban pediatric training programs completed a survey, developed de novo, before and after primary care redesign. Differences in the proportion of positive (≥4 of 5) ratings before and after redesign were compared using chi-squared tests in 2 practice sites, each of which focused on improving specific aspects of their practice.

RESULTS

The response rate was >70% in both sites and in both years. Residents in the site focused on teamwork and continuity were more likely to report improved teamwork training (64% vs 83%; P < .05) and teamwork among residents (82% vs 98%; P < .05) after redesign. Perception of overall quality of care in clinic also improved (47% vs 68%; P < .05). Residents in the site focused on clinic flow were more likely to report that physicians, nurses, and administrative staff worked together to optimize patient flow after redesign (25% vs 48%; P < .05). No improvements were seen in domains without focused interventions in either site.

CONCLUSIONS

Practice redesign focused on clinical outcomes can positively affect resident perception of their training and clinical experience in continuity clinic. Future redesign efforts deliberately involving residents might further enhance continuity clinic training.

ABCs of Safety and Quality for the Pediatric Resident and Fellow

The role of resident and fellow trainees in patient-centered improvement processes is critical to a health care system's success. There is a growing impetus to incorporate patient safety and quality improvement into the educational framework of physicians in training. As part of the Next Accreditation System, practice-based learning and improvement and systems-based practice domains mandate that residents and fellows be assessed on their ability to enhance the quality of care and advocate for patient safety. Best practices for incorporating quality improvement and patient safety into the curriculum of residents and fellows remains an area of interest for educators.

Improvement in influenza vaccination rates in a pediatric sickle cell disease clinic

BACKGROUND

Children with sickle cell disease (SCD) are at increased risk of complications from influenza. However, despite widespread recommendations that these patients receive an annual influenza immunization, reported vaccination rates remain very low at under 50%.

PROCEDURE

Our aim was to increase the influenza vaccination rate among our pediatric patients with SCD aged 6 months to 21 years over two influenza seasons, 2012-2013 and 2013-2014, to 80%, consistent with the Health People 2020 goal. We used multiple quality improvement methods, based on the literature and our previous experience in other aspects of SCD care, including parent and provider education, enhancement of our EHR, use of a SCD patient registry and reminder and recall done by a patient navigator.

RESULTS

We vaccinated 80% of our pediatric patients with SCD for influenza during the 2012-2013 season and 90% of patients in 2013-2014. Our early season vaccination rates were nearly double that of those for the general population.

CONCLUSIONS

Use of quality improvement methods can increase rates of influenza vaccination for this high-risk population, suggesting that less health care utilization and lower cost might result.

Meeting Resident Scholarly Activity Requirements Through a Longitudinal Quality Improvement Curriculum

BACKGROUND

Quality improvement (QI) skills are learned during residency, yet there are few reports of the scholarly activity outcomes of a QI curriculum in a primary care program.

INTERVENTION

We examined whether scholarly activity can result from a longitudinal, experiential QI curriculum that involves residents, clinic staff, and faculty.

METHODS

The University of Pittsburgh Medical Center Shadyside Family Medicine Residency implemented a required longitudinal outpatient practice improvement rotation (LOPIR) curriculum in 2005. The rotation format includes weekly multidisciplinary work group meetings alternating with resident presentations delivered to the entire program. Residents present the results of a literature review and provide 2 interim project updates to the residency. A completed individual project is required for residency graduation, with project results presented at Residency Research Day. Scholarly activity outcomes of the curriculum were analyzed using descriptive statistics.

RESULTS

As of 2014, 60 residents completed 3 years of the LOPIR curriculum. All residents satisfied the 2014 Accreditation Council for Graduate Medical Education (ACGME) scholarly activity and QI requirements with a literature review presentation in postgraduate year 2, and the presentation of a completed QI project at Residency Research Day. Residents have delivered 83 local presentations, 13 state/regional presentations, and 2 national presentations. Residents received 7 awards for QI posters, as well as 3 grants totaling $21,639. The educational program required no additional curriculum time, few resources, and was acceptable to residents, faculty, and staff.

CONCLUSIONS

LOPIR is an effective way to meet and exceed the 2014 ACGME scholarly activity requirements for family medicine residents.

Embedding Quality and Safety in Otolaryngology–Head and Neck Surgery Education

Education in patient safety (PS) and quality improvement (QI) helps both medical students and residents understand the health care environment in the United States, where these concepts are now incorporated into virtually every aspect of patient care. The Accreditation Council of Graduate Medical Education has made PS/QI a mandatory component of resident education, and a number of specialties have published their experiences with incorporating PS/QI into their training programs. In otolaryngology–head and neck surgery, a strong curriculum can be built by teaching residents about the principles of PS/QI through both didactic and experiential learning, and morbidity and mortality and QI conferences can serve as the cornerstone of this curriculum. Understanding the potential challenges in PS/QI education can allow training programs to plan their strategy effectively for successful incorporation into their existing curricula.

Trainee and program director perceptions of quality improvement and patient safety education: preparing for the next accreditation system

OBJECTIVE

To assess the current state of quality improvement and patient safety (QIPS) education at a large teaching hospital.

METHODS

We surveyed 429 trainees (138 residents, 291 clinical fellows) and 38 program directors (PDs; 2 were PDs of >1 program) from 39 Accreditation Council for Graduate Medical Education-accredited training programs.

RESULTS

Twenty-nine PDs (76.3%) and 259 trainees (60.3%) responded. Most trainees (68.8%) reported participation in projects culminating in scholarly products (39.9%) or clinical innovations (44%). Most PDs reported that teaching (88.9%) and project supervision (83.3%) are performed by expert faculty. Nearly half of the PDs (45.8%) and trainees (49.6%) perceived project-based learning to be of equal value to formal curricula. Compared with trainees, a greater proportion of PDs reported needs for funding for projects, teaching faculty to provide mentorship, and faculty development (P < .05).

CONCLUSIONS

Providing additional financial, administrative, and operational support could enhance the value of curricula and projects. Developing expert teaching faculty is paramount.

The current and ideal state of mental health training: pediatric program director perspectives

OBJECTIVE

To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents' knowledge and skills in MH care.

METHODS

We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics' MH competencies. PDs then ranked their residents' knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence.

RESULTS

Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics competencies, and PDs infrequently rated their residents' MH skills and knowledge to be above average. Attention-deficit/hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P = .04).

CONCLUSIONS

PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents' knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.

Pediatric resident education in quality improvement (QI): a national survey

OBJECTIVE

To assess pediatric residents' perceptions of their quality improvement (QI) education and training, including factors that facilitate learning QI and self-efficacy in QI activities.

METHODS

A 22-question survey questionnaire was developed with expert-identified key topics and iterative pretesting of questions. Third-year pediatric residents from 45 residency programs recruited from a random sample of 120 programs. Data were analyzed by descriptive statistics, chi-square tests, and qualitative content analysis.

RESULTS

Respondents included 331 residents for a response rate of 47%. Demographic characteristics resembled the national profile of pediatric residents. Over 70% of residents reported that their QI training was well organized and met their needs. Three quarters felt ready to use QI methods in practice. Those with QI training before residency were significantly more confident than those without prior QI training. However, fewer than half of respondents used standard QI methods such as PDSA cycles and run charts in projects. Residents identified faculty support, a structured curriculum, hands-on projects, and dedicated project time as key strengths of their QI educational experiences. A strong QI culture was also considered important, and was reported to be present in most programs sampled.

CONCLUSIONS

Overall, third-year pediatric residents reported positive QI educational experiences with strong faculty support and sufficient time for QI projects. However, a third of residents thought that the QI curricula in their programs needed improvement, and a quarter lacked self-efficacy in conducting future QI activities. Continuing curricular improvement, including faculty development, is warranted.