Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program

Changes, Challenges, and Variations in Neonatal-Perinatal Medicine Fellowship: A View from the Program Directors

OBJECTIVES

Neonatal-perinatal medicine (NPM) fellowship programs in the United States support >800 learners annually. Understanding variations in the programmatic structure, challenges, and needs is essential to optimize the educational environment and ensure the specialty's future.

STUDY DESIGN

NPM fellowship program directors (PDs) and associate program directors (APDs) were invited to complete an electronic survey on their program administration, recruitment, clinical training, assessment methods, scholarly program, and career pathways. Each participant identified individual programmatic strengths, challenges, opportunities, and threats to the field.

RESULTS

Representatives from 59 NPM fellowships provided data (response rate 59/96 = 61%). In total, 30% of PDs received less than the Accreditation Council for Graduate Medical Education -recommended protected time for administrative duties, and 44% of APDs received no protected time. Fellow clinical service assignments varied widely from 13 to 18 months and 90 to 175 call nights over 3 years. Recruitment practices varied across programs; 59% of respondents raised concerns over the pipeline of applicants. Conflicts between fellows and advanced practice providers were identified by 61% of responders. Programs varied in their scholarly offerings, with 44% of NPM fellowships interested in adding broader research opportunities.

CONCLUSION

NPM fellowship leaders identified a need for improved programmatic support, enhanced measures to assess competency, opportunities to strengthen scholarly programs, shared curricular resources, and strategies to balance education with clinical demands. PDs and APDs identified threats to the future of NPM training programs including the diminishing pipeline of applicants into neonatology, challenges with clinical exposure and competence, inadequate support for the educational mission, issues supporting high-quality scholarship, and fewer graduates pursuing physician-investigator pathways. National organizations and academic institutions should take action to address these challenges so that fellowships can optimally prepare graduates to meet their patients' needs.

KEY POINTS

· Numerous challenges exist for current program directors in NPM including balancing clinical work with scholarly activities, accurately assessing competency, optimizing the culture of the learning environment, and ensuring that fellows are adequately prepared for a range of postgraduate positions.. · Significant variation exists across NPM fellowship programs in clinical service/calls assigned over 3 years of fellowship training, as well as opportunities to pursue scholarly activities across a variety of areas.. · Challenges exist related to ensuring an adequate number of future applicants into the specialty, including those from backgrounds traditionally underrepresented in medicine, as well as those seeking to pursue careers as physician-investigators..

Process evaluation of paediatric fellowship training programs at a University Hospital in Pakistan

BACKGROUND

Fellowship programs offer training in a subspecialty focusing on distinct and advanced clinical/academic skills. This advanced postgraduate training allows physicians, who desire a more specialized practice, to further develop clinical, academic, research, and leadership/administrative skills. The Aga Khan University (AKU) is one of the few institutes offering paediatric sub-specialty training in Pakistan. We aimed to evaluate the current Paediatric fellowship programs at AKU.

METHODS

Process evaluation of six paediatric fellowship programs (cardiology, neurology, endocrinology, critical care medicine, neonatology, and infectious disease) was conducted from September 2020 to April 2021 by senior clinicians and medical educationists. Evidence was collected through document review (using existing postgraduate medical education program information form), observation of teaching and learning support, and focused group discussions/interviews with program faculty and fellows were conducted. A review of the evaluation report was done as part of this study. This study received an exemption from the ethical review committee. The quantitative data were analyzed using SPSS (22.0) while the reports of discussion with fellows and friends underwent content analysis.

RESULTS

All fellowship programs met the criteria for having a robust competency-based fellowship curriculum as per the institutional and national guidelines. Formative assessment in the form of continuous evaluation was found to be integrated into all the fellowship programs, however, most of the programs were found to lack a summative assessment plan. Fellows in training and program faculty were satisfied with the opportunities for mentorship, teaching, and learning. Thematic analysis of the discussion reports with faculty and fellows revealed three key themes including, program aspects translating into strengthening the training, gaps in the training program in delivering the expectations, and making ways to reach par excellence.

CONCLUSIONS

The process evaluation of paediatric fellowship programs provided an opportunity to holistically review the current strengths and quality of the training in individual programs along with the unmet needs of the trainees. This will help the program stakeholders to prioritize, align and allocate the resources to further enhance the quality of training and outcome of individual fellowship programs to ensure wider impacts at a regional, national, and international health system level.

Quality improvement knowledge in pediatric hematology/oncology physicians: A need for improved education

Pediatric hematology/oncology fellows face unique quality improvement challenges given the danger of chemotherapy and caring for immunocompromised patients. Curricula to teach pediatric hematology/oncology fellows about quality improvement are lacking. We conducted a needs assessment of pediatric hematology/oncology physicians as a first step for creating a quality improvement curriculum for pediatric hematology/oncology fellows. Curricular topics were identified: root cause analysis, run charts, process mapping, chemotherapy/medication safety, implementation/adherence to guidelines. Identified barriers to curriculum implementation included a possible lack of quality improvement expertise, lack of awareness of quality improvement resources, and limited time.

Launching a new fellowship in microrestorative and endodontics for postgraduates in conservative dentistry and endodontics

Expanding and refining the skill sets of postgraduates specialists is required by the many current and changing demands of dental science education and research. To meet this challenge, the Indian Board of Micro Restorative and Endodontics under the aegis of the Indian Association of Conservative Dentistry and Endodontics has begun a fellowship program in Micro Restorative and Endodontics; the main aim being to improve the knowledge and skills of these specialists empowering them to go a step higher and beyond their areas of specialization. The objectives of the fellowship course are as follows: (1) Achieving necessary skills in managing routine and advanced restorative and endodontic scenarios using modern magnification technology. (2) Constantly enhancing the existing knowledge by pursuing new arenas in magnification technology. (3) Complete understanding and application of cutting edge research in the practice of microrestorative and endodontics. (4) Ensuring the highest possible patient-centric quality of care. Learning experiences shall be provided under the guidance and supervision of competent mentors at predesignated centers all over India. The learning strategies will be through workshops, contact sessions, and learning assignments. The carefully designed curriculum shall prepare the restorative dentists and endodontists, to be an autonomous, effective, safe, and a compassionate professional, who practices collaboratively in a variety of clinical and academic setups, responsive to the current and future needs of the restorative and endodontic health-care system. A passion for microdentistry would be a great way to make a positive difference to your patient care and creative work.

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.

Treating patients in a safe environment: a cross-sectional study of patient safety attitudes among doctors in the Gaza Strip, Palestine

BACKGROUND

Patient safety is important, as in increasingly complex medical systems, the potential for unintended harm to patients also increases. This study assessed the attitudes of doctors in the Gaza Strip towards patient safety and medical error. It also explored variables that impacted their attitudes.

METHODS

Doctors, working for at least 6 months in one of the four major government hospitals of the Gaza Strip, were invited to complete a 28-item, self-administered Arabic version of the Attitudes to Patient Safety Questionnaire III (APSQ-III); which assessed patient safety attitudes over nine domains, independent of the workplace.

RESULTS

A total of 150 doctors from four government hospitals participated in this study, representing 43.5% of all 345 doctors working in the four study hospitals at the time of the study. The mean age was 36.6 (±9.7) years. The majority (72.7%) were males, 28.7% worked in surgical, 26.7% in pediatric, 23.3% in medical, 16.7% in obstetrics and gynecology, and 4.7% in other departments. Most participants (62.0%) had never received patient safety training. The overall APSQ score was 3.58 ± 0.3 (of a maximum of 5). The highest score was received by the domain "Working hours as a cause of errors" (4.16) and the lowest score by "Importance of Patient Safety in the Curriculum" (3.25). Older doctors with more professional experience had significantly higher scores than younger doctors (p = 0.003), demonstrating more positive attitudes toward patient safety. Furthermore, patient safety attitudes became more positive with increasing years of experience in some domains. However, no significant impact on overall APSQ scores was found by workplace, specialty or whether the participants had received previous training about patient safety.

CONCLUSION

Doctors in Gaza demonstrated relatively positive patient safety attitudes in areas of "team functioning" and "working hours as a cause for error", but neutral attitudes in understanding medical error or patient safety training within the curriculum. Patient safety concepts appear to be acquired by doctors via informal learning over time in the job. Inclusion of such concepts into formal postgraduate curricula might improve patient safety attitudes among younger and less experienced doctors, support behaviour change and improve patient outcomes.

Quality Improvement Education in Residency Training: A Review

Hospitals and healthcare institutions have strong external and internal pressures to improve patient safety and healthcare quality. Quality improvement education has been mandated for resident physicians by the Accreditation Council for Graduate Medical Education. This review describes didactic and experiential curricula for residents in quality improvement interventions as well as factors that create challenges to implementing such a curriculum and those that foster it. Resident attitudes, faculty capacity, institutional resources, and dedicated time are critical elements influencing the success of quality improvement curricula. Faculty interest in quality improvement could be enhanced by academic recognition of their work. Recommendations to facilitate publication of quality improvement efforts are described.

Teaching Quality Improvement in Emergency Medicine Training Programs: A Review of Best Practices

International graduate medical accreditation bodies are placing increasing emphasis on resident education and competency in the principles of quality improvement and patient safety (QIPS). Current QIPS educational curricula are heterogeneous and variably attain stated objectives. We have conducted a review of QIPS curricular best practices and barriers to implementation of successful QIPS curricula and provide clear solutions aimed at overcoming these barriers. Emergency medicine programs provide fertile ground for QIPS initiatives and can become world leaders in QIPS curricular development and education.

Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives

Healthcare increasingly is moving from volume- to value-based care, with an emphasis on linking a larger percentage of payments to the quality of care provided. There is a renewed interest in designing a focused, strategic approach to quality and safety education and engagement of trainees in hospital-wide quality, safety, and patient experience initiatives. Hospitals, trainees, and patients benefit as a result of engaging frontline learners in these activities. Hospitals can leverage the intelligence from the front line to contribute to improved hospital safety, increased employee and patient engagement, and better identification of vulnerable areas of safety risks. Trainees benefit from increased engagement by acquiring fundamentals in quality and safety; are able to satisfy Clinical Learning Environment Review recommendations; have an opportunity to practice a number of skill sets (leadership, communication, collaboration); and complete quality and safety hands-on projects. Patients benefit from a more engaged work force, safer environment for their healthcare, and an improved overall experience. In this article, the current state of the Johns Hopkins Department of Anesthesiology and Critical Care Medicine's efforts to engage its front line in quality, safety, and patient experience initiatives that are in evolutionary phases of implementation is presented. Evolutionary concepts relate to the Johns Hopkins Health System and the aim of its training program to continuously improve and innovate.

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.

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.

The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review

OBJECTIVE

To systematically review the latest evidence for patient safety education for physicians in training and medical students, updating, extending and improving on a previous systematic review on this topic.

DESIGN

A systematic review.

DATA SOURCES

Embase, Ovid Medline and PsycINFO databases.

STUDY SELECTION

Studies including an evaluation of patient safety training interventions delivered to trainees/residents and medical students published between January 2009 and May 2014.

DATA EXTRACTION

The review was performed using a structured data capture tool. Thematic analysis also identified factors influencing successful implementation of interventions.

RESULTS

We identified 26 studies reporting patient safety interventions: 11 involving students and 15 involving trainees/residents. Common educational content included a general overview of patient safety, root cause/systems-based analysis, communication and teamwork skills, and quality improvement principles and methodologies. The majority of courses were well received by learners, and improved patient safety knowledge, skills and attitudes. Moreover, some interventions were shown to result in positive behaviours, notably subsequent engagement in quality improvement projects. No studies demonstrated patient benefit. Availability of expert faculty, competing curricular/service demands and institutional culture were important factors affecting implementation.

CONCLUSIONS

There is an increasing trend for developing educational interventions in patient safety delivered to trainees/residents and medical students. However, significant methodological shortcomings remain and additional evidence of impact on patient outcomes is needed. While there is some evidence of enhanced efforts to promote sustainability of such interventions, further work is needed to encourage their wider adoption and spread.

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.