The State of Quality Improvement Teaching in Medical Schools: A Systematic Review

Twelve tips for creating a longitudinal quality improvement and safety education for early health professions students

Despite the numerous calls for integrating quality improvement and patient safety (QIPS) curricula into health professions education, there are limited examples of effective implementation for early learners. Typically, pre-clinical QIPS experiences involve lectures or lessons that are disconnected from the practice of medicine. Consequently, students often prioritize other content they consider more important. As a result, they may enter clinical settings without essential QIPS skills and struggle to incorporate these concepts into their early professional identity formation. In this paper, we present twelve tips aimed at assisting educators in developing QIPS education early in the curricula of health professions students. These tips address various key issues, including aligning incentives, providing longitudinal experiences, incorporating real-world care outcomes, optimizing learning environments, communicating successes, and continually enhancing education and care delivery processes.

Kolb Meets Quality: Applying Learning Theory to a Process Improvement and Safety Curriculum

The healthcare landscape is changing, and the Accreditation Council for Graduate Medical Education has recognized the importance of training our physician workforce to demonstrate competency in quality, safety, and process improvement. In the renewal of our quality improvement and patient safety curriculum, we set out to create an impactful and relevant course of study using adult learning theories as a scaffold to design the curriculum and inform our teaching methods. In this Perspective, we describe a few key learning theories and demonstrate how we have used them in the teaching of quality improvement and patient safety concepts. Our intent was to create a curriculum that could equip the next generation of physicians with the knowledge, skills, and attitudes they will need to adapt to the changes they face in practice and improve their work environments.

Community action projects: community-engaged quality improvement for medical students

BACKGROUND

Healthcare Quality Improvement (QI) is an essential skill for medical students to acquire, although there is insufficient empirical research which suggests the best educational methods to do this. This study explored the experiences of medical students participating in two versions of a Community Action Project (CAP) which gave medical students the opportunity to learn QI skills in a community setting. The first version (GPCAP) was pre-pandemic where students identified and delivered QI projects on placement in general practice to improve local population health. The second version (Digi-CAP) ran remotely where students worked on QI projects identified by local voluntary sector organisations focused on local community priorities during COVID-19.

METHODS

Semi-structured interviews were conducted with volunteers from the two cohorts of students who had taken part in quality improvement initiatives. Transcriptions were independently coded by two researchers and analysed through thematic analysis.

RESULTS

Sixteen students were interviewed. Whilst students had mixed experiences of completing their CAP, engagement and successful learning was associated with the following themes from the two versions of QI CAP projects: finding a sense of purpose and meaning in QI projects; preparedness for responsibility and service-driven learning; the importance of having supportive partnerships throughout the project duration and making a sustainable difference.

CONCLUSIONS AND IMPLICATIONS

The study provides valuable insights into the design and implementation of these community-based QI projects, which enabled students to learn new and often hard to teach skills, whilst working on projects which have a sustainable impact on local community outcomes.

Enhancing Resident Education by Embedding Improvement Specialists Into a Quality and Safety Curriculum

Background

Quality improvement and patient safety (QIPS) curricula are critical in graduate medical education, yet barriers limit the educational experience and project outcomes.

Objective

To explore the impact of QIPS curricular enhancements and integration of continuous improvement specialists (CIS) by examining the A3 document, the primary project product and surrogate for project quality.

Methods

Since 2009, University of Michigan internal medicine and medicine-pediatric residents participate in a QIPS curriculum, which includes a 4-week group project. In 2016, residency leaders collaborated with CIS staff, non-clinical experts in QIPS with backgrounds in engineering and business, to improve the curriculum. Informed by a needs assessment, the intervention was implemented in 2017 and consisted of a set of enhancements including integration of CIS staff into groups as co-facilitators. In this retrospective cohort study, a blinded reviewer evaluated all available A3 documents before and after the intervention using a quantitative analysis tool.

Results

All residents participated in the curriculum during the pre-intervention (July 2009 to June 2016, n=351) and post-intervention (July 2017 to June 2020, n=148) periods. A total of 23 of 84 (27%) pre-intervention and 31 of 34 (91%) post-intervention A3 documents were available for review. Scores improved significantly for 17 of 23 (74%) A3 items and for 7 of 8 (88%) sections. Mean A3 total scores increased from 29.0 to 47.0 (95% CI 12.6-23.4; P<.001) out of a possible 69.0.

Conclusions

Embedding CIS experts into residency QIPS curricula is associated with improved A3 document quality.

Implementation and evaluation of an elective quality improvement curriculum for preclinical students: a prospective controlled study

BACKGROUND

Quality improvement (QI) is a systematic approach to improving healthcare delivery with applications across all fields of medicine. However, exposure to QI is minimal in early medical education. We evaluated the effectiveness of an elective QI curriculum in teaching preclinical health professional students foundational QI concepts.

METHODS

This prospective controlled cohort study was conducted at a single academic institution. The elective QI curriculum consisted of web-based video didactics and exercises, supplemented with in-person classroom discussions. An optional hospital-based QI project was offered. Assessments included pre- and post-intervention surveys evaluating QI skills and beliefs and attitudes, quizzes, and Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) cases. Within-group pre-post and between-group comparisons were performed using descriptive statistics.

RESULTS

Overall, 57 preclinical medical or physician assistant students participated under the QI curriculum group (N = 27) or control group (N = 30). Twenty-three (85%) curriculum students completed a QI project. Mean quiz scores were significantly improved in the curriculum group from pre- to post-assessment (Quiz 1: 2.0, P < 0.001; Quiz 2: 1.7, P = 0.002), and the mean differences significantly differed from those in the control group (Quiz 1: P < 0.001; Quiz 2: P = 0.010). QIKAT-R scores also significantly differed among the curriculum group versus controls (P = 0.012). In the curriculum group, students had improvements in their confidence with all 10 QI skills assessed, including 8 that were significantly improved from pre- to post-assessment, and 4 with significant between-group differences compared with controls. Students in both groups agreed that their medical education would be incomplete without a QI component and that they are likely to be involved in QI projects throughout their medical training and practice.

CONCLUSIONS

The elective QI curriculum was effective in guiding preclinical students to develop their QI knowledge base and skillset. Preclinical students value QI as an integral component of their medical training. Future directions involve evaluating the impact of this curriculum on clinical clerkship performance and across other academic institutions.

The Clinical Microsystems Clerkship at University of California, San Francisco: Integrating Clinical Skills and Health Systems Improvement for Early Medical Students

PROBLEM

Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills.

APPROACH

The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship.

OUTCOMES

Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%).

NEXT STEPS

Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.

Developing future clinical leaders in patient safety: the Irish experience

Introduction

It is 20 years since the Institute of Medicine advocated a national approach to improve care and patient safety. Patient safety infrastructure has greatly improved in certain countries. In Ireland, patient safety infrastructure is in ongoing development. To contribute to this, the Royal College of Physicians of Ireland/International Society for Quality in Healthcare Scholar in Residence Programme was launched in 2016. This programme aims to improve patient safety and develop a movement of future clinician leaders to drive improvements in patient safety and the quality of care.

Methods

Doctors in postgraduate training complete a year-long immersive mentorship. This involves monthly group meetings with key patient safety opinion makers, one-on-one mentorship, leadership courses, conference attendance and presentations. Each scholar undertakes a quality improvement (QI) project.

Results

A QI project was associated with a decrease in caesarean section rates from 13.7% to 7.6% (p=0.0002) among women in spontaneous labour at term with a cephalic presentation. Other projects are ongoing.

Conclusion

Medical error, patient safety and QI must be addressed comprehensively at both undergraduate and postgraduate level. We believe the Irish mentorship programme will help to change the paradigm and improve patient safety.

Educational Approaches That Enhance Online Clinical Clerkship during the COVID-19 Pandemic

Objective This cross-sectional national study determined which educational approaches are associated with the effectiveness of online clerkship for medical students. Method A survey was conducted for medical students at 78 medical schools in Japan from May 29 to June 14, 2020. It comprised the following aspects: (a) participants' profiles, (b) number of opportunities to learn from each educational approach (lecture, medical quiz, assignment, oral presentation, observation of a physician's practice, clinical skill practice, participation in interprofessional meetings, and interactive discussions with physicians) in online clerkship, (c) frequency of technical problems, and (d) educational outcome measurement (satisfaction, motivation, knowledge acquisition, skill acquisition, change in self-study time, and understanding of the importance of medical care team). Results Of the 2,640 respondents, 2,594 (98.3%) agreed to cooperate. Ultimately, 1,711 matched our inclusion criteria. All educational approaches but assignments were positively associated with satisfaction and motivation. All educational approaches excluding assignment submission and interprofessional meeting were positively associated with knowledge acquisition. Observation, practice, and interprofessional meeting were positively associated with skill acquisition. Only assignment submission was positively associated with the change in self-study time. Educational approaches excluding medical quizzes were positively associated with understanding the importance of the medical care team. Technical problems were negatively associated with motivation, knowledge acquisition, and skill acquisition. Conclusions Educators should implement various educational approaches, especially observation and practice, even in online clinical clerkship. They also need to minimize the technical problems associated with the Internet, as they reduce the effectiveness of online clerkship.

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.

Quality Improvement Content in Physical Therapist Education: A Scoping Review

OBJECTIVE

The purpose of this study was to systematically review the literature regarding teaching quality improvement (QI) in physical therapist education based on the Institute of Medicine's 6-element definition of QI. Educational activities in QI methods in physical therapist professional education curricula, their developmental stage, and their level of evaluation were described.

METHODS

Keywords related to physical therapist students and QI educational activities were used to search studies indexed in PubMed, CINAHL, and ERIC published from 2004 through November 2020. This search yielded 118 studies. After applying inclusion and exclusion criteria, 13 studies were retained for full-text review, which was conducted independently by 2 reviewers. The University of Toronto framework was used to assess developmental stage, and Kirkpatrick's taxonomy was used to assess the evaluation level of 4 retained studies.

RESULTS

The scope of QI educational activities in the 4 retained studies was limited to 3 of the 6 elements of QI: identifying opportunities for improvement, designing and testing interventions, and identifying errors and hazards in care. None of the studies included educational activities to teach understanding and measuring quality of care. Three of the 4 studies spanned the first 2 stages of the University of Toronto framework (exposure and immersion); 1 study was limited to exposure. None of the studies assessed competence in QI methods. Evaluation of QI education was limited to Kirkpatrick levels 1 (reaction) or 2 (learning). None of the studies evaluated activities at level 3 (transfer of new behaviors) or level 4 (results).

CONCLUSION

Education in QI methods in professional physical therapist curricula may be limited in scope due to constraints in physical therapist education and the strategic objective of the profession to differentiate itself from other professions.

IMPACT

Entry-level physical therapists might not be educated to fully participate in interprofessional teams that use QI methods to continuously improve the quality of patient-centered care.

Partnering with healthcare organisations to teach pre-registration health professions students about quality improvement: A systematic review

AIMS AND OBJECTIVES

To describe what higher education and healthcare organisation partnerships can be identified in the published literature to teach pre-registration health professions students quality improvement and the impact of these partnerships.

BACKGROUND

Quality improvement has been gaining traction in the Western world and has been incorporated in varying degrees into the curricula for pre-registration health professions students. Providing quality improvement education in partnership with healthcare organisations has been found to be a valuable experiential learning solution, but the impacts of higher education and healthcare organisation partnerships have not been explored.

DESIGN AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was undertaken using the Ovid MEDLINE, Emcare, CINAHL, Scopus and Eric databases. Studies were subject to quality appraisal using the Critical Appraisal Skills Program validated tools and a thematic analysis and narrative synthesis was undertaken.

RESULTS

Eight studies were included in this review. Features of existing quality improvement partnerships included experiential learning, time pressures and barriers to successful quality improvement partnerships. The impacts of quality improvement partnerships were demonstrated by an increase in quality improvement knowledge and understanding, students leading change and the implementation of quality improvement projects.

CONCLUSION

Several key elements were identified that may act as barriers or enablers to successful implementation of quality improvement partnerships. This review advances understandings of the need for a shift in focus that pays attention to the culture of teaching quality improvement in education partnerships and how this can be achieved in a mutually beneficial way.

RELEVANCE TO CLINICAL PRACTICE

The development of quality improvement partnerships has been found to increase student knowledge and understanding, potentially improving patient outcomes, systems performance and professional development. More research is required on the establishment of quality improvement partnerships and the benefit these collaborations have on students, staff and patients.

Quality improvement for age-friendly care: an experiential model for instructing medical students in system-based practice

Early learning experiences in quality improvement (QI) can prepare medical students for practice in complex health systems and can improve processes of care for various groups, including older adult patients with multiple chronic conditions. We applied the Institute for Healthcare Improvement (IHI) Age-Friendly Health Systems 4Ms framework to a twelve-week geriatrics-focused QI project for third-year medical students training in rural medicine. Students (N = 40) conducted their projects at primary care practice sites and focused on the identified needs of older adult patients within the 4Ms framework areas of Mobility, Mentation, Medication, and What Matters. Students completed evaluation surveys to rate the usefulness of training and to self-assess knowledge and skills using five-point Likert-type items. Students (n = 23) reported increased knowledge and skills in conducting QI activities and improved understanding of the importance of improving processes and patient care. Such projects for QI training can support competency development in systems-based practice while also implementing practice frameworks for improving processes and patient care, such as the use of Age-Friendly practices and resources within a health care setting.

Predicting the effectiveness of the online clinical clerkship curriculum: Development of a multivariate prediction model and validation study

Given scientific and technological advancements, expectations of online medical education are increasing. However, there is no way to predict the effectiveness of online clinical clerkship curricula. To develop a prediction model, we conducted cross-sectional national surveys in Japan. Social media surveys were conducted among medical students in Japan during the periods May–June 2020 and February–March 2021. We used the former for the derivation dataset and the latter for the validation dataset. We asked students questions in three areas: 1) opportunities to learn from each educational approach (lectures, medical quizzes, assignments, oral presentations, observation of physicians’ practice, clinical skills practice, participation in interprofessional meetings, and interactive discussions with physicians) in online clinical clerkships compared to face-to-face, 2) frequency of technical problems on online platforms, and 3) satisfaction and motivation as outcome measurements. We developed a scoring system based on a multivariate prediction model for satisfaction and motivation in a cross-sectional study of 1,671 medical students during the period May–June 2020. We externally validated this scoring with a cross-sectional study of 106 medical students during February–March 2021 and assessed its predictive performance. The final prediction models in the derivation dataset included eight variables (frequency of lectures, medical quizzes, oral presentations, observation of physicians’ practice, clinical skills practice, participation in interprofessional meetings, interactive discussions with physicians, and technical problems). We applied the prediction models created using the derivation dataset to a validation dataset. The prediction performance values, based on the area under the receiver operating characteristic curve, were 0.69 for satisfaction (sensitivity, 0.50; specificity, 0.89) and 0.75 for motivation (sensitivity, 0.71; specificity, 0.85). We developed a prediction model for the effectiveness of the online clinical clerkship curriculum, based on students’ satisfaction and motivation. Our model will accurately predict and improve the online clinical clerkship curriculum effectiveness.

A Quality Education: A Comprehensive Review of a Combined Longitudinal and Specialty Track Quality Improvement and Patient Safety Medical School Curriculum

Structured quality improvement and patient safety (QI/PS) education has increased at every level of medical education; however, great variability exists in the content taught. Here, the authors present a longitudinal model for medical student QI/PS education that is currently implemented at the University of Florida College of Medicine. The curriculum is taught with a variety of teaching methods incorporated into each year with increasing levels of clinical implementation. This curriculum is multimodal and introduces students to QI/PS concepts, presents mock scenarios, and eventually encourages clinical application to situations students experience during their own clinical practice. Additionally, a specialized track for students to have further immersion into this field of medicine is described, which involves specialized training, expanded educational opportunities, and a capstone project. Both the curriculum and specialized track contain explicit clinical integration to ensure students are prepared to enter the medical profession to engage in QI/PS endeavors.

Evolution and Evaluation of a Quality and Patient Safety Fellowship for Practicing Health Professionals

Developing clinical quality champions is an important strategy for improving health care quality. The NorthShore Quality and Patient Safety Fellowship was a yearlong program for practicing physicians devoting 4 hours/wk to a didactic curriculum and quality practicum. Thirty-seven clinicians completed the Fellowship from 2011 to 2018. Sixty percent of graduates reported a significant impact on their quality-related career trajectory, with 44% of early graduates and 64% of recent graduates reporting a new quality role or responsibility as a result of the Fellowship. Fifty-four percent of practicum projects were adopted or adapted by the organization. The Fellowship has been an effective framework to identify and train future quality champions and has led to further quality leadership opportunities for many graduates. Evolution of the Fellowship aligned practicum projects with organizational quality priorities. This curricular framework may be useful for other organizations that seek to develop quality champions among practicing physicians.

Factors associated with the research efficiency of clinical specialties in a research-oriented hospital in China

Research-oriented hospitals are responsible for medical services tasks, medical education, and scientific research, playing an important role in medical research and application. The research efficiency of a clinical specialty is influenced by factors such as the characteristics of the specialty, the organizational atmosphere, and the clinical director’s leadership. The present study aimed to describe the research efficiency of clinical specialties, explore the factors influencing it, and clarify the argument of co-evolution theory regarding the collaborative development of medical services, education, and research. Logistic regression and multiple linear regression were adopted to estimate the correlation between influencing factors and scientific research efficiency. Hospital H, which is representative of research hospitals in China, was taken as an example. Taking three efficiency values—comprehensive technical efficiency (CTE), pure technical efficiency (PTE), and scale efficiency (SE)—as dependent variables, the independent variables affecting research productivity were statistically analyzed. This study also examined the scientific research efficiency of 41 specialties between 2013 and 2017, and found that the independent variables affected CTE, PTE, and SE to various degrees. Collaborative innovation in medical education and research must be based on clinical research; how to balance medical and teaching quality, and research efficiency requires further discussion. While young people play a major role on the research team because of their creativity and initiatives, which improve CTE and PTE, high-level researchers with better research and leadership abilities lead to the rational allocation and effective utilization of resources, thus improving SE. In 2013–2017, discipline construction focused on scale expansion, resulting in the decline of SE in China. Therefore, this study suggests further improvements for the efficiency of clinical specialties in research hospitals.

Development and validation of an A3 problem-solving assessment tool and self-instructional package for teachers of quality improvement in healthcare

PURPOSE

A3 problem solving is part of the Lean management approach to quality improvement (QI). However, few tools are available to assess A3 problem-solving skills. The authors sought to develop an assessment tool for problem-solving A3s with an accompanying self-instruction package and to test agreement in assessments made by individuals who teach A3 problem solving.

METHODS

After reviewing relevant literature, the authors developed an A3 assessment tool and self-instruction package over five improvement cycles. Lean experts and individuals from two institutions with QI proficiency and experience teaching QI provided iterative feedback on the materials. Tests of inter-rater agreement were conducted in cycles 3, 4 and 5. The final assessment tool was tested in a study involving 12 raters assessing 23 items on six A3s that were modified to enable testing a range of scores.

RESULTS

The intraclass correlation coefficient (ICC) for overall assessment of an A3 (rater's mean on 23 items per A3 compared across 12 raters and 6 A3s) was 0.89 (95% CI 0.75 to 0.98), indicating excellent reliability. For the 20 items with appreciable variation in scores across A3s, ICCs ranged from 0.41 to 0.97, indicating fair to excellent reliability. Raters from two institutions scored items similarly (mean ratings of 2.10 and 2.13, p=0.57). Physicians provided marginally higher ratings than QI professionals (mean ratings of 2.17 and 2.00, p=0.003). Raters averaged completing the self-instruction package in 1.5 hours, then rated six A3s in 2.0 hours.

CONCLUSION

This study provides evidence of the reliability of a tool to assess healthcare QI project proposals that use the A3 problem-solving approach. The tool also demonstrated evidence of measurement, content and construct validity. QI educators and practitioners can use the free online materials to assess learners' A3s, provide formative and summative feedback on QI project proposals and enhance their teaching.