Quality improvement and patient safety in the pediatric ambulatory setting: current knowledge and implications for residency training

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.

Disclosure of Adverse Events in Pediatrics

Despite increasing attention to issues of patient safety, preventable adverse events (AEs) continue to occur, causing direct and consequential injuries to patients, families, and health care providers. Pediatricians generally agree that there is an ethical obligation to inform patients and families about preventable AEs and medical errors. Nonetheless, barriers, such as fear of liability, interfere with disclosure regarding preventable AEs. Changes to the legal system, improved communications skills, and carefully developed disclosure policies and programs can improve the quality and frequency of appropriate AE disclosure communications.

Pediatrics Residents' Confidence and Performance Following a Longitudinal Quality Improvement Curriculum

BACKGROUND

Quality improvement (QI) training is an integral part of residents' education. Understanding the educational value of a QI curriculum facilitates understanding of its impact.

OBJECTIVE

The purpose of this study was to evaluate the effects of a longitudinal QI curriculum on pediatrics residents' confidence and competence in the acquisition and application of QI knowledge and skills.

METHODS

Three successive cohorts of pediatrics residents (N = 36) participated in a longitudinal curriculum designed to increase resident confidence in QI knowledge and skills. Key components were a succession of progressive experiential projects, QI coaching, and resident team membership culminating in leadership of the project. Residents completed precurricular and postcurricular surveys and demonstrated QI competence by performance on the pediatric QI assessment scenario.

RESULTS

Residents participating in the Center for Advancing Pediatric Excellence QI curriculum showed significant increases in pre-post measures of confidence in QI knowledge and skills. Coaching and team leadership were ranked by resident participants as having the most educational value among curriculum components. A pediatric QI assessment scenario, which correlated with resident-perceived confidence in acquisition of QI skills but not QI knowledge, is a tool available to test pediatrics residents' QI knowledge.

CONCLUSIONS

A 3-year longitudinal, multimodal, experiential QI curriculum increased pediatrics residents' confidence in QI knowledge and skills, was feasible with faculty support, and was well-accepted by residents.

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.

Patient safety training in pediatric emergency medicine: a national survey of program directors

OBJECTIVES

The Accreditation Council for Graduate Medical Education requires training in patient safety and medical errors but does not provide specification for content or methods. Pediatric emergency medicine (EM) fellowship directors were surveyed to characterize current training of pediatric EM fellows in patient safety and to determine the need for additional training.

METHODS

From June 2013 to August 2013, pediatric EM fellowship directors were surveyed via e-mail.

RESULTS

Of the 71 eligible survey respondents, 57 (80.3%) completed surveys. A formal curriculum was present in 24.6% of programs, with a median of 6 hours (range = 1 to 18 hours) dedicated to the curriculum. One program evaluated the efficacy of the curriculum. Nearly 91% of respondents without formal programs identified lack of local faculty expertise or interest as the primary barrier to implementing patient safety curricula. Of programs without formal curricula, 93.6% included at least one component of patient safety training in their fellowship programs. The majority of respondents would implement a standardized patient safety curriculum for pediatric EM if one was available.

CONCLUSIONS

Despite the importance of patient safety training and requirements to train pediatric EM fellows in patient safety and medical errors, there is a lack of formal curriculum and local faculty expertise. The majority of programs have introduced components of patient safety training and desire a standardized curriculum.

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

BACKGROUND

The Accreditation Council for Graduate Medical Education requires residents to learn quality improvement (QI) methods to analyze, change, and improve their practice. Little is known about how pediatric residency programs design, implement, and evaluate QI curricula to achieve this goal. We sought to describe current QI educational practices, evaluation methods, and program director perceptions through a national survey.

METHODS

A survey of QI curricula was developed, pilot tested, approved by the Association of Pediatric Program Directors (APPD), and distributed to pediatric program directors. Descriptive statistics were used to analyze the data.

RESULTS

The response rate was 53% (104 of 197). Most respondents reported presence of a QI curriculum (85%, 88 of 104), including didactic sessions (83%) and resident QI projects (88%). Continuous process improvement was the most common methodology addressed (65%). The most frequent topics taught were "Making a Case for QI" (68%), "PDSA [plan-do-study-act] Cycles" (66%), and "Measurement in QI" (60%). Projects were most frequently designed to improve clinical care (90%), hospital operations (65%), and the residency (61%). Only 35% evaluated patient outcomes, and 17% had no formal evaluation. Programs had a mean of 6 faculty members (standard deviation 4.4, range 2-20) involved in teaching residents QI. Programs with more faculty involved were more likely to have had a resident submit an abstract to a professional meeting about their QI project (<5 faculty, 38%; 5-9, 64%; >9, 92%; P = .003). Barriers to teaching QI included time (66%), funding constraints (39%), and absent local QI expertise (33%). Most PPDs (65%) believed that resident input in hospital QI was important, but only 24% reported resident involvement. Critical factors for success included an experiential component (56%) and faculty with QI expertise (50%).

CONCLUSIONS

QI curricular practices vary greatly across pediatric residency programs. Although pediatric residency programs commit a fair number of resources to QI education and believe that resident involvement in QI is important, fundamental QI topics are overlooked in many programs, and evaluation of existing curricula is limited. Success as perceived by pediatric program directors appears to be related to the inclusion of a QI project and the availability of faculty mentors.

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.

Quality improvement in medical education: current state and future directions

CONTEXT

During the last decade, there has been a drive to improve the quality of patient care and prevent the occurrence of avoidable errors. This review describes current efforts to teach or engage trainees in patient safety and quality improvement (QI), summarises progress to date, as well as successes and challenges, and lists our recommendations for the next steps that will shape the future of patient safety and QI in medical education.

CURRENT STATUS

Trainees encounter patient safety and QI through three main groups of activity. First are formal curricula that teach concepts or methods intended to facilitate trainees' participation in QI activities. These curricula increase learner knowledge and may improve clinical processes, but demonstrate limited capacity to modify learner behaviours. Second are educational activities that impart specific skills related to safety or quality which are considered to represent core doctor competencies (e.g. effective patient handover). These are frequently taught effectively, but without emphasis on the general safety or quality principles that inform the relevant skills. Third are real-life QI initiatives that involve trainees as active or passive participants. These innovative approaches expose trainees to safety and quality by integrating QI activities into trainees' day-to-day work. However, this integration can be challenging and can sometimes result in tension with broader educational goals.

FUTURE DIRECTIONS

To prepare the next generation of doctors to make meaningful contributions to the quality mission, we propose the following call to action. Firstly, a major effort to build faculty capacity, especially among teachers of QI, should be instigated. Secondly, accreditation standards and assessment methods, both during training and at end-of-training certification examinations, should explicitly target these competencies. Finally, and perhaps most importantly, we must refocus our attention at all levels of training and instil fundamental, collaborative, open-minded behaviours so that future clinicians are primed to promote a culture of safer, higher-quality care.

Improving reporting of outpatient pediatric medical errors

OBJECTIVE

Limited information exists about medical errors in ambulatory pediatrics and on effective strategies for improving their reporting. We aimed to implement nonpunitive error reporting, describe errors, and use a team-based approach to promote patient safety in an academic pediatric practice.

PATIENTS AND METHODS

The setting was an academic general pediatric practice in Charlotte, North Carolina, that has ∼26 000 annual visits and primarily serves a diverse, low-income, Medicaid-insured population. We assembled a multidisciplinary patient safety team to detect and analyze ambulatory medical errors by using a reporter-anonymous nonpunitive process. The team used systems analysis and rapid redesign to evaluate each error report and recommend changes to prevent patient harm.

RESULTS

In 30 months, 216 medical errors were reported, compared with 5 reports in the year before the project. Most reports originated from nurses, physicians, and midlevel providers. The most frequently reported errors were misfiled or erroneously entered patient information (n = 68), laboratory tests delayed or not performed (n = 27), errors in medication prescriptions or dispensing (n = 24), vaccine errors (n = 21), patient not given requested appointment or referral (n = 16), and delay in office care (n = 15), which together comprised 76% of the reports. Many recommended changes were implemented.

CONCLUSIONS

A voluntary, nonpunitive, multidisciplinary team approach was effective in improving error reporting, analyzing reported errors, and implementing interventions with the aim of reducing patient harm in an outpatient pediatric practice.

Policy statement--principles of pediatric patient safety: reducing harm due to medical care

Pediatricians are rendering care in an environment that is increasingly complex, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown in the 10 years since the Institute of Medicine published its report To Err Is Human, and patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification. Pediatricians in all venues must have a working knowledge of patient-safety language, advocate for best practices that attend to risks that are unique to children, identify and support a culture of safety, and lead efforts to eliminate avoidable harm in any setting in which medical care is rendered to children.

Quality improvement for asthma care within a hospital-based teaching clinic

OBJECTIVE

The aim of this study was to determine if a quality improvement intervention in a teaching clinic was associated with the following: 1) improved asthma action plan creation and distribution, 2)increased classification of asthma patients as intermittent or persistent, 3) increased prescriptions of asthma controller medications, 4) decreased emergency department visits and hospitalizations, and 5) sustainable changes in outcomes after the intervention year.

METHODS

A retrospective analysis was conducted of a quality improvement project involving children aged >2 years who were diagnosed with asthma, evaluated in a large hospital-based teaching clinic. Outcomes were assessed for 1 year before and 3 years after quality improvement intervention.

RESULTS

Data from children with asthma seen in the clinic over the 4 years of the study (N = 1797) were analyzed. Mixed effects model regressions showed that children after the intervention were over twofold more likely to receive an asthma action plan (using 2006 as referent, adjusted risk ratio [ARR] 2.29, 95% confidence interval [CI] 2.03-2.56 in 2007; ARR 2.40, 95% CI 2.15-2.66 in 2008; ARR 2.86, 95% CI 2.60-3.20 in 2009). Recorded assessment of asthma severity was 31% to 47% more likely post-intervention (ARR 1.31, 95% CI 1.26-1.36 in 2007, ARR 1.44 95% CI 1.38-1.50 in 2008, ARR 1.47 95% 1.41-1.54 in 2009). Controller medication prescribing increased postintervention ARR 1.08, 95% CI, 1.02-1.14 in 2007; ARR 1.11, 95% CI, 1.04-1.17 in 2008; ARR 1.11, 95% CI, 1.05-1.19 in 2009. Emergency department visits and hospitalizations trended lower postintervention (not significant).

CONCLUSIONS

A quality improvement intervention in a hospital-based teaching clinic was associated with increased use of asthma action plans, classification of asthma severity, and controller medications, and possibly a trend toward fewer emergency visits and hospitalizations.

Quality Education and Safe Systems Training (QuESST): Development and Assessment of a Comprehensive Cross-Disciplinary Resident Quality and Patient Safety Curriculum

BACKGROUND

Over the past decade, regulatory bodies have heightened their emphasis on health care quality and safety. Education of physicians is a priority in this effort, with the Accreditation Council for Graduate Medical Education requiring that trainees attain competence in practice-based learning and improvement and systems-based practice. To date, several studies about the use of resident education related to quality and safety have been published, but no comprehensive interdisciplinary curricula seem to exist. Effective, formal, comprehensive cross-disciplinary resident training in quality and patient safety appear to be a vital need.

METHODS

To address the need for comprehensive resident training in quality and patient safety, we developed and assessed a formal standardized cross-disciplinary curriculum entitled Quality Education and Safe Systems Training (QuESST). The curriculum was offered to first-year residents in a large urban medical center. Preintervention and postintervention assessments and participant perception surveys evaluated the effectiveness and educational value of QuESST.

RESULTS

A total of 138 first-year medical and pharmacy residents participated in the QuESST course. Paired analysis of preintervention and postintervention assessments showed significant improvement in participants' knowledge of quality and patient safety. Participants' perceptions about the value of the curriculum were favorable, as evidenced by a mean response of 1.8 on a scale of 1 (strongly agree) to 5 (strongly disagree) that the course should be taught to subsequent residency classes.

CONCLUSION

QuESST is an effective comprehensive quality curriculum for residents. Based on these findings, our institution has made QuESST mandatory for all future first-year resident cohorts. Other institutions should explore the value of QuESST or a similar curriculum for enhancing resident competence in quality and patient safety.