Quality improvement, patient safety, and continuing education: a qualitative study of the current boundaries and opportunities for collaboration between these domains

Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles

INTRODUCTION

Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers.

METHODS

Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying.

RESULTS

Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit.

CONCLUSIONS

Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

In EPAs we trust, is quality and safety a must? A cross-specialty analysis of entrustable professional activity guides

PURPOSE

The inclusion of quality improvement (QI) and patient safety (PS) into CanMEDS reflects an expectation that graduating physicians are competent in these areas upon training completion. To ensure that Canadian postgraduate specialty training achieves this, the translation of QI/PS competencies into training standards as part of the implementation of competency-based medical education requires special attention.

METHODS

We conducted a cross-specialty, multi-method analysis to examine how QI/PS was incorporated into the EPA Guides across 11 postgraduate specialties in Canada.

RESULTS

We identify cross-specialty variability in how QI/PS is incorporated, positioned, and emphasized in EPAs and milestones. QI/PS was primarily referenced alongside clinical activities rather than as a sole competency or discrete activity. Patterns were characterized in how QI/PS became incorporated into milestones through repetition and customization. QI/PS was also decoupled, conceptualized, and emphasized differently across specialties.

CONCLUSIONS

Variability in the inclusion of QI/PS in EPAs and milestones has important implications considering the visibility and influence of EPA Guides in practice. As specialties revisit and revise EPA Guides, there is a need to balance the standardization of foundational QI/PS concepts to foster shared understanding while simultaneously ensuring context-sensitive applications across specialties. Beyond QI/PS, this study illuminates the challenges and opportunities that lie in bridging theoretical frameworks with practical implementation in medical education, prompting broader consideration of how intrinsic roles and emergent areas are effectively incorporated into competency-based medical education.

CME providers' experiences and practices in Pakistan: a case study

BACKGROUND

Pakistan has made numerous attempts to establish and implement a national mandatory CME program which currently do not exist. The purpose of this study is to explore the views of major CME providers in order to identify possible strengths and weaknesses in the current program, and offer evidence-based recommendations to help further enhance the national CME program in Pakistan.

METHODS

An exploratory study design using a case study approach through in depth interviews was conducted to examine CME providers' experiences and perceptions. The study was conducted in Pakistan between August and November 2019 with CME providers from Sindh, Punjab, the North-West Frontier Province, and the Federal Capital Territory. Thirty-six providers recognised by the Pakistan Medical and Dental Council who were involved in providing CME activities at the national level and whose contact information was publicly available on their websites, were selected for the study. Of the 36 providers invited, 22 participated in this study.

RESULTS

The results generated several organising themes grouped into three major themes: (1) CME current practices, (2) CME past experiences, and (3) Future developments.

CONCLUSION

Participants recommended needs-based educational activities for physicians, a well-structured central regulatory CME body collaborating with existing providers, involving experienced providers for rural CME, accrediting diverse local providers, limiting commercial entities' role, and implementing CME with proper preparation and a phased approach.

Understanding Quality Improvement and Continuing Professional Mentorship: A Needs Assessment Study to Inform the Development of a Community of Practice

INTRODUCTION

Quality improvement (QI) programming attempts to bridge the gap between patient care and standards of care. Mentorship could be a means through which QI is fostered, developed, and incorporated into continuing professional development (CPD) programs. The current study examined (1) models of implementation for mentorship within the Department of Psychiatry of a large Canadian academic center; (2) mentorship as a potential vehicle for alignment of QI practices and CPD; and (3) needs for the implementation of QI and CPD mentorship programs.

METHODS

Qualitative interviews were conducted with 14 individuals associated with the university's Department of Psychiatry. The data were analyzed through thematic analyses with two independent coders using COREQ guidelines.

RESULTS

Our results identified uncertainty among the participants regarding the conceptualization of QI and CPD, illustrating difficulties in determining whether mentorship could be used to align these practices. Three major themes were identified in our analyses: sharing of QI work through communities of practices; the need for organizational support; and relational experiences of QI mentoring.

DISCUSSION

A greater understanding of QI is necessary before psychiatry departments can implement mentorship to enhance QI practices. However, models of mentorship and needs for mentorship have been made clear and include a good mentorship fit, organizational support, and opportunities for both formal and informal mentorship. Changing organizational culture and providing appropriate training is necessary for enhancing QI.

Rethinking Context in Continuing Professional Development: From Identifying Barriers to Understanding Social Dynamics

INTRODUCTION

For continuing professional development (CPD) to reach its potential to improve outcomes requires an understanding of the role of context and the influencing conditions that enable interventions to succeed. We argue that the heuristic use of frameworks to design and implement interventions tends to conceptualize context as defined lists of barriers, which may obscure consideration of how different contextual factors interact with and intersect with each other.

METHODS

We suggest a framework approach that would benefit from postmodernist theory that explores how ideologies, meanings, and social structures in health care settings shape social practices. As an illustrative example, we conducted a Foucauldian discourse analysis of diabetes care to make visible how the social, historical, and political conditions in which clinicians experience, practice, and shape possibilities for behavior change.

RESULTS

The discursive construction of continuing education as a knowledge translation mechanism assumes and is contingent on family physicians to implement guidelines. However, they enact other discursively constituted roles that may run in opposition. This paradoxical position creates a tension that must be navigated by family physicians, who may perceive it possible to provide good care without necessarily implementing guidelines.

DISCUSSION

We suggest marrying "framework" thinking with postmodernist theory that explores how ideologies, meanings, and social structures shape practice behavior change. Such a proposed reconceptualization of context in the design of continuing professional development interventions could provide a more robust and nuanced understanding of how the dynamic relationships and interactions between clinicians, patients, and their work environments shape educational effectiveness.

Advancing Curriculum Development and Design in Health Professions Education: A Health Equity and Inclusion Framework for Education Programs

ABSTRACT

The COVID-19 pandemic has exacerbated pre-existing health inequities in vulnerable and marginalized patient populations. Continuing professional development (CPD) can be a critical driver of change to improve quality of care, health inequities, and system change. In order for CPD to address these disparities in care for patient populations most affected in the health care system, CPD programs must first address issues of equity and inclusion in their education development and delivery. Despite the need for equitable and inclusive CPD programs, there remains a paucity of tools and frameworks available in the literature to guide CPD and broader education providers on how best to develop and deliver equitable and inclusive education programs. In this article, we describe the development and application of a Health Equity and Inclusion (HEI) Framework for education and training grounded in the Analyze, Design, Develop, Implement, and Evaluate model for instructional design. Using a case example, specifically a hospital-wide trauma-informed de-escalation for safety program, we demonstrate how the HEI Framework can be applied practically to CPD programs to support equity and inclusion in the planning, development, implementation, and evaluation phases of education program delivery. The case example illustrates how the HEI Framework can be used by CPD providers to respect learner diversity, improve accessibility for all learners, foster inclusion, and address biases and stereotypes. We suggest that the HEI Framework can serve as an educational resource for CPD providers and health professions educators aiming to create equitable and inclusive CPD programs.

A Patient Safety Champion Program for Interprofessional Health Care Educators: Implementation and Outcomes

INTRODUCTION

Health care educators are challenged with helping clinicians develop competencies beyond their foundational training. In health care systems where continuing professional development is not integral to practice, clinicians may have few opportunities. We describe the design, implementation, and evaluation of a professional development program in patient safety for Japanese clinical educators to acquire simulation instructional skills and become Patient Safety Champions at their organizations.

METHODS

Mixed methods were used in a longitudinal pre/post study design. The Kirkpatrick evaluation model was used to evaluate outcomes of a workshop, overall program, on-site training experiences, and impact as Patient Safety Champions. Self-assessment data on skills and knowledge of patient safety, simulation instructional methods, interprofessional collaboration, and leadership were collected and analyzed.

RESULTS

Eighty-nine percent of participants facilitated on-site patient safety training within 6 months of workshop completion. Skills and knowledge improvement were observed immediately postworkshop in four categories: patient safety, simulation instructional methods, interprofessional collaboration and communication, and leadership as a patient safety champion. Skills and knowledge increased at 6 months after facilitation of on-site safety training. Program mean satisfaction scores ranged from 84% to 92%. Mean Patient Safety Champion in-facility evaluations were 4.2 to 4.7 on a 5-point scale.

DISCUSSION

High levels of knowledge, skill retention, and behavior change are attributed to goal setting, outcome-oriented pedagogy, and reflective sessions. The Patient Safety Champion model and experiential learning approach gave Japanese clinical educators in medicine, nursing, and pharmacy an opportunity to learn from each other in simulations reflecting the practice environment.

Interprofessional continuing professional development programs can foster lifelong learning in healthcare professionals: experiences from the Project ECHO model

BACKGROUND

The success of continuing professional development (CPD) programs that foster skills in lifelong learning (LLL) has been well established. However, healthcare professionals often report barriers such as access to CPD and cost which limit uptake. Further research is required to assess how accessible CPD programs, such as those delivered virtually, impact orientation to LLL. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a CPD model that has a growing body of evidence demonstrating improvements in knowledge and skills. Central to this model is the use of a virtual platform, varied teaching approaches, the promotion of multi-directional learning and provider support through a community of practice. This study aimed to explore whether participation in a provincial mental health ECHO program had an effect on interprofessional healthcare providers' orientation to LLL.

METHODS

Using a pre-post design, orientation to LLL was measured using the Jefferson Scale of Lifelong Learning. Eligible participants were healthcare professionals enrolled in a cycle of ECHO Ontario Mental Health from 2017 to 2020. Participants were classified as 'high' or 'low' users using median session attendance as a cut-point.

RESULTS

The results demonstrate an increase in orientation to LLL following program participation (Pre: 44.64 ± 5.57 vs. Post: 45.94 ± 5.70, t (66) = - 3.023, p < .01, Cohen's d = 0.37), with high ECHO users demonstrating greater orientation to LLL post-ECHO.

CONCLUSION

Findings are discussed in the context of self-determination theory and suggest there may be components of CPD programs that more readily support increased motivation for LLL for interprofessional healthcare professionals.

Randomized Controlled Trial of Interactive Spaced Education to Support Constipation Management by Pediatric Primary Care Providers

INTRODUCTION

Integrating continuing medical education and quality improvement (QI) initiatives is challenging. We aimed to compare one method, Interactive Spaced Education (ISE/QI), with standard (sTD/Qi) education embedded within a constipation management Qi initiative.

METHODS

We conducted a randomized, controlled study to compare ISE/QI and STD/QI education. Pediatric primary care providers (PCPs) were recruited from a network of local private practices. The QI initiative was implemented with all providers before education interventions. ISE/QI participants received questions by email weekly, provided answers, received feedback, and repeated questions over a 4-month period. The STD/QI group received a Power Point with the same educational content. Pre- and post-surveys evaluated usability, self-assessed confidence, and practice changes while quizzes evaluated knowledge. Process control charts tracked subsequent visits to gastroenterology (GI).

RESULTS

Of the 212 eligible PCPs, 101 (48%) enrolled, with 49 PCPs in the ISE/QI arm and 52 in STD/QI education arm. Quiz scores improved in the ISE/QI arm with a strong effect size (Cohen d 1.76). Mean increase in confidence managing difficult cases was higher in the ISE/QI group (1.84 vs 1.21, P  = 0.030). ISE/QI participants were more likely to rate the activity better than most online education (odds ratio [OR] 18.1, P < 0.0001) and incorporate practice changes (OR 3.35, P = 0.0152). Visits to GI decreased among the entire population, but the effect on GI visits within each education arm was mixed.

CONCLUSIONS

ISE/QI improved knowledge and confidence managing difficult cases. ISE/QI participants reported higher likelihood to change practice, but no differences were seen in GI referrals.

Aligning Practice Data and Institution-specific CPD: Medical Quality Management as the Driver for an eLearning Development Process

For hospital physicians, alignment of Continuing Professional Development (CPD) with quality improvement efforts is often absent or rudimentary. The purpose of this study was to evaluate a CPD development process that created accessible learning opportunities and aligned CPD with practice data. We conducted a chart audit to identify patient safety and quality of care issues within the institution, then established an eLearning approach that supported quick and cost effective development of high-quality interactive CPD opportunities. We tested a pilot module on the management of common infections in sub-acute care settings with fifteen (68%) residents and three staff physicians to evaluate the approach. One resident and three staff agreed to a follow-up interview. The satisfaction survey indicated that participants felt the content was generally appropriate and the module well designed. Significant improvements to knowledge were reported in the multi-drug resistance (Mean Difference = 25%, p = 0.002), infection management (MD = 32%, p < 0.001), and cellulitis risk factor (MD = 22%, p = 0.02) questions, as well as in the overall score (MD = 19%, p < 0.001). In terms of confidence in their answers, the mean rating pre-module was 3.17, rising significantly to 3.92 post-module (p < 0.001). In this way, collaboration between quality management and education committees allowed for the development of relevant CPD for physicians, with eLearning providing a timely and accessible way to deliver training on emerging issues.

Making the Learning Continuum a Reality: The Critical Role of a Graduate Medical Education-Continuing Medical Education Partnership

A true continuum of learning in physician education, envisioned as the seamless integration of undergraduate, graduate, and continuing medical education that results in lifelong learning, has yet to be realized. Rapid clinical change, evolving systems of health care, and a shift to competency-based training make the continuum and lifelong learning even more critical. Because they function independently, the efforts of Graduate Medical Education (GME) and Continuing Medical Education (CME) have fallen short of the integrated ideal. The complementary threads of accreditation requirements, expertise, resources, and scholarly activities provide an opportunity for GME and CME to operate in a more integrated and coordinated fashion. Our local GME-CME partnership model demonstrates that these complimentary threads can be tied together to effectively facilitate lifelong learning and promote an integrated learning continuum.

Data and Lifelong Learning Protocol: Understanding Cultural Barriers and Facilitators to Using Clinical Performance Data to Support Continuing Professional Development

Continuing professional development (CPD) can support delivery of high-quality care, but may not be optimized until we can understand cultural barriers and facilitators, especially as innovations emerge. Lifelong learning (LLL), linked with quality improvement, competence, and professionalism, is a core competency in medical education. The purpose of this study is to examine cultural factors (individual, organizational, and systemic) that influence CPD and specifically the use of clinical data to inform LLL and CPD activities. This mixed-method study will examine the perceptions of two learner groups (psychiatrists and general surgeons) in three phases: (1) a survey to understand the relationship between data-informed learning and orientation to LLL; (2) semistructured interviews using purposive and maximum variation sampling techniques to identify individual-, organizational-, and system-level barriers and facilitators to engaging in data-informed LLL to support practice change; and (3) a document analysis of legislation, policies, and procedures related to the access and the use of clinical data for performance improvement in CPD. We obtained research ethics approval from the University Health Network in Toronto, Ontario, Canada. By exploring two distinct learner groups, we will identify contextual features that may inform what educators should consider when conceptualizing and designing CPD activities and what initial actions need to be taken before CPD activities can be optimized. This study will lead to the development of a framework reflective of barriers and facilitators that can be implemented when planning to use data in CPD activities to support data adoption for LLL.

CPD of the future: a partnership between quality improvement and competency-based education

CONTEXT

Many of those involved in continuing professional development (CPD) over the past 10 years have engaged in discussions about its goals and activities. Whereas in the past CPD was viewed as an education intervention directed towards the medical expert role, recent research highlights the need to expand the scope of CPD and to promote its more explicit role in improving patient care and health outcomes. Recent developments in quality improvement (QI) and competency-based medical education (CBME), guided by appropriate theories of learning and change, can shed light on how the field might best advance. This paper describes principles of QI and CBME and how they might contribute to CPD, explores theoretical perspectives that inform such an integration and suggests a future model of CPD.

DISCUSSION

Continuing professional development seeks to improve patient outcomes by increasing physician knowledge and skills and changing behaviours, whereas QI takes the approach of system and process change. Combining the strengths of a CPD approach with strategies known to be effective from the field of QI has the potential to harmonise the contributions of each, and thereby to lead to better patient outcomes. Similarly, competency-based CPD is envisioned to place health needs and patient outcomes at the centre of a CPD system that will be guided by a set of competencies to enhance the quality of practice and the safety of the health system.

CONCLUSIONS

We propose that the future CPD system should adhere to the following principles: it should be grounded in the everyday workplace, integrated into the health care system, oriented to patient outcomes, guided by multiple sources of performance and outcome data, and team-based; it should employ the principles and strategies of QI, and should be taken on as a collective responsibility by physicians, CPD provider organisations, regulators and the health system.

Bridging Continuing Medical Education and Quality Improvement Efforts: A Qualitative Study on a Health Care System in the Kingdom of Saudi Arabia

INTRODUCTION

There have been initial efforts to link continuing medical education (CME), quality improvement (QI), and patient safety in North America. However, limited empirical research has been performed to characterize the relationship and integration between CME and QI/patient safety in the Kingdom of Saudi Arabia (KSA). To explore health care leaders' perceptions and experiences of collaboration between the CME department (CME-D) and the quality management administration (QMA), we conducted an exploratory qualitative study at a large governmental health care center named [blinded for peer review] in [blinded for peer review], KSA.

METHODS

The health care managers at [blinded for peer review] were asked to identify their perception on the state of collaboration between the CME-D and QMA. Data collection, in the form of one-to-one semistructured interviews, was directed by an interview guide. Interviews were transcribed verbatim, and the participants' perspectives were analyzed thematically using a theoretical framework.

RESULTS

Fifteen participants were recruited: one top manager of the CME-D, three top managers from the QMA, seven representatives from the medical board, and four representatives from the executive board. Key findings of the interviews were the presence of some shared ad hoc goals between the CME-D and QMA. However, insufficiency of other collaborative factors reflected a "potential collaboration" (level 1) based on D'Amour's model of collaboration.

DISCUSSION

This is the first qualitative study to explore the perceptions and experiences of CME and QI health care managers on their collaboration at one of the largest health centers in the KSA. Further research should investigate the feasibility of implementing interventions to intensify collaboration between CME and QI.

Toward interprofessional learning and education: Mapping common outcomes for prequalifying healthcare professional programs in the United Kingdom

INTRODUCTION

Interprofessional education (IPE) continues to be a key component in prequalifying health professional education, with calls for regulators to publish a joint statement regarding IPE outcomes. To date, the regulatory documents for healthcare education in the United Kingdom have not been examined for common learning outcomes; information that could be used to inform such a statement and to identify opportunities for interprofessional learning.

METHODS

A mapping of the outcomes/standards required by five, UK, health profession regulatory bodies was undertaken. This involved the identification of common outcomes, a keyword search and classification of common outcomes/standards; presented as themes and subthemes.

RESULTS

Seven themes were identified: knowledge for practice, skills for practice, ethical approach, professionalism, continuing professional development (CPD), patient-centered approach and teamworking skills, representing 22 subthemes. Each subtheme links back to the outcomes/standards in the regulatory documents.

CONCLUSIONS

This study identifies the key areas of overlap in outcomes/standards expected of selected healthcare graduates in the United Kingdom. The mapping provides a framework for informing prequalifying IPE curricula, for example, identifying possible foci for interprofessional education outcomes and associated learning opportunities. It allows reference back to the standards set by regulatory bodies, a requirement for all institutions involved in health profession education.