Quality improvement in medical education: current state and future directions

Trends in patient safety education research for healthcare professional students over the past two decades: a bibliometric and content analysis

Research and practice in patient safety education have garnered widespread attention; however, a comprehensive bibliometric analysis is lacking. This study aimed to provide a comprehensive understanding of the research focus and research trends in the globalization of the field of patient safety education and to describe the general characteristics of publications. Data on articles and reviews about student safety education were extracted from Web of Science. Microsoft Excel 2019, CiteSpace 6.1.R3, VOSviewer 1.6.18, SATI 3.2, Scimago Graphica, and Pajek were used for quantitative analysis. Collaboration networks of countries, institutions, journals, authors, and keywords were visualized based on publications from January 2000 to September 2022. A total of 573 papers were published between 2000 to 2022, showing an overall increasing trend. The USA, England, and Australia are the top three most prolific countries; Johns Hopkins University, the University of Technology Sydney, and the University of Toronto are the top three most productive institutions; Nurse Education Today, Journal of Nursing Education, and BMC Medical Education are the most productive journals; Based on content analysis five research hotspots focused on: (1) Quality Improvement of Patient safety Teaching and Learning; (2) Patient safety Teaching Content; (3)Specialized Teaching in Patient Safety; (4) Integrating Patient Safety and Clinical Teaching; (5)Patient Safety Teaching Assessment Content. Through keyword clustering analysis, five research hotspots and relevant contents were identified. According to this study, simulation, communication, collaboration, and medication may attract more attention from researchers and educators, and could be the major trend for future study.

Crafting medical MCQs with generative AI: A how-to guide on leveraging ChatGPT

As medical educators grapple with the consistent demand for high-quality assessments, the integration of artificial intelligence presents a novel solution. This how-to article delves into the mechanics of employing ChatGPT for generating Multiple Choice Questions (MCQs) within the medical curriculum. Focusing on the intricacies of prompt engineering, we elucidate the steps and considerations imperative for achieving targeted, high-fidelity results. The article presents varying outcomes based on different prompt structures, highlighting the AI's adaptability in producing questions of distinct complexities. While emphasizing the transformative potential of ChatGPT, we also spotlight challenges, including the AI's occasional "hallucination", underscoring the importance of rigorous review. This guide aims to furnish educators with the know-how to integrate AI into their assessment creation process, heralding a new era in medical education tools.

Effects of Entry Grades on Students' Academic Performance Under Homogeneous Educational Resources

Background

A minor difference in college entrance examination scores can result in vastly different educational resources in China, so it has been debated whether it is the difference in the student population or the difference in educational resources that causes the difference in medical graduates. We aimed to evaluate the effects of entry grades on students' academic performance under homogeneous educational resources.

Methods

Students in grade 2016 with 13-point difference in the average admission scores of 2 medicine schools in Sun Yat-sen University were educated in mixed classes and were taught with the same educators during the 5 years of undergraduate period. The grades, graduation, and postgraduate enrollment rates of the students were compared between the two campuses.

Results

The average admission scores for Shenzhen Campus (SZC) students are 13 points lower than those of Guangzhou North Campus (GZNC) (613 points vs 626 points). After 5 years of homogeneous education, comparing the GZNC students with the SZC students, there were no significant differences in the average total score (80.2 ± 4.6 vs 80.0 ± 5.6, P = 0.691), the average compulsory course (78.9 ± 3.4 vs 78.4 ± 6.1, P = 0.438), the average core course score (78.8 ± 7.4 vs 78.7 ± 5.0, P=0.860) and the average clerkship score (85.1 ± 7.2 vs 84.6 ± 2.7, P=0.275). However, the completion rate for SZC was higher than for GZNC (93.94% vs 86.27%, P=0.009). There was no statistical difference in postgraduate enrolment between the two institutions (P=0.758).

Conclusion

Given the same educational resources, more medical students with lower entrance scores completed their studies and achieved the same percentage of postgraduate acceptance. This finding suggests that a key component of improving the quality of medical higher education in China may be to further rationalize the allocation of high-quality educational resources, rather than to pursuing students with high entrance examination scores.

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.

ChatGPT versus human in generating medical graduate exam multiple choice questions-A multinational prospective study (Hong Kong S.A.R., Singapore, Ireland, and the United Kingdom)

INTRODUCTION

Large language models, in particular ChatGPT, have showcased remarkable language processing capabilities. Given the substantial workload of university medical staff, this study aims to assess the quality of multiple-choice questions (MCQs) produced by ChatGPT for use in graduate medical examinations, compared to questions written by university professoriate staffs based on standard medical textbooks.

METHODS

50 MCQs were generated by ChatGPT with reference to two standard undergraduate medical textbooks (Harrison's, and Bailey & Love's). Another 50 MCQs were drafted by two university professoriate staff using the same medical textbooks. All 100 MCQ were individually numbered, randomized and sent to five independent international assessors for MCQ quality assessment using a standardized assessment score on five assessment domains, namely, appropriateness of the question, clarity and specificity, relevance, discriminative power of alternatives, and suitability for medical graduate examination.

RESULTS

The total time required for ChatGPT to create the 50 questions was 20 minutes 25 seconds, while it took two human examiners a total of 211 minutes 33 seconds to draft the 50 questions. When a comparison of the mean score was made between the questions constructed by A.I. with those drafted by humans, only in the relevance domain that the A.I. was inferior to humans (A.I.: 7.56 +/- 0.94 vs human: 7.88 +/- 0.52; p = 0.04). There was no significant difference in question quality between questions drafted by A.I. versus humans, in the total assessment score as well as in other domains. Questions generated by A.I. yielded a wider range of scores, while those created by humans were consistent and within a narrower range.

CONCLUSION

ChatGPT has the potential to generate comparable-quality MCQs for medical graduate examinations within a significantly shorter time.

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.

Scholarship in anesthesiology: the role of critical appraisal, literature review, quality improvement, journal club, and presentation skills

If asked to describe the term "anesthesiologist scholar", one may receive a variety of definitions depending on the individual's area of practice, location in the world, and the generation in which they trained. In this article, we review the roles of five core elements that make an anesthesiologist a "scholar": skills in critical appraisal, literature review, quality improvement, journal club participation, and presentation delivery. Although this list of scholarly components is not comprehensive, review of each element's role in the everyday practice and training of physicians will offer insight into their evolution and may offer a glimpse into the future of anesthesiologist scholars. Overall, through the dissemination, recognition, and support of scholarship through these practices, we will continue to achieve meaningful outcomes for our patients and promote a culture of collaboration worldwide. We should ensure that these topic areas become a bedrock of medical education globally, and we must foster opportunities for those who have already completed training to develop and master these skills as a part of their clinical and academic practice.

Current state and future direction of quality improvement in pediatric neurosurgery: a survey of pediatric neurosurgeons

OBJECTIVE

Quality improvement (QI) is a methodology used to implement sustainable, meaningful change to improve patient outcomes. Given the complex pathologies observed in pediatric neurosurgery, QI projects could potentially improve patient care. Overall, there is a need to characterize the degree of QI opportunities, training, and initiatives within the field of pediatric neurosurgery. Herein the authors aimed to define the current QI landscape in pediatric neurosurgery.

METHODS

A cross-sectional survey was sent to all members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Pediatric Neurological Surgery via email. The responses were anonymized. Questions addressed several relatable QI topics including 1) training and participation in QI; 2) QI infrastructure; 3) QI program incentives; and 4) general opinions on the National Surgical Quality Improvement Program (NSQIP) database, various QI topics, and QI productivity.

RESULTS

Responses were received from 129 participants (20% response rate). Most respondents practiced in an academic setting (59.8%) and at a free-standing pediatric hospital (65.4%). Participation in QI projects was high (81.7%), but only 23.8% of respondents had formal QI training. Only 36.5% of respondents had institutional requirements for QI work; the majority of those were only required to participate as a project team member. Nearly half of the respondents did not receive incentives or institutional support for QI. The majority agreed ("strongly" and "somewhat") that a QI course would be beneficial (75.5%), that QI projects should be considered for publication in neurosurgery journals (88.1%), and that there is a need for national quality metrics (81.4%). Over 88% have an interest in seeing QI project presentations at the annual Pediatric Joint Section meeting. Only 26.3% believed that the NSQIP was a useful QI guide. Respondents suggested further study of the following QI topics: overall rates of infection and their prevention, hydrocephalus, standardized treatment algorithms for common disorders, team communication, pediatric neurosurgery-specific database, access to care, and interprofessional education.

CONCLUSIONS

Areas of opportunity include specialty-specific QI education, tactics for obtaining support to build the QI infrastructure, increased visibility of QI work within pediatric neurosurgery, and a review of available registries to provide readily available data relevant to this specialty.

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.

Stakeholder Participation and Cross-Sectoral Cooperation in a Quality Circle on Community-Based Teaching: Results of a Qualitative Interview Study

Introduction

Community-based learning in family medicine practices is an increasingly important part of the medical curriculum internationally. It is widely regarded as one solution to healthcare system needs, such as training and retaining a workforce willing to work in primary care. However, the perspectives of community-based medical educators and representatives from university-based medical education are rarely integrated. To improve teaching quality and promote exchange between those two sectors of medical education, the Institute for General Practice and Interprofessional Care at Tübingen University started a quality circle in family medicine teaching involving stakeholders from both sectors in 2018. The study aims to describe how the participants of this specific QC describe the cross-sectoral cooperation and participation of stakeholders in the quality management of community and university medical education.

Methods

After an observed meeting of the quality circle, semi-structured interviews were conducted with n=12 participants of the quality circle. Interview transcripts were analyzed using grounded theory.

Results

According to the participants, the quality circle provides a dynamic continuity which allows participants to navigate known barriers to transsectoral collaboration in the quality management of community-based medical education. The quality circle is perceived as an instrument for quality improvement that offered continuity and direction. At the same time, it allows for enough freedom and flexibility for the involved stakeholders to creatively work together on quality management and be inspired by their experiences.

Discussion

The quality circle has the potential to facilitate collaboration between the two teaching settings, form a creative community, and give medical students an active role in educational quality management.

Incorporating Patient Safety and Quality Into the Medical School Curriculum: An Assessment of Student Gains

BACKGROUND

Global efforts are being made to improve health care standards and the quality of care provided. It has been shown through research that the introduction of patient safety (PS) and quality improvement (QI) concepts in the medical curriculum prepares medical students to face future challenges in their professional careers.

PURPOSE

This study aimed to evaluate how a brief course on QI and PS affects the knowledge, efficacy, and system thinking of medical students.

METHODS

A 5-day QI and PS intervention course was implemented at the Aga Khan University medical college for 98 third-year medical students in March 2021. This weeklong course of lectures, interactive sessions, and hands-on skill workshops was conducted before the students began their clinical rotations. Students' knowledge, self-efficacy, and system thinking were assessed with pretest and posttest. Students were also asked to write personal reflections and fill out a satisfaction survey at the end of the intervention.

RESULTS

Comparisons of pretest and posttest scores showed that the course significantly improved students' knowledge by a mean of 2.92 points (95% confidence interval, 2.30-3.53; P < 0.001) and system thinking by 0.16 points (95% confidence interval, 0.03-0.29; P = 0.018) of the maximum scores of 20 and 5 points, respectively. The students' self-assessment of PS knowledge also reflected statistically significant increases in all 9 domains ( P < 0.001). Students reported positive experiences with this course in their personal reflections.

CONCLUSIONS

The medical students exhibited increases in knowledge, self-efficacy, and system thinking after this weeklong intervention. The design of the course can be modified as needed and implemented at other institutions in low- and middle-income countries. A targeted long-term assessment of knowledge and attitudes is needed to fully evaluate the impact of this course.

The Evaluation of an Interprofessional QI Program: A Qualitative Study

Background: Quality Improvement (QI) is the key for every healthcare organization. QI programs may help healthcare professionals to develop the needed skills for interprofessional collaboration through interprofessional education. Furthermore, the role of diversity in QI teams is not yet fully understood. This evaluation study aimed to obtain in-depth insights into the expectations and experiences of different stakeholders of a hospital-wide interprofessional QI program. Methods: This qualitative study builds upon 20 semi-structured interviews with participants and two focus groups with the coaches and program advisory board members of this QI program. Data were coded and analyzed using thematic analysis. Results: Three themes emerged from the analysis: "interprofessional education", "networking" and "motivation: presence with pitfalls". Working within interprofessional project groups was valuable, because participants with different experiences and skills helped to move the QI project forward. It was simultaneously challenging because IPE was new and revealed problems with hierarchy, communication and planning. Networking was also deemed valuable, but a shared space to keep in contact after finalizing the program was missing. The participants were highly motivated to finish their QI project, but they underestimated the challenges. Conclusions: A hospital-wide QI program must explicitly pay attention to interprofessional collaboration and networking. Leaders of the QI program must cherish the motivation of the participants and make sure that the QI projects are realistic.

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.

Science of quality improvement - from vision to reality: Experience from a leading academic healthcare center in Qatar

Quality improvement and patient safety are cornerstones to the delivery of effective patient care. The introduction of a quality improvement curriculum for medical students and trainee physicians can have a significant effect on their understanding of the science of improvement and its role in improving the quality of healthcare delivery and patient safety. The article describes the development and implementation of a quality improvement curriculum for trainee physicians in the department of internal medicine at a tertiary care center in Qatar through online training courses, workshops, didactic activities, and trainee-led quality improvement projects.

A Systematic Review of Approaches for Continuous Quality Improvement Capacity-Building

CONTEXT

Continuous quality improvement (CQI) has become prominent in public health settings; yet, little consolidated guidance exists for building CQI capacity of community-based organizations.

OBJECTIVE

To synthesize relevant literature to identify guiding principles and core components critical to building the capacity of organizations to adopt and use CQI.

DESIGN

We employed a systematic review approach to assess guiding principles and core components for CQI capacity-building as outlined in the literature.

ELIGIBILITY CRITERIA

Studies meeting the following criteria were eligible for review: (1) empirical, peer-reviewed journal article, evaluation study, review, or systematic review; (2) published in 2010 or later; and (3) capacity-building activities were described in enough detail to be replicable. Studies not including human subjects, published in a language other than English, or for which full text was not available were excluded.

STUDY SELECTION

The initial return of records included 6557 articles, of which 1455 were duplicates. The research team single-screened titles and abstracts of 5102 studies, resulting in the exclusion of 4842 studies. Two hundred sixty-two studies were double-screened during full-text review, yielding a final sample of 61 studies from which data were extracted.

MAIN OUTCOME MEASURES

Outcome measures of interest were operationalized descriptions of guiding principles and core components of the CQI capacity-building approach.

RESULTS

Results yielded articles from medical education, health care, and public health settings. Findings included guiding principles and core components of CQI capacity-building identified in current practice, as well as infrastructural and contextual elements needed to build CQI capacity.

CONCLUSIONS

This consolidation of guiding principles and core components for CQI capacity-building is valuable for public health and related workforces. Despite the uneven distribution of articles from health care, medical education, and public health settings, our findings can be used to guide public health organizations in building CQI capacity in a well-informed, systematic manner.

Effect of Patient Safety Curriculum for Internal Medicine Residents on a Health Care System

Background

Healthcare organizations seeking to promote a safety culture depend on engaged clinicians. Academic medical centers include a community of physicians-in-training; however, medical residents and fellows are historically less engaged in patient safety (PS) than are other clinicians. Increased attention has been focused on integrating PS into graduate medical education. Nonetheless, developing curricula that result in real-world system changes is difficult.

Objective

To develop an interactive PS curriculum for internal medicine (IM) residents that analyzes real-word PS problems.

Methods

A multidisciplinary group developed a five-session, case-based PS curriculum for IM residents in the context of a 3-year, longitudinal quality-improvement, PS, and high-value-care curriculum. The curriculum was facilitated by a PS analyst and incorporated mock root cause analysis (RCA) based on actual resident-reported PS events. Each mock RCA developed an action plan, and outcomes were tracked. Pre- and postcurriculum assessments with participating residents were conducted to evaluate the curriculum.

Results

Twenty-eight IM residents completed the curriculum during four iterations from 2017 to 2020. The curriculum identified multiple potential PS risks, led to tangible changes in clinical processes, and enhanced resident confidence in improving systems of care.

Conclusions

We describe an active-learning PS curriculum for IM residents that addressed actual resident-reported PS problems. Through RCA, action items were identified and meaningful system changes were made. Leveraging the expertise of local PS experts in the design and delivery of PS curricula may improve the translation of learner recommendations into real system changes and cultivate a positive PS culture.

An Active-Learning Quality Improvement Curriculum for Faculty in Hospital Medicine

INTRODUCTION

Despite the growing importance of quality improvement (QI) training in medical education, there is a lack of faculty with expertise in QI at many academic medical centers. In this report, we describe the design, implementation, and evaluation of a QI training program for faculty in hospital medicine at an academic medical center aimed at increasing faculty capacity in QI.

METHODS

With input from an initial focus group of hospital medicine faculty, we developed a 12-session, active-learning curriculum incorporating core concepts in QI applied to a real-life QI problem. We used a survey instrument to assess changes in self-reported confidence, the Quality Improvement Knowledge Application Tool-Revised to assess changes in applied knowledge, and a second focus group to obtain qualitative feedback regarding the curriculum.

RESULTS

Self-reported confidence in numerous QI skills increased after completion of the curriculum; however, concurrent improvement in applied knowledge was not observed. Qualitatively, participants not only described improved understanding of QI methodology and greater confidence contributing to QI initiatives but also a sense they were not prepared to lead a QI project independently.

DISCUSSION

An active-learning faculty training program is feasible with limited resources and was associated with increased faculty confidence in QI skills.

Complexities of Continuing Professional Development in Context: Physician Engagement in Clinical Coaching

INTRODUCTION

Effective continuing professional development (CPD) is critical for safe and effective health care. Recent shifts have called for a move away from didactic CPD, which often fails to affect practice, toward workplace learning such as clinical coaching. Unfortunately, coaching programs are complex, and adoption does not guarantee effectiveness. To resolve this problem, thus ensuring resources are well spent, there is a critical need to understand what physicians try to achieve and how they engage. Therefore, we examined the types of change physicians pursue through clinical coaching and the impact of context on their desired changes.

METHODS

In the context of two clinical coaching programs for rural physicians, we applied a generic qualitative approach. Coachees (N = 15) participated in semistructured interviews. Analysis involved iterative cycles of initial, focused, and theoretical coding.

RESULTS

Coachees articulated desired practice changes along a spectrum, ranging from honing their current practice to making larger changes that involved new skills outside their current practice; changes also ranged from those focused on individual physicians to those focused on the practice system. Desired changes were affected by factors in the learning/practice environment, including those related to the individual coachee, coach, and learning/practice context.

DISCUSSION

These results suggest that the current focus on acquiring new knowledge through CPD may miss important learning that involves subtle shifts in practice as well as learning that focusses on systems change. Moreover, an appreciation of the contextual nature of CPD can ensure that contextual affordances are leveraged and barriers are acknowledged.

Core Competency-Related Professional Behaviors During Patient Encounters: A Report From the Association for Athletic Training Education Research Network

CONTEXT

To enhance the quality of patient care, it is important that athletic trainers integrate the components of the core competencies (CCs; evidence-based practice [EBP], patient-centered care [PCC], health information technology [HIT], interprofessional education and collaborative practice [IPECP], quality improvement [QI], professionalism) as a part of routine clinical practice. In what ways, if any, athletic training students (ATSs) are currently integrating CCs into patient encounters (PEs) during clinical experiences is unclear.

OBJECTIVE

To describe which professional behaviors associated with the CCs were implemented by ATSs during PEs that occurred during clinical experiences.

DESIGN

Multisite panel design.

SETTING

A total of 12 professional athletic training programs (5 bachelor's, 7 master's level).

PATIENTS OR OTHER PARTICIPANTS

A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences participated.

MAIN OUTCOME MEASURE(S)

During each PE, ATSs were asked to report whether professional behaviors reflecting 5 of the CCs occurred (the professionalism CC was excluded). Summary statistics, including means ± SDs, counts, and percentages were tabulated for the professional behaviors of each CC.

RESULTS

Data from 30 630 PEs were collected during the study period. Professional behaviors related to EBP were the most frequently incorporated during PEs (74.3%, n = 22 773), followed by QI (72.3%, n = 22 147), PCC (56.6%, n = 17 326), HIT (35.4%, n = 10 857), and IPECP (18.4%, n = 5627).

CONCLUSIONS

It is unsurprising that EBP and PCC behaviors were 2 of the most frequently incorporated CCs during PEs due to the emphasis on these competencies during the past several years. However, it is surprising that ATSs did not incorporate behaviors related to either HIT (in 65% of PEs) or IPECP (in 82% of PEs). These findings suggest that directed efforts are needed to ensure that ATSs are provided opportunities to incorporate professional behaviors related to the CCs during clinical experiences.

Co-Learning Curriculum in Quality Improvement for Surgical Residents- Five-Year Experience from the University of Toronto

OBJECTIVE

We describe our five-year experience with a novel co-learning curriculum in quality improvement (CCQI)¹ for the largest reported cohort of surgical residents. The program introduces trainees to principles of quality improvement (QI)² and empowers them to complete collaborative projects with mentorship from faculty experts.

DESIGN

Each iteration consists of three interactive seminars. Residents are required to complete and present a QI project in the third seminar. To assess the impact of the program, graduates of the 2020-2021 iteration were surveyed using validated tools to examine changes in confidence and knowledge of QI principles.

SETTING

Department of Surgery, University of Toronto, Toronto, ON, Canada.

PARTICIPANTS

Participation ranged from 57 to 63 residents yearly, from diverse surgical disciplines including General Surgery, Plastic Surgery, Obstetrics and Gynecology, amongst others. Multiple small groups consisted of 4-6 residents from each speciality, mentored by a faculty lead from the same specialty.

RESULTS

Approximately 300 first-year surgical residents have participated in the CCQI since 2015, with over 60 completed QI projects. A total of 41(66%) and 51(82%) residents completed the survey in its pre- and post-course administration in 2020-2021, respectively. There was a significant increase in confidence scores with respect to describing a QI issue, building a team, and testing the change, amongst other aspects. There was also a statistically significant increase in mean knowledge scores for both scenarios of the Quality Improvement Knowledge Application Tool. 69% and 73% of residents reported "some improvement" in their knowledge, and confidence in applying QI principles to patient care, respectively. A majority of residents (73%) found the QI curriculum somewhat valuable, with 23% reporting it to be very valuable to their residency and future surgical career.

CONCLUSIONS

We describe successful long-term implementation of a novel co-learning curriculum in quality improvement. Residents derive value from this curriculum with a meaningful increase in confidence and knowledge of QI as an integral part of surgical practice.

Analysis of the Interprofessional Clinical Learning Environment for Quality Improvement and Patient Safety From Perspectives of Interprofessional Teams

BACKGROUND

In 2018 the Clinical Learning Environment Review (CLER) Program reported that quality improvement and patient safety (QIPS) programs in graduate medical education (GME) were largely unsuccessful in their efforts to transfer QI knowledge and substantive interprofessional QIPS experiences to residents, and CLER 2.0 called for improvement. However, little is known about how to improve the interprofessional clinical learning environment (IP-CLE) for QIPS in GME.

OBJECTIVE

To determine the current state of the IP-CLE for QIPS at our institution with a focus on factors affecting the IP-CLE and resident integration into interprofessional QIPS teams.

METHODS

We interviewed an interprofessional group of residents, faculty, and staff of key units engaged in IP QIPS activities. We performed thematic analysis through general inductive approach using template analysis methods on transcripts.

RESULTS

Twenty individuals from 6 units participated. Participants defined learning on interprofessional QIPS teams as learning from and about each other's roles through collaboration for improvement, which occurs naturally when patients are the focus, or experiential teamwork within QIPS projects. Resident integration into these teams had various benefits (learning about other professions, effective project dissemination), barriers (difficult rotations or program structure, inappropriate assumptions), and facilitators (institutional support structures, promotion of QIPS culture, patient adverse events). There were various benefits (strengthened relationships, lowered bar for further collaboration), barriers (limited time, poor communication), and facilitators (structured meetings, educational culture) to a positive IP-CLE for QIPS.

CONCLUSIONS

Cultural factors prominently affected the IP-CLE and patient unforeseen events were valuable triggers for IP QIPS learning opportunities.

Lessons From Learners: Adapting Medical Student Education During and Post COVID-19

In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement was developed through the curriculum more readily than in traditional clerkships. These could be considered as integral learning objectives in future curricular design.

Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study

Purpose

To evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle.

Methods

A quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level.

Results

We included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, − 61.7; 95% confidence interval [CI], − 72.2 to − 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control.

Conclusion

A quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02143-7.

A Tale of Four Programs: How Residents Learn About Quality Improvement during Postgraduate Medical Education at the University of Calgary

Phenomenon: Quality Improvement (QI) has become increasingly incorporated into competency frameworks for physician learners over the past two decades. As contemporary medical education adapts competency-based models of training, learners will be required to demonstrate competency in QI. There is a need to explore how various residency programs are currently teaching QI, including how residents might participate in experiential QI activities, and the various outcomes of these strategies. Approach: A collective case study examined how residents in four postgraduate programs at a single academic institution have learned about QI since the formal integration of QI as a cross-cutting competency. Data from surveys, interviews, observations, and archival records were collected in order to develop a comprehensive understanding of each case in its real-life context and explore current and historical trends and patterns within and across the four programs. Findings: Teaching and resident involvement in QI projects increased across all four programs since its formal integration into the national physician competency framework. Two programs had a longitudinal, hybrid QI curriculum involving didactic and experiential components. Two programs had didactic-alone QI curricula, with minimal resident engagement in applied QI activities. Between-program differences were quantified with regards to learning climate, safety climate, QI knowledge, skills, and attitudes, attitudes toward research during residency, and quality of mentorship for scholarly activities. Residents in programs with experiential learning reported higher knowledge, skills, and attitudes toward QI were motivated to lead improvement efforts in their future practice. Residents in programs with didactic-only QI teaching perceived that the historical operationalization of the scholarly project as research was a barrier to their involvement in QI, as it was not valued or legitimized in their academic and clinical contexts. Common barriers and facilitators to engagement with QI across all programs included time, mentorship, motivation, and competing demands such as feeling pressure to conduct research in order to obtain competitive fellowship positions or employment. Common across all programs was the perception of the residency scholarly project requirement as a "checkbox." Associations were quantified between the constructs of learning climate with safety culture, and safety culture with QI knowledge, skills, and attitudes. Insights: While hybrid QI curricula with experiential learning remains an effective curriculum strategy, tensions between research and QI may be a critical barrier to learner engagement in experiential activities. In addition to providing learners with support, time, mentorship, and explicitly communicating the value QI by the program, the local safety culture may impact QI learning beyond the core curriculum. Reconceptualization of the scholarly project requirements to normalize QI activities and recognizing the potential influence of the local organizational culture on QI learning and how trainees can positively or negatively shape these cultures warrants consideration.

Integrating Physicians Into Lean Quality Improvement Through a Structured Educational Program: The ECLIPSE Program

In the increasingly complex health care system, physicians require skills and knowledge to participate with multidisciplinary team members in quality improvement (QI) that adds value to health care organizations. The Educational and Clinical Leaders Improving Performance with Structured E3L training (ECLIPSE) program was developed to address this challenge. Clinically relevant components of lean management were leveraged to create an online, flipped-classroom curriculum, and this was paired with Kaizen adapted specifically for physicians and multidisciplinary clinicians to promote experiential skills utilization. The focus of each adapted Kaizen was a topic of institutional QI priority, such as improving patient throughput or reducing readmission rates. Participants were awarded certification in the E3 Leadership management system-a patient-centered, equity-focused system based on lean principles. After 4 years, 50 E3 Leadership certificates were awarded to multidisciplinary clinicians, including 30 to physicians; participants scored an average 85% on module quizzes. The ECLIPSE program has improved physician participation in multidisciplinary QI projects with institutional alignment.

Prevalence and Characteristics of House Staff Quality and Safety Councils Within Clinical Learning Environments: Results of a National Survey

House Staff Quality and Safety Councils (HQSCs) are relatively new multispecialty groups led by residents and fellows that focus on quality and safety activities at their training site. The authors sought to estimate the prevalence of HQSCs, describe their common characteristics and determine any perceived impacts. A national survey was conducted with Designated Institutional Officers (DIO) of graduate medical education programs in 2019. For institutions with an HQSC, a second survey was sent to program leaders to obtain additional details. Responses were obtained from 204 DIOs, 47% of whom currently have an HQSC. Forty-five percent of sites provided details about HQSC membership, leadership, funding, activities/initiatives, facilitators, and barriers. The majority reported positive program outcomes. This study found that HQSCs are common and share key characteristics, yet at the same time have many unique features tailored to their clinical learning environment. Participants report positive outcomes associated with these groups.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Clinicians' perspectives on quality: do they match accreditation standards?

BACKGROUND

Quality of training is determined through programs' compliance with accreditation standards, often set for a number of years. However, perspectives on quality of training within these standards may differ from the clinicians' perspectives on quality of training. Knowledge on how standards relate to clinicians' perspectives on quality of training is currently lacking yet is expected to lead to improved accreditation design.

METHODS

This qualitative study design was based on a case-study research approach. We analyzed accreditation standards and conducted 29 interviews with accreditors, clinical supervisors and trainees across Australia and the Netherlands about the quality and accreditation of specialist medical training programs. The perspectives were coded and either if applicable compared to national accreditation standards of both jurisdictions, or thematized to the way stakeholders encounter accreditation standards in practice.

RESULTS

There were two evident matches and four mismatches between the perspectives of clinicians and the accreditation standards. The matches are: (1) accreditation is necessary (2) trainees are the best source for quality measures. The mismatches are: (3) fundamental training aspects that accreditation standards do not capture: the balance between training and service provision, and trainee empowerment (4) using standards lack dynamism and (5) quality improvement; driven by standards or intrinsic motivation of healthcare professionals.

CONCLUSION

In our Australian and Dutch health education cases accreditation is an accepted phenomenon which may be improved by trainee empowerment, a dynamic updating process of standards and by flexibility in its use.

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.

A Longitudinal Ambulatory Quality Improvement Curriculum That Aligns Resident Education With Patient Outcomes: A 3-Year Experience

Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration-based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre-post survey assessed residents' confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly (P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.

An experiential learning collaborative on quality improvement for interprofessional learners

Growing evidence supports the need to teach future healthcare practitioners the fundamentals of quality improvement (QI), but curricula rarely include opportunities to apply QI principles or develop relevant teamwork skills. We initiated a program in 2017 called QUEST to engage our learners in interprofessional health care improvement through a 7-month learning collaborative. QUEST pairs learners with mentors in clinical QI teams and provides structured content, tasks, and feedback. The model is intentionally experiential, intended to use existing expertise and opportunities in the clinical learning environment to support QI training. Three cohorts of health professions learners have completed QUEST (n = 45), resulting in 27 unique quality improvement projects and poster presentations. QI knowledge, as measured by the QIKAT-R, increased from 5.48 to 6.34 on a 9-point scale (p = .01). Teamwork readiness also improved: ISVS-9B scores increased from 5.25 to 6.23 on a 7-point scale (p < .01). Feedback has been positive with participants noting the unique learning opportunity, benefit to learner professional development, and enjoyment found in working across professions. QUEST continues to grow each year. Ongoing modifications are addressing mentor development and curricular standardization.

Quality Improvement and Patient Safety Education in Internal Medicine Residency Training Program: An Exploratory Qualitative Study

BACKGROUND

Quality improvement and patient safety (QIPS) are a global health priority. Accordingly, QIPS education in medical education became mandatory. Despite that, information about QIPS education in postgraduate training in Saudi Arabia is limited. This study aimed to explore the educational aspects of QIPS in the internal medicine residency training program at King Abdulaziz Hospital in Al Ahsa, Saudi Arabia.

METHODS

This was a qualitative study employing the constructivist grounded theory approach. The sample size was determined using the theoretical saturation point, and we utilized a purposeful sampling technique. A semi-structured interview was used for data collection and was conducted between September 6 and October 20, 2020.

RESULTS

Twenty-two internal medicine trainee residents were required to serve the study purpose. The emerged themes were organized under awareness, education, barriers and opportunities and improvement priorities. Awareness of participants about the QIPS concept, importance, and value of education was found. The participants did not recognize specific dedicated QIPS education components under the structured training program. However, they recognized participation in patient safety-oriented activities but not in quality improvement activities. Consultants' observations and written exams were perceived as the assessment tools. Barriers including time limitation and opportunities including participation in quality improvement projects were identified. Participants suggested making QIPS education mandatory under the training program as an improvement priority.

CONCLUSION

This study highlighted the awareness of internal medicine residents of the QIPS concept, importance, and value of QIPS education. However, we found crucial gaps related to education including lack of a dedicated QIPS component under the training program. There is a need for multicenter studies to measure the magnitude of our findings for improvement of QIPS education in residency training in Saudi Arabia. This is the first study about QIPS education in residency training in Saudi Arabia up to our best knowledge.

Using the AHEC Scholars Program to Enhance Health Professions Learners' Self-Efficacy for Practice Transformation

The Indiana Area Health Education Centers Scholars program is a 2-year leadership program designed to supplement health professions students' academic training and enhance practice readiness around 6 core topic areas including practice transformation. The study was a retrospective cohort study assessing learners' reported level of self-efficacy on a set of 6 competencies around practice transformation and quality improvement. A total of 68 students graduating in the first cohort responded to the competency questions. Area Health Education Center Scholars reported a significant increase in self-efficacy on the competencies Identify issues emerging in health care delivery such as accountable care organizations, medical homes, and health insurance exchanges; understand how to practice effectively within the organization and culture of the interprofessional team, practice setting, and local health care system, and use an electronic health record to retrieve relevant information and to document care. This study found that learners reported a significant increase in self-efficacy related to implementing practiced transformation.

Medical Students' perceptions and attitudes toward Medical Leadership and Management

Objectives:

To find out medical students’ perceptions and attitudes toward medical leadership and management (MLM).

Methods:

A total of 336 medical students from the 2^nd to 6^th academic years from King Abdulaziz University (KAU), Jeddah, Kingdom of Saudi Arabia (KSA), were included in this cross-sectional study. This study was conducted in January-February 2020. The students were asked about their perceptions, attitudes, and interests in the leadership of medical care and clinicians. A four-part questionnaire was used for collecting data. SPSS-21 was used for analysis.

Results:

The participants included 172 (51.2%) males and 164 (48.8%) females. In total, 105 (31.3%) participants agreed that they had been very well educated about their perception, behavior, and interest in the field of medical leadership and clinic management, and 175 (52.1%) students agreed that clinicians should influence management decisions in a healthcare setting. Overall, 167 (49.7%) students agreed that management/leadership skills are important for clinicians. In total, 145 students (43.2%) desired to have more leadership training in medical school, and 129 (38.4%) students agreed to seek additional leadership/management training in their postgraduate research studies. When asked about their self-perception of good leadership skills, the students indicated that good leadership skills included integrity (47.9%), conflict resolution (46.7%), organization (44.4%), confidence (41.9%), communication (40.5%), self-reflection (40.2%), time management (33.6%), the ability to motivate others (36.9%), and the ability to keep calm under stress (33.3%).

Conclusion:

Many students were well aware of the MLM concepts. However, students agreed that management/leadership skills are important for clinicians, and there should be more leadership training in medical schools.

Establishing a Multi-Institutional Quality and Patient Safety Consortium: Collaboration Across Affiliates in a Community-Based Medical School

The landscape of health care delivery and medical education is evolving. Institutions must continually reassess priorities, strategies, and partnerships to align the knowledge and skills of the health care workforce with the delivery of quality, socially accountable, collaborative health care that meets the needs of diverse populations in communities. This article describes the development, implementation, and early outcomes of the University of Missouri-Kansas City's Health Care Quality and Patient Safety Consortium. Inspired by an actual patient safety event, the consortium aimed to improve patient outcomes by establishing quality improvement and patient safety (QIPS) education and scholarship as foundational within its unique, horizontal-matrix academic health center, which comprises 6 affiliated hospitals and 4 university-based health sciences schools. The consortium established a governance structure with leaders who, collectively, represent the diverse members and stakeholders of the consortium. The members share a common agenda and mutual goals. The consortium measures success by applying published conceptual frameworks for evaluating the outcomes of educational programs on learners (Kirkpatrick) and patients (Bzowyckyj and colleagues). Consortium learner and patient outcomes span all levels of these frameworks. Undergraduate and graduate QIPS-based projects with meaningful health system or improved individual health outcomes signify a Level 4 outcome (the highest level) for learners and patients alike. Factors critical to success include a financial gift, leadership buy-in and support, a clear champion, shared goals and a united vision, a willingness to collaborate across health systems with varied strengths and priorities, and a stable communication platform. Aspirational goals of the consortium include increasing involvement across health professional schools, incorporating simulation into QIPS activities, and aligning the consortium's projects with broader community needs.

Experiential Learning in Project-Based Quality Improvement Education: Questioning Assumptions and Identifying Future Directions

PURPOSE

Project-based experiential learning is a defining element of quality improvement (QI) education despite ongoing challenges and uncertainties. The authors examined stakeholders' perceptions and experiences of QI project-based learning to increase understanding of factors that influence learning and project experiences.

METHOD

The authors used a case study approach to examine QI project-based learning in 3 advanced longitudinal QI programs, 2 at the University of Toronto and 1 at an academic tertiary-care hospital. From March 2016 to June 2017, they undertook 135 hours of education program observation and 58 interviews with learners, program directors, project coaches, and institutional leaders and reviewed relevant documents. They analyzed data using a conventional and directed data analysis approach.

RESULTS

The findings provide insight into 5 key factors that influenced participants' project-based learning experiences and outcomes: (1) variable emphasis on learning versus project objectives and resulting benefits, tensions, and consequences; (2) challenges integrating the QI project into the curriculum timeline; (3) project coaching factors (e.g., ability, capacity, role clarity); (4) participants' differing access to resources and ability to direct a QI project given their professional roles; and (5) workplace environment influence on project success.

CONCLUSIONS

The findings contribute to an empirical basis toward more effective experiential learning in QI by identifying factors to target and optimize. Expanding conceptualizations of project-based learning for QI education beyond learner-initiated, time-bound projects, which are at the core of many QI educational initiatives, may be necessary to improve learning and project outcomes.

Quality Olympics: Experiential Interprofessional Learning to Improve Quality and Safety

BACKGROUND

Effective communication and teamwork is essential to improve the safety, quality, and cost-effectiveness of patient care. Quality Olympics, a competitive, educational intervention, was designed to offer nursing and medical students the opportunity to apply new knowledge on safety quality and cost in an interprofessional environment.

METHOD

Nursing (N = 220) and medical students (N = 163) participated in Quality Olympics. Student perceptions of teamwork were analyzed using the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R).

RESULTS

In years one and two, significance was found for nursing students on all survey items. Medical student responses reached significance on four items in year two.

CONCLUSION

The contrast in findings between these professions suggests that students would benefit from early, additional opportunities to link patient safety and outcomes to interprofessional collaboration. In doing so, educators may ensure that future providers have the attitudes, knowledge, and skills to impact individualized care and transform health care systems.[J Nurs Educ. 2020;59(10):589-593.].

Quality improvement education in surgical specialty training: A comparison of Vascular Surgery resident and Urology Resident experiences and attitudes

BACKGROUND

Academic institutions have increasingly focused on educating physicians and surgeons in concepts of value-based care, including quality improvement (QI). The extent to which QI curricular competencies are addressed in specialty surgical residency training is unclear.

METHODS

A survey instrument was developed by content experts and sent to Vascular Surgery and Urology residents electronically. Descriptive statistics and bivariate associations were calculated using StataMP 13.1.

RESULTS

Vascular Surgery and Urology residents reported exposure to similar types of QI curriculum. Fewer than half of residents reported achieving targets for graduation (Vascular 31%, Urology 42%) related to QI, and few residents in either group felt very well-prepared to lead a QI initiative (Vascular 13%, Urology 8%).

CONCLUSION

QI education in surgical specialty training amongst Vascular Surgery and Urology residencies is similar and insufficient. Surgical specialties may benefit from collaborative efforts to improve the quality of QI education.

Evaluation of continuous quality improvement in accreditation for medical education

BACKGROUND

Accreditation systems are based on a number of principles and purposes that vary across jurisdictions. Decision making about accreditation governance suffers from a paucity of evidence. This paper evaluates the pros and cons of continuous quality improvement (CQI) within educational institutions that have traditionally been accredited based on episodic evaluation by external reviewers.

METHODS

A naturalistic utility-focused evaluation was performed. Seven criteria, each relevant to government oversight, were used to evaluate the pros and cons of the use of CQI in three medical school accreditation systems across the continuum of medical education. The authors, all involved in the governance of accreditation, iteratively discussed CQI in their medical education contexts in light of the seven criteria until consensus was reached about general patterns.

RESULTS

Because institutional CQI makes use of early warning systems, it may enhance the reflective function of accreditation. In the three medical accreditation systems examined, external accreditors lacked the ability to respond quickly to local events or societal developments. There is a potential role for CQI in safeguarding the public interest. Moreover, the central governance structure of accreditation may benefit from decentralized CQI. However, CQI has weaknesses with respect to impartiality, independence, and public accountability, as well as with the ability to balance expectations with capacity.

CONCLUSION

CQI, as evaluated with the seven criteria of oversight, has pros and cons. Its use still depends on the balance between the expected positive effects-especially increased reflection and faster response to important issues-versus the potential impediments. A toxic culture that affects impartiality and independence, as well as the need to invest in bureaucratic systems may make in impractical for some institutions to undertake CQI.

A National Assessment on Patient Safety Curricula in Undergraduate Medical Education: Results From the 2012 Clerkship Directors in Internal Medicine Survey

OBJECTIVES

Patient safety is a cornerstone of quality patient care, and educating medical students about patient safety is of growing importance. This investigation was a follow-up to a 2006 study to assess the current status of patient safety curricula within undergraduate medical education in North America with the additional goals of identifying areas for improvement and barriers to implementation.

METHODS

Thirteen items regarding patient safety were part of the 2012 Clerkship Directors in Internal Medicine annual survey. Questions addressed curriculum content, delivery, and barriers to implementation.

RESULTS

Ninety-nine clerkship directors (82%) responded. Forty-one (45.6%) reported that their medical school had a patient safety curriculum taught during medical school as compared with 25% in a 2006 survey. Fifteen (20%) reported satisfaction with students' level of safety competency at the end of the clerkship. Barriers to implementation included lack of faculty time (n = 57, 78.1%), lack of trained faculty (n = 47, 65.3%), and lack of a mandate from school's dean's office (n = 27, 38.0%).

CONCLUSIONS

Our study found that less than half of North American medical schools have a formal patient safety curriculum; although this is higher than in 2006, it still exemplifies a major gap in undergraduate medical education.

Learning by Doing: Design and Evaluation of a Quality Improvement Curriculum for Pediatric Hospitalists

Quality improvement (QI) is a core competency for Pediatric Hospital Medicine (PHM) and required for maintenance of certification, but many hospitalists lack QI training. This project set out to increase a PHM faculty’s QI knowledge and comfort participating in QI projects, while concurrently applying the skills learned to a QI project in the hospital.

QIPS CURE: Implementing a Quality Improvement and Patient Safety Curriculum and Resident Experience

BACKGROUND

Resident participation in quality improvement and patient safety (QIPS) programs is an essential training experience and Accreditation Council for Graduate Medical Education requirement. However, the most effective approach to achieve this is unclear.

OBJECTIVE

We developed an experiential Quality Improvement and Patient Safety Curriculum and Resident Experience (QIPS CURE) program, which provides internal medicine (IM) residents with foundational QIPS knowledge, and evaluated its effectiveness.

METHODS

After reviewing IM residency QIPS curricula and obtaining input from institutional stakeholders in 2013-2014, we launched a longitudinal QIPS curriculum for all 66 postgraduate year 1-3 IM residents in July 2014. The QIPS CURE included 2 major elements: didactics, delivered through a variety of sources, including online modules and workshops, and hands-on projects. We delivered this curriculum annually from 2014 to 2018. We used project completion and an attitude survey of participants to evaluate it.

RESULTS

Six projects were completed in 2014-2015, and 10 projects completed yearly for the next 3 academic years. Residents presented all projects at regional meetings. Surveyed residents reported improvement in understanding (M = 5.71, SD = 1.07 pre- to M = 6.38, SD = 0.49 post-curriculum, P = .013) and competence (M = 3.31, SD = 1.18 pre- to M = 6.08, SD = 0.77, post-curriculum, P < .001) when comparing graduates of the curriculum with incoming interns. Qualitative analysis revealed perceived acquisition of skills needed to carry out successful QIPS projects.

CONCLUSIONS

This QIPS program was sustainable over 4 years and generally well-received by residents, with many projects completed each year.

Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.

Students' Assessment on the Patient Safety Education: The Case of College of Medicine and Health Sciences, University of Gondar

Background:

It is well-known that clinical practice could never be free from medical errors. Respectively, in the case of a large number of students with a huge diversity of disciplines, the breach of patients' safety is not uncommon. Thus, this study aimed to assess students' evaluation of patients' safety education in their curriculum.

Materials and Methods:

A cross-sectional study was conducted among 338 students at the University of Gondar. A descriptive analysis was done by using Stata version 13 software and data were presented in tables and text.

Results:

As stated by 33.40% of medical interns and 51.10% of nursing students, patients' safety education was given as a chapter of a course. On the contrary, 48.20% of midwifery and 32.10% of health officer students stated that it was given as a small portion in a chapter in their curriculum. Almost 60% of students of all professional categories self-reported that their average level of knowledge on the patients' safety rested between “fair” and “poor.” Likewise, more than half of students of all professional categories had a “neutral” to “disagree” level of attitude for attitude items. Concerning teaching methods, most students preferred real-life examples and problem-based learning approaches as helpful in patients' safety education.

Conclusions:

Patients' safety education has been given less emphasis. Students also self-reported that their average level of knowledge was low. Real-life examples and problem-based learning approaches were preferred learning methods among most of the students.

Quality improvement education for medical students: a near-peer pilot study

BACKGROUND

Quality improvement (QI) is an essential component of modern clinical practice. Front-line professionals offer valuable perspectives on areas for improvement and are motivated to deliver change. In the UK, all junior doctors are expected to participate in QI in order to advance to the next stage of their training. However, UK undergraduates receive no standardized training in QI methods. This is perpetuated within medical schools by a lack of teaching capacity and competing priorities, and may lead to tokenistic engagement with future QI projects.

METHODS

We describe a near-peer teaching programme designed to introduce students to QI methods. This pilot study was conceived and delivered in full by junior doctors and used existing resources to ensure high quality teaching content. 111 fifth-year medical students from the University of Cambridge were taught in interactive, participative workshops that encourage them to develop their own QI change ideas and projects. Core topics included the model for improvement, driver diagrams, stakeholder engagement, measurement for improvement and analysing and presenting data. Students completed surveys before and immediately after this intervention to assess their understanding of and confidence in utilizing QI methods. Questionnaires were also completed by junior doctor tutors.

RESULTS

Analysis of questionnaires completed before and immediately after the intervention revealed statistically significant improvements in students' self-reported understanding of QI (p < 0.05) and confidence in applying techniques to their own work (p < 0.05). Students expressed a preference for QI teaching delivered by junior doctors, citing a relaxed learning environment and greater relevance to their stage of training. Tutors reported increased confidence in using QI techniques and a greater willingness to engage with QI in future.

CONCLUSIONS

In this single-centre study, near-peer teaching produced significant improvements in students' self-reported understanding of QI and confidence in applying QI methods. Near-peer teaching may constitute a sustainable means of teaching essential QI skills at undergraduate level. Future work must evaluate objective measures of student engagement with and competence in conducting QI.

Efficacy of quality improvement and patient safety workshops for students: a pilot study

BACKGROUND

While the Association of American Medical Colleges encourages medical schools to incorporate quality improvement and patient safety (QI/PS) into their curriculum, medical students continue to have limited QI/PS exposure. To prepare medical students for careers that involve QI/PS, the Institute for Healthcare Improvement chapter at an allopathic medical school and school of allied health professions initiated self-directed learning by offering student-led workshops to equip learners with skills to improve the quality and safety of healthcare processes.

METHODS

In this prospective cohort study, workshops were hosted for medical students between 2015 and 2018 on five QI/PS topics: Process Mapping, Root-Cause Analysis (RCA), Plan-Do-Study-Act (PDSA) Cycles, Evidence Based Medicine (EBM), and Patient Handoffs. Each workshop included a hands-on component to engage learners in practical applications of QI/PS skills in their careers. Change in knowledge, attitudes, and behaviors was assessed via pre- and post-surveys using 5-point Likert scales, and analyzed using either the McNemar test or non-parametric Wilcoxon signed-rank test. Surveys also gathered qualitative feedback regarding strengths, future areas for improvement, and reasons for attending the workshops.

RESULTS

Data was collected from 88.5% of learners (n = 185/209); 19.5% of learners reported prior formal instruction in these topics. Statistically significant improvements in learners' confidence were observed for each workshop. Additionally, after attending workshops, learners felt comfortable teaching the learned QI/PS skill to colleagues (mean pre/post difference 1.96, p < 0.0001, n = 139) and were more likely to pursue QI/PS projects in their careers (mean pre/post difference 0.45, p < 0.0001, n = 139). Lastly, learners demonstrated a statistically significant increase in knowledge in four out of five skills workshop topics.

CONCLUSION

Few medical students have formal instruction in QI/PS tools. This pilot study highlights advantages of incorporating an innovative, student-directed modified 'flipped classroom' methodology, with a focus on active experiential learning and minimal didactic instruction.

How Successful Are Residents and Fellows at Quality Improvement?

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

"I Think I Was Losing the Forest for the Trees": Evaluation of an Internal Medicine Residency Quality Improvement Curriculum

INTRODUCTION

Quality improvement (QI) training during residency may not be adequately preparing physicians for achieving Accreditation Council for Graduate Medical Education goals and the Institute for Healthcare Improvement (IHI) Triple Aim. The purpose of this evaluation was to identify residents' perceptions and impact of their QI curriculum.

METHODS

We conducted a mixed-methods evaluation of an active-learning QI curriculum for internal medicine residents at one academic medical center. Data from 2017 to 2018 included a focus group, pre-post survey, project data, and curricular materials. Results were categorized using Kirkpatrick's model of evaluation.

RESULTS

All second-year internal medicine residents completed the curriculum (N = 14). Residents were satisfied with the structure and perceived accomplishment with the curriculum, however were dissatisfied by the impact of inconsistent attendance due to clinical conflicts. Their confidence in QI increased; however, they reported difficulty retaining knowledge and skills. Survey scores related to usefulness and anticipated application of QI were unchanged from baseline.

CONCLUSIONS

This applied QI curriculum appeared to improve short-term learning. However, the curriculum did not promote long-term understanding of QI. Finding ways to promote skills and retention beyond the curriculum requires further study.