Developing future clinical leaders for quality improvement: experience from a London children's hospital

A Decision-oriented Approach to Evaluating a Leadership Curriculum in Fellowship

Background

Graduate Medical Education (GME) emphasizes the role of the annual program evaluation to identify opportunities, create action plans, and track improvements longitudinally. There is a lack of a systematic approach to the evaluation of educational curricula. Comprehensive curriculum evaluation can inform the educators about specific modifications to achieve high standards, desired outcomes, and the anticipated objectives.

Objective

To evaluate a leadership in quality improvement program in a pulmonary/critical care fellowship training program using the context, input, process, product (CIPP) model. The CIPP model, given its focus on evaluating different aspects of a program, provides concrete and targeted feedback to guide improvement decisions.

Methods

Evaluation questions addressing the four focused areas were created, pilot tested, and revised. The questions were framed toward optimization of alignment (e.g., program activities with stated objectives, program goals with theoretical perspective, program curriculum with trainee needs) and gaining information about the efficacy of the program in achieving the desired outcomes. To enhance the validity of the results, we triangulated the data-gathering approach by administering surveys and conducting interviews and focus groups by random selection from the eligible participants. Qualitative data were transcribed, coded, and categorized into themes aligning with the four aspects of the CIPP model.

Results

We interviewed 9 participants and conducted three focus groups with 20 participants. The surveys provided vital quantitative information that was cross-verified with the qualitative data; 23 of the 25 (92%) participants completed the survey. The results of qualitative thematic analysis were organized in the CIPP format. The context evaluation of the program revealed that the fellows and faculty were unfamiliar with the guiding principles of the course. The input evaluation highlighted the competing interests that hampered the engagement of the fellows during the evening weekly report-outs. The process evaluation revealed clustering of didactic sessions at the start of the course. The product evaluation stressed the difficulty in completing the quality improvement projects in the allotted timeframe.

Conclusion

Conducting a robust evaluation of an educational curriculum provides insights into gaps in the various stages of the program. Time and resources needed for conducting evaluation by using the CIPP model should be considered.

Practical strategies to enhance resident engagement in clinical quality improvement

BACKGROUND

Engaging residents in meaningful quality improvement (QI) is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. Various strategies to address these challenges for engagement have been described, but not as a unified approach. This paper describes a bundle of practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program.

METHODS

62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA (Plan-Do-Study-Act) cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents, and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1 = least desired and 5 = most desired result. Data were analyzed by paired t-test.

RESULTS

All 62 residents participated in the program as members of ten QI teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p = 0.03), frequency of QI use (3.3 to 3.9, p = 0.001), and opinion about using QI in clinical work (3.9 to 4.0, p = 0.21). Resident assessment of QI priority in clinical work did not change.

CONCLUSIONS

We implemented a practical strategies bundle to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents' own practice, and real-time faculty coaching.

Aligning quality improvement with better child health for the 21st century

Quality improvement (QI) has tremendous potential to tackle the shortcomings of health services. But health professionals have not yet fully embraced QI as part of their day-to-day concerns. Indeed, QI is sometimes experienced as a brake on quality rather than a catalyst for improvement. This can happen, for example, if there is too much emphasis on meeting short-term institutional goals rather than on addressing long-term health needs. This emphasis also risks equating quality with safety and efficiency measures while neglecting patient-centredness and equity. QI does not have to be like this. We suggest that the conscientious and critical engagement of health professionals in QI can lead to genuinely better and more far-reaching outcomes for child health. We also distinguish between QI projects that repair the status quo and those that seek to reform it, arguing that there is an important place for both.

Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety

BACKGROUND

Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education.

OBJECTIVE

The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University.

METHODS

A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline.

RESULTS

A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described.

CONCLUSIONS

We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

Financial Incentives to Enhance Participation of Resident Physicians in Hospital-Based Quality Improvement Projects

BACKGROUND

Methods to promote successful trainee participation in quality improvement projects are poorly studied. This project studied the effects of a trainee pay-for-performance program and quality improvement education at a safety-net hospital.

METHODS

In this program, trainees worked with quality improvement faculty, participated in projects aligned with the hospital's priorities, and designed their program-specific project. Each trainee who worked at least 88 days in the institution was eligible to earn $400 for every target achieved for at least six months (maximum of $1,200).

RESULTS

Among hospitalwide goals, needlestick injuries per quarter decreased from [mean (standard deviation; SD)] 18 (4.6) to 12 (2.6), 95% confidence interval (CI) = -10.1-1.9, p = 0.02; percentage of excellent provider communication improved from 76.8% to [mean (SD)] 80.5% (2.9), 95% CI = 0.8-8.3, p = 0.08; and mean length of stay for discharged emergency department patients requiring specialist consultation decreased from [mean (SD)] 523 (120) to 461 (40) minutes, 95% CI = -162-37.2, p = 0.11. Among resident-initiated projects, the percentage of Family Medicine patients undergoing colorectal screening increased from 65.1% to [mean (SD)] 67.7% (0.4), 95% CI = 1.7-3.5, p = 0.01; percentage of at-risk patients receiving naloxone at hospital discharge increased from 9% to [mean (SD)] 63% (7.2), 95% CI = 36.1-71.9, p = 0.01; percentage of adolescents screened for chlamydia increased from 34% to [mean (SD)] 55.8% (6.4), 95% CI = 5.9-37.6, p = 0.03; and percentage of high-dose opioid prescriptions following cesarean section decreased from 28% to [mean (SD)] 1.7% (2.9), 95% CI = -33.5 to -19.2, p = 0.001. Eleven of 14 programs achieved three goals. All resident-led goals were met.

CONCLUSION

A pay-for-performance improvement program that aligns educational and hospital priorities can provide meaningful experiential learning for trainees and improve patient care.

Fueling leadership in yourself: a leadership development program for all types of health-care workers

PURPOSE

Leadership development may be a key strategy to enhance job satisfaction, reduce burnout and improve patient safety in health-care systems. This study aims to assess feasibility of a leadership development series in an effort to invigorate a collaborative culture, create peer networks and elevate autonomy in daily work.

DESIGN/METHODOLOGY/APPROACH

The authors implemented a collectivistic leadership development series titled Fueling Leadership in Yourself. The series was designed for all types of health-care workers in the medicine service at a tertiary referral center for veterans. Two series of leadership development sessions with varied experiential learning methods were facilitated by content experts. Subjects focused on leadership approaches and attributes applicable to all roles within a health-care system. The authors collected participant perceptions using pre- and post-series surveys. Primary outcomes were understanding and applicability of leadership concepts, employee engagement in leadership, satisfaction with training and work environment and qualitative reflections.

FINDINGS

A total of 26 respondents (of 38 participants) from 8 departments and several role types increased their knowledge of leadership techniques, were highly satisfied with and would recommend the series and found leadership principles applicable to their daily work. Participants continued to use skills years after the series.

PRACTICAL IMPLICATIONS

Short, intermittent, collectivistic leadership development sessions appear effective in expanding knowledge, satisfaction and skills used in daily practice for a diverse group of health-care workers.

ORIGINALITY/VALUE

Novel programmatic aspects included inviting all types of health-care workers, practicing universally applicable content and using a variety of active, experiential learning methods.

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.

A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts?

BACKGROUND

With the integration of quality improvement (QI) into competency-based models of physician training, there is an increasing requirement for medical students and residents to demonstrate competence in QI. There may be factors that commonly facilitate or inhibit the desired outcomes of QI curricula in undergraduate and postgraduate medical education. The purpose of this review was to synthesise attributes of QI curricula in undergraduate and postgraduate medical education associated with curricular outcomes.

METHODS

A realist synthesis of peer-reviewed and grey literature was conducted to identify the common contexts, mechanisms, and outcomes of QI curricula in undergraduate and postgraduate medical education in order to develop a programme theory to articulate what works, for whom, and in what contexts.

RESULTS

18854 records underwent title and abstract screening, full texts of 609 records were appraised for eligibility, data were extracted from 358 studies, and 218 studies were included in the development and refinement of the final programme theory. Contexts included curricular strategies, levels of training, clinical settings, and organisational culture. Mechanisms were identified within the overall QI curricula itself (eg, clear expectations and deliverables, and protected time), in the didactic components (ie, content delivery strategies), and within the experiential components (eg, topic selection strategies, working with others, and mentorship). Mechanisms were often associated with certain contexts to promote educational and clinical outcomes.

CONCLUSION

This research describes the various pedagogical strategies for teaching QI to medical learners and highlights the contexts and mechanisms that could potentially account for differences in educational and clinical outcomes of QI curricula. Educators may benefit from considering these contexts and mechanisms in the design and implementation of QI curricula to optimise the outcomes of training in this competency area.

Preparedness of medical students and junior doctors for their role as clinical leaders: A systematic review

Introduction: Clinical leadership skills are essential across all levels of a healthcare organization and must be employed by those most appropriate to the situation, regardless of position or profession. However, most medical students and junior doctors remain unaware of how leadership can be assimilated into their everyday clinical practice.Aim: To investigate the perceived preparedness of medical students and junior doctors for their role as clinical leaders.Methods: A systematic search was performed of the MEDLINE, ERIC and PubMed databases. Papers pertaining to medical students and junior doctors that included primary data on preparedness for clinical leadership or behaviors associated with being a clinical leader were included.Results: Sixteen papers were included and analyzed after screening 254. No studies specifically assessed the transition to clinical leader. Evidence suggests that new graduates perceive leadership as individualistic and hierarchical, and that they are only partially prepared to fill this role. Preparedness for clinical leadership was associated with increasing responsibility, experience and time-served.Conclusions: New graduates are unlikely to question senior colleagues as they lack leadership-specific communication skills. Further research is required into how to actively promote leadership in medical students and ease the transition to leadership roles within clinical teams.

Theories of learning and teaching methods used in postgraduate education in the health sciences: a scoping review

OBJECTIVE

The objective of this scoping review was to determine the theories of learning and methods used in teaching in postgraduate education in the health sciences. The longer-term objective was to use the information gathered to design a workshop for teachers of postgraduate students.

INTRODUCTION

Whilst undergraduate teaching in the health sciences has received considerable attention in the literature in terms of methods used, innovative ideas and outcomes, the same cannot be said of postgraduate education. A considerable amount of postgraduate teaching takes place in the workplace and often in the form of informal teaching. The increasing complexity of health problems calls for innovative teaching.

INCLUSION CRITERIA

Papers included in this review were those that considered postgraduate education in the health science disciplines, including but not limited to medicine, nursing, occupational therapy, physiotherapy, pharmacy and dentistry, and that described theories of learning and/or teaching methods used in teaching.

METHODS

Five databases were searched for the period 2001 through 2016. PubMed yielded the most records (3142). No relevant papers were identified through hand searching of the references of the included papers. A data extraction table was developed and used to extract relevant information from included papers.

RESULTS

Sixty-one papers were included in the review. Most of the included papers were from the USA, with 17 published in 2015. Descriptive study designs were the most frequently identified study design. Most of the papers were from the medical disciplines. Twenty-seven papers did not refer to a teaching and learning theory, a further group referred to a theory but often towards the end of the paper, and seven papers had as their focus the importance of theories in medical education. The theories named were of a wide variety. Likewise, a wide range of teaching methods were identified.

CONCLUSIONS

It is clear that a range of theories and teaching methods are used in postgraduate health science education, with educators feeling the need to explore more innovative methods.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review

PURPOSE

There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice.

METHOD

We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized.

RESULTS

There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed.

CONCLUSIONS

Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.

Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature

BACKGROUND

The importance of clinical leadership in ensuring high quality patient care is emphasized in health systems worldwide. Of particular concern are the high costs to health systems related to clinical litigation settlements. To avoid further cost, healthcare systems particularly in High-Income Countries invest significantly in interventions to develop clinical leadership among frontline healthcare workers at the point of care. In Low-Income Countries however, clinical leadership development is not well established. This review of the literature was conducted towards identifying a model to inform clinical leadership development interventions among frontline healthcare providers, particularly for improved maternal and newborn care.

METHODS

A structural literature review method was used, articles published between 2004 and 2017 were identified from search engines (Google Scholar and EBSCOhost). Additionally, electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, Science Direct and Ovid®), electronic journals, and reference lists of retrieved published articles were also searched.

RESULTS

Employing pre-selected criteria, 1675 citations were identified. After screening 50 potentially relevant full-text papers for eligibility, 24 papers were excluded because they did not report on developing and evaluating clinical leadership interventions for frontline healthcare providers, 2 papers did not have full text available. Twenty-four papers met the inclusion criteria for review. Interventions for clinical leadership development involved the development of clinical skills, leadership competencies, teamwork, the environment of care and patient care. Work-based learning with experiential teaching techniques is reported as the most effective, to ensure the clinical leadership development of frontline healthcare providers.

CONCLUSIONS

All studies reviewed arose in High-Income settings, demonstrating the need for studies on frontline clinical leadership development in Low-and Middle-Income settings. Clinical leadership development is an on-going process and must target both novice and veteran frontline health care providers. The content of clinical leadership development interventions must encompass a holistic conceptualization of clinical leadership, and should use work-based learning, and team-based approaches, to improve clinical leadership competencies of frontline healthcare providers, and overall service delivery.

Leadership Training in Graduate Medical Education: A Systematic Review

BACKGROUND

Leadership is a critical component of physician competence, yet the best approaches for developing leadership skills for physicians in training remain undefined.

OBJECTIVE

We systematically reviewed the literature on existing leadership curricula in graduate medical education (GME) to inform leadership program development.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched MEDLINE, ERIC, EMBASE, and MedEdPORTAL through October 2015 using search terms to capture GME leadership curricula. Abstracts were reviewed for relevance, and included studies were retrieved for full-text analysis. Article quality was assessed using the Best Evidence in Medical Education (BEME) index.

RESULTS

A total of 3413 articles met the search criteria, and 52 were included in the analysis. Article quality was low, with 21% (11 of 52) having a BEME score of 4 or 5. Primary care specialties were the most represented (58%, 30 of 52). The majority of programs were open to all residents (81%, 42 of 52). Projects and use of mentors or coaches were components of 46% and 48% of curricula, respectively. Only 40% (21 of 52) were longitudinal throughout training. The most frequent pedagogic methods were lectures, small group activities, and cases. Common topics included teamwork, leadership models, and change management. Evaluation focused on learner satisfaction and self-assessed knowledge. Longitudinal programs were more likely to be successful.

CONCLUSIONS

GME leadership curricula are heterogeneous and limited in effectiveness. Small group teaching, project-based learning, mentoring, and coaching were more frequently used in higher-quality studies.

Is the delivery of a quality improvement education programme in obstetrics and gynaecology for final year medical students feasible and still effective in a shortened time frame?

BACKGROUND

Teaching clinical audit skills to nascent health professionals is one strategy to improve frontline care. The undergraduate medical curriculum at the University of Auckland provides improvement science theory and skills in Year 5 teaching, and the opportunity to put this into practice during an Obstetrics and Gynaecology (O&G) clinical attachment in Year 6. In 2015, a revised medical school curriculum at the university resulted in a planned reduction of the O&G attachment from five weeks to four, necessitating revision of the Year 6 Quality Improvement (QI) project. The aim of this study was to evaluate if the revised programme provided an important experiential learning opportunity for medical students without imposing an unsustainable burden on clinical services.

METHODS

Based on a CIPP (Context/Input/Process/Product) evaluation model, the study was conducted in several stages to get a sense of the context as the new programme was being planned (Context evaluation), the feasibility of an alternative approach to meet the educational need (Input evaluation), the implementation of the revised programme (Process evaluation) and finally, the programme outcomes (Product evaluation). We used multiple data sources (supervisors, students, academic administrators, and hospital staff) and data collection methods (questionnaires, focus groups, individual interviews, consultative workshops, student reports and oral presentations).

RESULTS

The context evaluation revealed the Year 6 QI programme to be valuable and contributed to O&G service improvements, however, the following concerns were identified: time to complete the project, timely topic selection and access to data, recognition of student achievement, and staff workload. The evaluation of the revised QI project indicated improvement in student perceptions of their QI knowledge and skills, and most areas previously identified as challenging, despite the concurrent reduction in the duration of the O&G attachment.

CONCLUSIONS

Applying the CIPP model for evaluation to our revised QI programme enabled streamlining of procedures to achieve greater efficiency without compromising the quality of the learning experience, or increasing pressure on staff. A four week clinical rotation is adequate for medical educators to consider opportunities for including QI projects as part of student experiential learning.

Evaluating investment in quality improvement capacity building: a systematic review

PURPOSE

Leading health systems have invested in substantial quality improvement (QI) capacity building, but little is known about the aggregate effect of these investments at the health system level. We conducted a systematic review to identify key steps and elements that should be considered for system-level evaluations of investment in QI capacity building.

METHODS

We searched for evaluations of QI capacity building and evaluations of QI training programmes. We included the most relevant indexed databases in the field and a strategic search of the grey literature. The latter included direct electronic scanning of 85 relevant government and institutional websites internationally. Data were extracted regarding evaluation design and common assessment themes and components.

RESULTS

48 articles met the inclusion criteria. 46 articles described initiative-level non-economic evaluations of QI capacity building/training, while 2 studies included economic evaluations of QI capacity building/training, also at the initiative level. No system-level QI capacity building/training evaluations were found. We identified 17 evaluation components that fit within 5 overarching dimensions (characteristics of QI training; characteristics of QI activity; individual capacity; organisational capacity and impact) that should be considered in evaluations of QI capacity building. 8 key steps in return-on-investment (ROI) assessments in QI capacity building were identified: (1) planning-stakeholder perspective; (2) planning-temporal perspective; (3) identifying costs; (4) identifying benefits; (5) identifying intangible benefits that will not be included in the ROI estimation; (6) discerning attribution; (7) ROI calculations; (8) sensitivity analysis.

CONCLUSIONS

The literature on QI capacity building evaluation is limited in the number and scope of studies. Our findings, summarised in a Framework to Guide Evaluations of QI Capacity Building, can be used to start closing this knowledge gap.

The Royal College of Physician's Quality Improvement Hub - how can it help physicians to improve patient care?

Doctors have a central role in managing patients across a multitude of clinical environments, which places them in the ideal position to identify systemic issues. Traditional medical training focuses on the knowledge and technical skills required; rarely are doctors trained in leadership, management or how to analyse and understand systems so as to design safer, better care. Quality improvement methodology is an approach that is known to enable improvement of the systems in which healthcare professionals work in order to provide safe, timely, evidence-based, equitable, efficient and patient-centred care. To address the current disparity, the Royal College of Physicians (RCP) has launched a Quality Improvement Hub, which will aim to support physicians to face the challenges of improving medical care, enabling them to navigate the tools with more confidence and share and implement the learning more swiftly.

Developing Quality Improvement capacity and capability across the Children in Fife partnership

A Project Manager from the Fife Early Years Collaborative facilitated a large-scale Quality Improvement (herein QI) project to build organisational capacity and capability across the Children in Fife partnership through three separate, eight month training cohorts. This 18 month QI project enabled 32 practitioners to increase their skills, knowledge, and experiences in a variety of QI tools including the Model for Improvement which then supported the delivery of high quality improvement projects and improved outcomes for children and families. Essentially growing the confidence and capability of practitioners to deliver sustainable QI. 27 respective improvement projects were delivered, some leading to service redesign, reduced waiting times, increased uptake of health entitlements, and improved accessibility to front-line health services. 13 improvement projects spread or scaled beyond the initial site and informal QI mentoring took place with peers in respective agencies. Multiple PDSA cycles were conducted testing the most efficient and effective support mechanisms during and post training, maintaining regular contact, and utilising social media to share progress and achievements.

Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule

BACKGROUND

Quality improvement (QI) is essential in clinical practice, requiring effective teaching in residency. Barriers include lack of structure, mentorship, and time.

OBJECTIVE

To develop a longitudinal QI curriculum for an internal medicine residency program with limited faculty resources and evaluate its effectiveness.

METHODS

All medicine residents were provided with dedicated research time every 8 weeks during their ambulatory blocks. Groups of 3 to 5 residents across all postgraduate year levels were formed. Two faculty members and 1 chief resident advised all groups, meeting with each group every 8 weeks, with concrete expectations for each meeting. Residents were required to complete didactic modules from the Institute for Healthcare Improvement. Current residents and alumni were surveyed for feedback.

RESULTS

Over 3 years, all eligible residents (92 residents per year in 2012-2014, 102 in 2014-2015) participated in the curriculum. Residents worked on 54 quality assessment and 18 QI projects, with 6 QI projects showing statistically significant indicator improvements. About 50 mentoring hours per year were contributed by 2 faculty advisors and a chief resident. No other staff or IT support was needed. A total of 69 posters/abstracts were produced, with 13 projects presented at national or regional conferences. Survey respondents found the program useful; most (75% residents, 63% alumni) reported it changed their practice, and 71% of alumni found it useful after residency.

CONCLUSIONS

Our longitudinal QI curriculum requires minimal faculty time and resulted in increased QI-related publications and measurable improvements in quality indicators. Alumni reported a positive effect on practice after graduation.

Residents' knowledge of quality improvement: the impact of using a group project curriculum

BACKGROUND

The Accreditation Council for Graduate Medical Education requires residents to learn and demonstrate proficiency in practice improvement. Quality improvement (QI) projects are a way to improve patient care as well as facilitate education on this core competency. There are inherent barriers to completing these goals in the structure of residency training including rigorous resident schedules and a limited number of projects and resources.

OBJECTIVES

We developed a QI programme using an experiential class project and incorporated it into our Internal Medicine Resident Core Curriculum to improve the residents' knowledge of QI methods. We assessed the residents' experience, knowledge and interest in practice and QI subject matter with a survey preimplementation and postimplementation.

METHODS

In 2009, 24 residents in the Internal Medicine resident programme completed a survey measuring their experience, knowledge and interest in QI initiatives. They then completed a QI 1-year programme, with monthly, 1-hour sessions combining didactics and a resident-designed project. At the conclusion of the year, the residents completed the same survey, and the results were compared and analysed.

RESULTS

Postcurriculum questionnaires revealed residents were more knowledgeable about QI methods, showing improvement in knowledge about institutional-wide QI projects, better preparation for implementing a QI project, and more likely to participate in QI in the future. The project completed was one which improved patients' knowledge of their anticipated date of discharge from the hospital.

CONCLUSIONS

A class quality project can teach QI to residents incorporating both didactic and practical methods to maximise the experience and minimise the barriers. We found that this method improved residents experience, knowledge and interest in quality initiatives.

Supporting colleagues to improve care: educating for quality improvement

Clinicians at the front line of healthcare delivery are very well positioned to identify and improve the system in which they work. Training curricula, however, have not always equipped them with the skills or knowledge to implement change. This article looks at educational approaches to support clinicians to be actively involved with quality improvement (QI). It looks at the role of doctors in postgraduate training (DrPGT) and their educational supervisors and builds on the topics discussed throughout the 'EQUIPPED' article series. Factors for success of a QI education programme and practical ideas for overcoming barriers to supporting clinicians in QI are discussed. We present examples of educational initiatives and a framework for evaluating such programmes, and we examine the role of faculty development to help inspire and support colleagues to improve care.

From harm to hope and purposeful action: what could we do after Francis?

Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key 'ingredients' required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.

In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today

There have been repeated calls from all quarters of healthcare for more clinicians to be leaders. The risks of not accepting this responsibility have been demonstrated by harrowing reports into failed care in England. Ambiguity persists over what clinical leadership encompasses, how it can be developed and how to inspire clinicians to practise it. A supportive organisational culture, dedicated resources and national support are needed to foster leadership skills among trainee clinicians. Here we discuss a possible blueprint based on the recent reviews of English NHS Trusts with high mortality rates for future initiatives in empowering medical and nursing trainees to learn from leaders and practise leadership skills.

Using queuing theory and simulation model to optimize hospital pharmacy performance

BACKGROUND

Hospital pharmacy is responsible for controlling and monitoring the medication use process and ensures the timely access to safe, effective and economical use of drugs and medicines for patients and hospital staff.

OBJECTIVES

This study aimed to optimize the management of studied outpatient pharmacy by developing suitable queuing theory and simulation technique.

PATIENTS AND METHODS

A descriptive-analytical study conducted in a military hospital in Iran, Tehran in 2013. A sample of 220 patients referred to the outpatient pharmacy of the hospital in two shifts, morning and evening, was selected to collect the necessary data to determine the arrival rate, service rate, and other data needed to calculate the patients flow and queuing network performance variables. After the initial analysis of collected data using the software SPSS 18, the pharmacy queuing network performance indicators were calculated for both shifts. Then, based on collected data and to provide appropriate solutions, the queuing system of current situation for both shifts was modeled and simulated using the software ARENA 12 and 4 scenarios were explored.

RESULTS

Results showed that the queue characteristics of the studied pharmacy during the situation analysis were very undesirable in both morning and evening shifts. The average numbers of patients in the pharmacy were 19.21 and 14.66 in the morning and evening, respectively. The average times spent in the system by clients were 39 minutes in the morning and 35 minutes in the evening. The system utilization in the morning and evening were, respectively, 25% and 21%. The simulation results showed that reducing the staff in the morning from 2 to 1 in the receiving prescriptions stage didn't change the queue performance indicators. Increasing one staff in filling prescription drugs could cause a decrease of 10 persons in the average queue length and 18 minutes and 14 seconds in the average waiting time. On the other hand, simulation results showed that in the evening, decreasing the staff from 2 to 1 in the delivery of prescription drugs, changed the queue performance indicators very little. Increasing a staff to fill prescription drugs could cause a decrease of 5 persons in the average queue length and 8 minutes and 44 seconds in the average waiting time.

CONCLUSIONS

The patients' waiting times and the number of patients waiting to receive services in both shifts could be reduced by using multitasking persons and reallocating them to the time-consuming stage of filling prescriptions, using queuing theory and simulation techniques.