E-learning Interventions for Quality Improvement Continuing Medical Education-A Scoping Review

INTRODUCTION

Improving health care quality and patient safety are top priorities for the medical field. Robust continuing medical education (CME) programs represent major interventions to effectively teach quality improvement (QI) principles to practicing physicians. In particular, eLearning, a term describing online and distance learning interventions using digital tools, provides a means for CME interventions to reach broader audiences. Although there has been a focus on CME addressing QI, no knowledge synthesis has focused specifically on eLearning interventions. The purpose of this review was to examine the current landscape of eLearning interventions in QI-focused CME.

METHODS

We conducted a scoping review using the framework developed by Arksey and O'Malley as revised by Levac. We searched five databases and identified 2467 prospective publications, which two authors independently screened for inclusion. From each included article, two authors independently extracted data on the instructional modalities and QI tools used and met regularly to achieve consensus.

RESULTS

Twenty-one studies were included. Most studies used blended instruction (n = 12) rather than solely eLearning interventions. Salient findings included the importance of coaching from QI experts and institutional support for planning and implementing eLearning interventions. Lack of protected time and resources for participants were identified as barriers to participation in CME activities, with small practices being disproportionately affected.

DISCUSSION

Partnerships between CME developers and sponsoring organizations are vital in creating sustainable eLearning interventions for QI-focused CME. Remote coaching can be an effective strategy to provide ongoing support to geographically separated learners.

A graduate medical education (GME) quality improvement curriculum leads to improved knowledge and participation in high quality improvement projects by trainees

BACKGROUND

There is increased awareness about the need for quality improvement (QI) education for trainees within clinical training programs. However, formal integration of a QI curriculum into graduate medical education (GME) remains a work-in-progress. We describe the creation and implementation of a novel, virtual QI curriculum complemented by virtual-based workshops.

OBJECTIVE

To determine the impact of a GME QI curriculum on 1) trainee QI knowledge; 2) Quality of QI projects.

METHODS

The GME Quality Improvement curriculum was transitioned to an optional formal curriculum in 2020. It is led by three faculty with expertise in QI training and education. The team developed four, web-based learning modules that focused on fundamental QI concepts. These modules are completed monthly and are paired with virtual workshops that facilitate applying learned QI concepts to project development. We evaluated the effectiveness of the curriculum by assessing participants' performance on knowledge-based quizzes before and after each online module. We used IBM SPSS (version 28), to conduct a two-sided paired samples t-test, comparing each post-session test scores with their corresponding pre-session scores. The alpha, or statistical threshold significance threshold, was 0.05. Additionally, two independent judges with expertise in QI evaluated the quality of the projects presented at the annual QI showcase using a standardized scoring rubric. The poster evaluation forms included 8 questions, rated on a scale from 1 to 5. Projects were graded into 4 quartiles (poor, fair, good, excellent).

RESULTS

In the knowledge assessment quiz, the difference between the mean pre- and post-session quiz scores was statistically significant (p < 0.01). The average score of the quality of the projects presented at the annual showcase was 31, in the fourth quartile which was graded as "excellent" quality.

CONCLUSION

A GME-led QI curriculum was effective in improving knowledge of QI concepts and producing high-quality scholarly projects.

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

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

How, and under what contexts, do academic-practice partnerships collaborate to implement healthcare improvement education into preregistration nursing curriculums: a realist review protocol

INTRODUCTION

Internationally, healthcare improvement remains a clinical and educational priority. Consensus in Europe, Canada and the USA to implement quality improvement (QI) education into preregistration nursing curricula ensures students become equipped with the skills and knowledge required to improve practice. Now, New Zealand and Australia are beginning to implement QI education into their nursing curricula. However, QI education is complex; comprising multiple components, each influenced by the contexts under which they are developed and implemented. Evaluation studies of QI education unanimously acknowledge that academic and practice partnerships (APPs) are essential to optimally embed QI into preregistration curricula, yet it is not understood how, and under what contexts, APPs collaborate to achieve this.

METHODS AND ANALYSIS

A realist review to determine how, and under what contexts, APPs collaborate to implement QI education in pre-registration nursing will be conducted using the Realist and Meta-narrative Evidence Syntheses: Evolving Standards Guidelines. International stakeholders will be consulted at each stage which includes (1) clarifying the scope of the review through empirical literature and tacit expert knowledge, (2) searching for evidence in healthcare and social science databases/grey literature, (3) appraising studies using the Evidence for Policy and Practice Information and Co-ordinating Centre weight of evidence framework and extracting data using Standards for QUality Improvement Reporting Excellence in Education Publication Guidelines, (4) synthesising evidence and drawing conclusions through the creation of context, mechanism and outcome configurations and (5) disseminating findings through conferences and peer-reviewed publications.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. Findings will be disseminated to international nurse educators, leaders and front-line staff implementing QI education within their own academic and practice contexts through conferences and peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021282424.

From Theory to Practice: The Enacted Curriculum of a Successful Master's Program in Quality Improvement and Leadership

INTRODUCTION

Blended learning has taken on new prominence in the fields of higher and continuing education, especially as programs have shifted in response to teaching in a global pandemic. The faculty at the Jönköping Academy's Masters in Quality Improvement and Leadership program has been offering a blended learning curriculum, based on four core design principles, since 2009. We studied key features of the enacted curriculum to understand conditions that can support an effective blended learning model.

METHODS

We used a case study approach underpinned by interactive research. Document analysis, a focus group, individual interviews, and stimulated recall interviews were used for data collection. Themes were identified through qualitative content analysis and data reduction, data display, and conclusion drawing.

RESULTS

We grouped data into six emergent themes that clarify the enacted curriculum of an established Master's program: focusing on a common purpose, developing technical and relational knowledge and skills, linking theory and practice in the workplace, leveraging collaboration for mutual benefit, concentrating on leadership and coaching, and applying a blended and interprofessional learning model.

CONCLUSION

Educators faced with increased demands to be flexible and to offer opportunities for distance education can learn from this case example of effective teaching of quality improvement and leadership in a blended format.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

INTRODUCTION

Quality improvement (QI) is a useful methodology for improving healthcare, often through iterative changes. There is no prior review on the application of QI in physical therapy (PT).

PURPOSE AND RELEVANCE

To characterize and evaluate the quality of the QI literature in PT.

METHODS

We searched four electronic databases from inception through September 1, 2022. Included publications focused on QI and included the practice of PT. Quality was assessed using the 16-point QI Minimum Quality Criteria Set (QI-MQCS) appraisal tool.

RESULTS

Seventy studies were included in the review, 60 of which were published since 2014 with most ( n = 47) from the United States. Acute care ( n = 41) was the most prevalent practice setting. Twenty-two studies (31%) did not use QI models or approaches and only nine studies referenced Revised Standards for QI Reporting Excellence guidelines. The median QI-MQCS score was 12 (range 7-15).

CONCLUSIONS/IMPLICATIONS

Quality improvement publications in the PT literature are increasing, yet there is a paucity of QI studies pertaining to most practice settings and a lack of rigor in project design and reporting. Many studies were of low-to-moderate quality and did not meet minimum reporting standards. We recommend use of models, frameworks, and reporting guidelines to improve methodologic rigor and reporting.

Teaching quality improvement concepts to pharmacy students using the Evidence-based Practice for Improving Quality (EPIQ) workshop

BACKGROUND AND PURPOSE

Despite the benefits of quality improvement (QI) training, there is a scarcity of information on QI teaching formats for undergraduate pharmacy education. The Evidence-based Practice for Improving Quality (EPIQ) workshop was evaluated as a teaching format for a group of multi-year undergraduate pharmacy students, assessing knowledge acquisition and learner reactions.

EDUCATIONAL ACTIVITY AND SETTING

Using a convergent mixed-method analysis, 10-item pre- and post-workshop multiple-choice questionnaires measured students' knowledge acquisition of foundational QI concepts. A six-item pre- and post-workshop survey and a voluntary post-workshop focus group evaluated students' attitudes towards QI training and the teaching format. Mann-Whitney U non-parametric test was used to analyze the quantitative data, while thematic analysis was applied to analyze the qualitative data.

FINDINGS

Twenty-nine pharmacy students participated in the workshop. There was a statistically significant improvement in pharmacy students' QI knowledge before and after participating in the workshop (77% vs. 86%, P = .008). The evaluation of the EPIQ teaching format resulted in three important findings: (1) undergraduate pharmacy students identified a QI learning need; (2) the EPIQ workshop effectively provided foundational QI literacy for all pharmacy student years using a "learning by sharing" methodology and pharmacy-specific case studies; and (3) interested students may benefit from an experiential elective to apply QI techniques.

SUMMARY

The perceived value of QI training for pharmacy students using the EPIQ workshop was demonstrated: students expressed an interest in lifelong learning and a desire to pursue QI projects at school, during a clinical rotation, or at work.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Using QI Methodology to Improve a Program's QI Curriculum: An Educational Improvement Project

Quality improvement (QI) as a method of obtaining meaningful change is increasingly valued. A few comprehensive, longitudinal curricula demonstrate efficacy, patient impact, and behavior change over time. This educational improvement study aimed to create a curriculum that increased resident proficiency in practicing QI principles, score on the QI Knowledge Application Tool-Revised, and QI projects completing at least 2 plan-do-study-act (PDSA) cycles in 5 years.

Methods

We utilized The Model for Improvement and sequential PDSA cycles, testing curricular components for improvement. Measures were analyzed annually (2014-2020). The curriculum includes modules and didactic workshops for foundational knowledge, rapid personal improvement projects for putting knowledge into practice, and experiential learning through developing and leading QI projects.

Results

Graduating residents reporting proficiency in practicing QI principles increased from 4 (44%) to 11 (100%). The average QI Knowledge Application Tool-Revised score increased from 50% to 94% (95% CI, 37-51). Resident QI projects completing at least 2 PDSA cycles increased from 30% (n = 3) to 100% (n = 4), P = 0.0005, while projects achieving improvement increased from 40% (n = 4) to 100% (n = 3), P = 0.002. Patients were also positively impacted, with 63% (n = 3) of clinical QI projects that measured patient-centered outcomes achieving improvement and 69% (n = 11) of clinical QI projects improving clinical processes.

Conclusions

This study developed a curriculum that successfully prepares residents to practice QI principles and lead multidisciplinary QI projects while demonstrating patient impact and behavior change. It offers an example of curriculum development and evaluation aided by QI science.

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.

Quality Improvement Content in Physical Therapist Education: A Scoping Review

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Implementing and Sustaining Brief Addiction Medicine Interventions with the Support of a Quality Improvement Blended-eLearning Course: Learner Experiences and Meaningful Outcomes in Kenya

Quality improvement methods could assist in achieving needed health systems improvements to address mental health and substance use, especially in low-middle-income countries (LMICs). Online learning is a promising avenue to deliver quality improvement training. This Computer-based Drug and Alcohol Training Assessment in Kenya (eDATA-K) study assessed users’ experience and outcome of a blended-eLearning quality improvement course and collaborative learning sessions. A theory of change, developed with decision-makers, identified relevant indicators of success. Data, analyzed using descriptive statistics and thematic analysis, were collected through extensive field observations, the eLearning platform, focus group discussions, and key informant interviews. The results showed that 22 community health workers and clinicians in five facilities developed competencies enabling them to form quality improvement teams and sustain the new substance-use services for the 8 months of the study, resulting in 4591 people screened, of which 575 received a brief intervention. Factors promoting course completion included personal motivation, prior positive experience with NextGenU.org’s courses, and a certificate. Significant challenges included workload and network issues. The findings support the effectiveness of the blended-eLearning model to assist health workers in sustaining new services, in a supportive environment, even in a LMIC peri-urban and rural settings.

The Clinical Safety and Effectiveness Course: Ten Years of Experiential Training in Quality Improvement for Practicing Professionals

Training in quality improvement (QI) and patient safety for clinicians are needed for continued progress in health care quality. A project-based QI curriculum training faculty, residents, and staff in an academic health center for >10 years are reviewed and evaluated. Didactic curriculum includes QI knowledge domains, and QI methods are applied to a project during the course. There are 638 graduates and 239 projects since implementation. Most projects (84%) effected behavior change, change in clinical practice, and benefit to patients. Faculty have used the training to develop formal QI programs for Graduate Medical Education (GME). Graduates value the skills for their professional and personal lives, and for career enhancement. Experiential QI training for practicing professionals is valuable and effective. Collaboration and support from stakeholders are key factors in success. The Clinical Safety & Effectiveness course is a reproducible and relevant model of interprofessional QI education for practicing professionals and staff.

Increasing Faculty Participation and Mentorship in Quality Improvement with an Experiential Four-Hour Workshop

BACKGROUND

Graduate medical education programs lack enough faculty trained in quality improvement (QI). A major barrier to increasing the number of faculty competent in QI is insufficient time to engage in training. Research is missing on the effectiveness of short faculty development workshops to teach academic faculty QI principles and promote participation and mentorship in QI projects.

OBJECTIVE

The authors assessed the ability of a four-hour experiential QI workshop to increase faculty proficiency in QI principles, enhance faculty involvement in QI, and improve resident mentorship in QI.

METHODS

From 2016 to 2017, the authors conducted seven QI faculty development workshops at a large academic medical center with 12 ACGME training programs. We evaluated the workshop using pre- and post-workshop surveys, as well as six- and twelve-month follow up surveys.

RESULTS

Sixty-five faculty participated in seven workshops over 13 months. All participants completed pre- and post-workshop surveys, while 38% (n = 25) responded to the six- and twelve-month follow up surveys. Overall, the workshop significantly increased confidence to lead and mentor residents on a QI project (25% pre vs. 72% post, p < .001), increased ability to teach QI (8% pre vs. 36% post, p < .001), increased participation in planning and decision making on a QI team (32% pre vs. 50% post, p = .002), and increased the mean number of QI projects implemented (.45 pre vs. 1.24 post; p < .05).

CONCLUSION

A four-hour QI workshop is a quick and effective training method to develop academic faculty to teach and mentor residents in QI. The principles taught increased perceived knowledge, confidence in mentorship, and participation in QI.

Implementation and Effects of a Team-Based Quality Improvement Training Program Across a Health System: The Northwestern Medicine Academy for Quality and Safety Improvement

BACKGROUND

Professional organizations emphasize the need to train health care professionals in quality improvement (QI). Many reports of QI education programs involve small numbers of participants. Little is known about QI education programs on a larger scale and whether participants subsequently engage in QI activities.

METHODS

The Northwestern Medicine Academy for Quality and Safety Improvement (NM AQSI) was developed to prepare individuals across the Northwestern health system to lead QI. The 7-month program consists of classwork and team-based project work. Participant knowledge was assessed using a multiple-choice test and adapted Quality Improvement Knowledge Application Tool (QIKAT). The study team surveyed participants 18 months after AQSI completion to assess their activity in QI. Project status was assessed at AQSI completion and at 18 months.

RESULTS

Over 8 years, 80 teams consisting of 441 individuals participated, representing a range of specialties, settings, and professions. Participants had higher multiple-choice test (70.7 ± 14.0 vs. 78.1 ± 13.0; p < 0.001) and adapted QIKAT scores (56.1 ± 15.9 vs. 60.8 ± 15.8; p < 0.001) after AQSI. The majority of participants at 18 months (180/243; 74.1%) had engaged in subsequent QI efforts; many (105/243; 43.2%) had led other QI projects, and (103/243; 42.4%) provided QI mentorship to others. The majority of teams (53/80; 66.3%) improved project measure performance.

CONCLUSION

NM AQSI is a team-based QI training program that shows measurable improvements in care and a high degree of participants' subsequent involvement in QI. Other health systems may use a similar approach to successfully train health care professionals to lead QI.

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.

Experiential QI Activity for Residents to Improve Women's Preventive Services

INTRODUCTION

The Accreditation Council for Graduate Medical Education (ACGME) requires family medicine residents to complete a quality improvement (QI) project. There is a need for more QI training activities to be shared to meet this requirement. Our objective was to describe an activity for residents to improve women's preventive health services in an underserved clinic. Specific aims were to determine: (1) how women's receipt of preventive services compared to benchmarks, (2) physician and staff knowledge of the process and barriers to receiving services, and (3) whether an intervention to increase awareness among physicians and staff improved preventive services.

METHODS

Residents (N=30) evaluated charts (N=505) to determine receipt of mammograms, pap tests, colon cancer screenings, and pneumonia vaccines. We compared estimates to existing clinic benchmarks. We presented initial (preintervention) results to physicians and staff at clinic team meetings. We collected perceptions of processes and barriers to preventive services. Preintervention methods were replicated (N=100) and results were compared (postintervention).

RESULTS

Preintervention, mammograms (72%) and Pap tests (65%) were lower than clinic benchmarks. Most (81%) women ages 65 and older received a pneumonia vaccine; however, this was lower than the national Healthy People 2020 goal. Fear, knowledge, and scheduling were identified as top barriers. Post-intervention, there was a statistically significant increase in Pap tests (P=.0013).

CONCLUSION

This activity trained residents how to impact their practice through QI methods and can be used in other programs as a foundation for developing basic QI initiatives. Future efforts should focus on evaluating barriers to preventive services from the patient perspective.

The Institute for Health care Quality, Safety, and Efficiency: A Comprehensive Approach to Improving Organization-Level Quality Performance

Despite decades of effort to drive quality improvement, many health care organizations still struggle to optimize their performance on quality metrics. The advent of publicly reported quality rankings and ratings allows for greater visibility of overall organizational performance, but has not provided a roadmap for sustained improvement in these assessments. Most quality training programs have focused on developing knowledge and skills in pursuit of individual and project-level improvements. To date, no training program has been associated with improvements in overall organization-level, publicly reported measures. In 2012, the Institute for Health care Quality, Safety, and Efficiency was launched, which is an integrated set of quality and safety training programs, with a focus on leadership development and support of performance improvement through data analytics and intensive coaching. This effort has trained nearly 2000 individuals and has been associated with significant improvement in organization-level quality rankings and ratings, offering a framework for organizations seeking systematic, long-term improvement.

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

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

Implementation of a Quality Improvement Roadmap in the Department of Internal Medicine of an Academic Medical Centre in Singapore

Background: Clarity in directions and constant engagement efforts are crucial to implementing high-quality interventions in Quality Improvement (QI) initiatives. It underpins the success to achieve impactful improvement, effectiveness of interventions through clinical leadership and project sustainability. Our objective was to implement a QI roadmap to improve QI participation of specialists and to clearly align projects and stakeholders to achieve departmental priorities and goals.

Methods: Baseline measurement of Department of Internal Medicine (DIM) specialists involved in QI projects was performed. Root cause analysis and prioritization was conducted to determine the interventions. Series of interventions to address challenges faced by stakeholders to ensure congruency of directions that included collective learning sessions, planning of communication, and documenting progress with checkpoint meetings were carried out. A survey was conducted before and after interventions.

Results: QI projects' participation rates of DIM specialists increased to 82.6% from 26.3% with an increase in uptake in leadership roles from three to nine specialists within the 12 months. The perception survey showed a positive shift in attitudes with greater ease in applying QI tools and concepts, with an increase of 25.7% in 2020 as compared to 2018. With the ease of completing QI projects, DIM specialists became more confident after intervention at 63.2% compared to 42.1% before and also regarded the department to be much stronger in QI culture with an improvement of 51.2%. DIM QI strategic themes model was borne from developing the core focus areas of the departments in order to align existing and prospective QI projects to the established themes.

Conclusion: Department-specific goals and priorities with dedicated interventions are important in driving the interest and ownership to initiate QI projects that align to solve operational problems. The ease in creating the strategic themes model targeting key performance indicators and matching QI projects to the relevant themes, lowers activation barrier and promotes spread due to its simplicity to create and use for communication.

Developing Leaders and Scholars in Health Care Improvement: The VA Quality Scholars Program Competencies

Despite the need for leaders in health care improvement across health professions, there are no standards for the knowledge and skills that should be achieved through advanced interprofessional health care improvement training. Existing health care improvement training competencies focus on foundational knowledge expected of all trainees or for specific career pathways. Health care improvement leaders fill multiple roles within organizations and promote interprofessional improvement practice. The diverse skill set required of modern health care improvement leaders necessitates the development of training competencies specifically for fellowships in applied health care improvement. The authors describe the development of the revised national Veterans Affairs Quality Scholars (VAQS) Program competencies. The VAQS Program is an interprofessional, postdoctoral training program whose mission is to develop leaders and scholars to improve health care. An interprofessional committee of VAQS faculty reviewed and revised the competencies over 4 months beginning in fall 2018. The first draft was developed using 111 competencies submitted by 11 VAQS training sites and a review of published competencies. The final version included 22 competencies spanning 5 domains: interprofessional collaboration and teamwork, improvement and implementation science, organization and system leadership, methodological skills and analytic techniques for improvement and research, and teaching and coaching. Once attained, the VAQS competencies will guide the skill development that interprofessional health care improvement leaders need to participate in and lead health care improvement scholarship and implementation. These broad competencies are relevant to advanced training programs that develop health care improvement leaders and scholars and may be used by employers to understand the knowledge and skills expected of individuals who complete advanced fellowships in applied health care improvement.

Evaluation of Changes in Quality Improvement Knowledge Following a Formal Educational Curriculum Within a Statewide Learning Collaborative

OBJECTIVE

Our objectives were to (1) develop a curriculum based upon participants' needs, (2) evaluate baseline QI knowledge of the Illinois Surgical Quality Improvement Collaborative (ISQIC) members, and (3) evaluate the effectiveness of the educational curriculum.

DESIGN

The Surgeon Champion (SC), Surgical Clinical Reviewer (SCR), and QI Designee at each ISQIC hospital completed a QI curriculum containing online modules and in-person trainings. A surgical adaptation of QI-KAT, a validated QI knowledge assessment with multiple-choice and free-response sections, was administered pre- and postcurriculum. Three blinded educators scored each exam using a rubric-based scoring tool (54 total points).

SETTING

The ISQIC is a 52-hospital learning collaborative. Generally, ISQIC participants had little prior formal training or experience with quality improvement.

RESULTS

Among 52 hospitals, 144 pretests and 112 post-tests were collected. Mean scores increased from 66% (35.6 points) to 77% (41.6 points; p < 0.001). Across all hospitals, all participant groups scored higher on the post-test (SCs 15%, SCRs 21%, QI Designees 17%). There was no significant difference in post-test mean scores among different team members: SCs 44 points, SCRs 42 points, QI Designees 44 points, (p = 0.76). When the post-test scores were aggregated at the hospital level, hospitals with new surgical QI programs improved more than hospitals with established programs (new 18%, established 11%, p < 0.05).

CONCLUSIONS

QI knowledge significantly improved after completion of the ISQIC curriculum. These data support the value of formalized curricula to rapidly advance QI knowledge and application skills as a foundation for implementing QI initiatives.

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.

Promoting Quality Improvement in Primary Care Through a Longitudinal, Project-Based, Interprofessional Curriculum

INTRODUCTION

Health professionals must demonstrate competencies in quality improvement (QI) and interprofessional (IP) practice. Yet few curricula are designed to address these competencies in an integrated, longitudinal way. Our experiential IP QI curriculum addresses this gap.

METHODS

The IP QI curriculum was part of a San Francisco VA Health Care System training program for second-year internal medicine residents and adult gerontology primary care nurse practitioner students, pharmacy residents, and postdoctoral psychology fellows. Trainees worked in mentored IP teams to select, design, implement, evaluate, and present a project as part of a 9-month curriculum. Teaching methodologies included didactics and project-based skills application. Curriculum evaluation included trainees' QI knowledge and skills self-assessments, trainee satisfaction, mentor appraisals, and project results and impact assessments.

RESULTS

From 2011-2012 to 2017-2018, 242 trainees completed the curriculum and 41 QI projects. Trainees reported high satisfaction with the introductory sessions (M = 4.4, SD = 0.7). They also reported improvement in comfort with QI knowledge and skills by the curriculum's completion. QI mentors (n = 23) observed growth in trainees' QI knowledge and skills, felt confident in trainees' ability to orchestrate a QI initiative, and believed their mentored QI projects added value to the organization. Thirty-eight projects resulted in system modifications.

DISCUSSION

This IP QI curriculum offers team-based, workplace experiences for trainees to learn and apply QI knowledge and skills. Leading factors for successful implementation included attention to team-building and faculty development. Challenges included reliably collecting evaluation data, accurately measuring ongoing systems changes, and variable trainee engagement.

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.

Organizational Support in Healthcare Redesign Education: A Mixed-Methods Exploratory Study of Expert Coach and Executive Sponsor Experiences

Healthcare organizations must continue to improve services to meet the rising demand and patient expectations. For this to occur, the health workforce needs to have knowledge and skills to design, implement, and evaluate service improvement interventions. Studies have shown that effective training in health service improvement and redesign combines didactic education with experiential project-based learning and on-the-ground coaching. Project-based learning requires organizational support and oversight, generally through executive sponsorship. A mixed-methods approach, comprising online surveys and semi-structured interviews, was used to explore the experiences of expert coaches and executive sponsors as key facilitators of workplace-based projects undertaken during an Australian postgraduate healthcare redesign course. Fifteen (54%) expert coaches and 37 (20%) executive sponsors completed the online survey. Ten expert coaches and six executive sponsors participated in interviews. The survey data revealed overall positive experiences for coaches and mixed experiences for sponsors. Interview participants expressed a sense of fulfillment that came from working with project teams to deliver a successful project and educational outcomes. However, concerns were raised about adequate resourcing, organizational recognition, competing priorities, and the skills required to effectively coach and sponsor. Expert coaches and executive sponsors sometimes felt under-valued and may benefit from cohort-tailored and evidence-based professional development.

Development of a Hybrid, Interprofessional, Interactive Quality Improvement Curriculum as a Model for Continuing Professional Development

Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in-and eventually, lead-QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner's Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners-wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams-can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.

Integrating a Reflective Learning Activity to Ensure Quality Improvement Project Success

This article describes a brief learning activity that provided reflective time to identify barriers, facilitators, and action steps to ensure quality improvement (QI) project success. Learners from our program participated in an interactive 90-minute session that used Liberating Structures to reflect on current barriers to implementation of their QI projects. Analysis of the individual reflective cards identified 10 barriers to QI success. Facilitators were grouped into 16 themes. Action steps were placed into six categories. Integration of reflection promotes important identification of QI project barriers, facilitators, and the creation of action steps.

Behavioural and operational outcomes of a Master's programme on improvement knowledge and leadership

PURPOSE

The purpose of this paper is to evaluate behavioural changes and operational outcomes resulting from a Master's programme on improvement knowledge and leadership in the Swedish welfare sector. The welfare sector is the collective term for tax-funded services the state, county councils and municipalities are responsible to provide.

DESIGN/METHODOLOGY/APPROACH

A survey combined open-ended and closed questions using a five-point Likert scale. The questions were based on the learning objectives of the Master's programme. The survey was sent to 139 graduates and achieved a response rate of 41 per cent (57 respondents). Responses were entered into a survey programme to enable the descriptive presentation of data; open-ended responses were analysed using conventional content analysis.

FINDINGS

Respondents reported their increased knowledge and changed behaviours had impacted operational outcomes, e.g. processes efficiency, compliance with guidelines and quality. They said the programme was of value to themselves and society but requested more leadership knowledge. All respondents recommended the programme to others.

ORIGINALITY/VALUE

By operationalizing the Kirkpatrick framework, the paper describes outcomes on levels three and four, and the use of numerous best practice techniques for adult learning. This is valuable knowledge for organisers of improvement knowledge educations.

Learning in Practice: Collaboration Is the Way to Improve Health System Outcomes

Evidence suggests that it is challenging for universities to develop workplace-relevant content and curricula by themselves, and this can lead to suboptimal educational outcomes. This paper examines the development, implementation, and evaluation of Australia’s first tertiary graduate course in healthcare redesign, a partnership initiative between industry and university. The course not only provides students with an understanding of person-centered sustainable healthcare but also the skills and confidence to design, implement, and evaluate interventions to improve health service delivery. Increasing students’ application of new knowledge has been through work-integrated learning, a pedagogy that essentially integrates theory with the practice of workplace application within a purposely designed curriculum. The specific aim of this study was to examine the outcomes of the course after two years, utilizing an anonymous online survey of graduates. Sixty-two graduates (48%) completed the survey. Kirkpatrick’s four-level evaluation model was used to analyze the data. The analysis revealed high satisfaction levels in relation to the course content and delivery. Through successful completion of the innovative course, students had increased their knowledge of health system redesign methods and, importantly, the ability to translate that knowledge into everyday practice. Graduates of the clinical redesign course reported that they had been able to transfer their skills and knowledge to others in the workplace and lead further improvement projects.

Development and psychometric evaluation of an instrument to measure knowledge, skills, and attitudes towards quality improvement in health professions education: The Beliefs, Attitudes, Skills, and Confidence in Quality Improvement (BASiC-QI) Scale

INTRODUCTION

Health professionals are increasingly expected to foster and lead initiatives to improve the quality and safety of healthcare. Consequently, health professions education has begun to integrate formal quality improvement (QI) training into their curricula. Few instruments exist in the literature that adequately and reliably assess QI-related competencies in learners without the use of multiple, trained raters in the context of healthcare. This paper describes the development and psychometric evaluation of the Beliefs, Attitudes, Skills, and Confidence in Quality Improvement (BASiC-QI) instrument, a 30-item self-assessment tool designed to assess knowledge, skills, and attitudes towards QI.

METHODS

Sixty first-year medical student participants completed the BASiC-QI and the Quality Improvement Knowledge Application Tool (QIKAT-R) prior to and immediately following a QI program that challenged learners to engage QI concepts in the context of their own medical education. Measurement properties of the BASiC-QI tool were explored through an exploratory factor analysis and generalizability study. Convergent validity was examined through correlations between BASiC-QI and QIKAT-R scores.

RESULTS

Psychometric evaluation of BASiC-QI indicated reliability and validity evidence based on internal structure. Analyses also revealed that BASiC-QI scores were positively correlated with the scores from the QIKAT-R, which stands an indicator of convergent validity.

CONCLUSION

BASiC-QI is a multidimensional self-assessment tool that may be used to assess beliefs, attitudes, skills, and confidence towards QI. In comparison with existing instruments, BASiC-QI does not require multiple raters or scoring rubrics, serving as an efficient, reliable assessment instrument for educators to examine the impact of QI curricula on learners.

Validity evidence for Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores: consequences of rater number and type using neurology cases

OBJECTIVES

To develop neurology scenarios for use with the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), gather and evaluate validity evidence, and project the impact of scenario number, rater number and rater type on score reliability.

METHODS

Six neurological case scenarios were developed. Residents were randomly assigned three scenarios before and after a quality improvement (QI) course in 2015 and 2016. For each scenario, residents crafted an aim statement, selected a measure and proposed a change to address a quality gap. Responses were scored by six faculty raters (two with and four without QI expertise) using the QIKAT-R. Validity evidence from content, response process, internal structure, relations to other variables and consequences was collected. A generalisability (G) study examined sources of score variability, and decision analyses estimated projected reliability for different numbers of raters and scenarios and raters with and without QI expertise.

RESULTS

Raters scored 163 responses from 28 residents. The mean QIKAT-R score was 5.69 (SD 1.06). G-coefficient and Phi-coefficient were 0.65 and 0.60, respectively. Interrater reliability was fair for raters without QI expertise (intraclass correlation = 0.53, 95% CI 0.30 to 0.72) and acceptable for raters with QI expertise (intraclass correlation = 0.66, 95% CI 0.02 to 0.88). Postcourse scores were significantly higher than precourse scores (6.05, SD 1.48 vs 5.22, SD 1.5; p < 0.001). Sufficient reliability for formative assessment (G-coefficient > 0.60) could be achieved by three raters scoring six scenarios or two raters scoring eight scenarios, regardless of rater QI expertise.

CONCLUSIONS

Validity evidence was sufficient to support the use of the QIKAT-R with multiple scenarios and raters to assess resident QI knowledge application for formative or low-stakes summative purposes. The results provide practical information for educators to guide implementation decisions.

A National Survey of Quality Improvement Education in Physician Assistant Programs

PURPOSE

Quality improvement (QI) is emerging as a leadership and career track for physician assistants (PAs). Information on how PA programs teach QI is sparse. This study aimed to define how PA programs are providing education in QI through a national program survey.

METHODS

Curriculum survey questions were deployed as a part of the 2014-2015 Physician Assistant Education Association program survey. Questions were grouped into 4 categories: QI champion, pedagogy, integration strategy, and curriculum content. Differences between groups were analyzed, and logistic regression models were built to explore associations.

RESULTS

All 194 (100%) PA programs responded to the survey. There were 137 (70.6%) programs that were teaching QI. The median number of total instructional hours was 12 (interquartile range = 16, overall range = 109). There were 37 (27%) programs that were categorized as having a "mature curriculum." Mature curricula were significantly associated with a QI champion who is an expert from an outside department/institution (odds ratio [OR], 5.05; 95% confidence interval [CI], 1.14-22.33) and with programs that have a QI capstone or thesis project (OR, 3.66; 95% CI, 1.14-11.72) whose educational hours correlated more with experiential learning (r = 0.51, P < .01), small group sessions (r = 0.42, P = .01), and web-based modules (r = 0.36, P = .03).

CONCLUSION

Quality improvement is an important skill set for PAs, but nearly one-third of PA programs do not have a QI curriculum. Mature curricula were associated with more experiential learning and project-based learning (including capstone/thesis). This study captured many elements of QI education for PAs, which can be used by programs to develop and improve their curricula.

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

An Interprofessional Quality Improvement Training Program That Improves Educational and Quality Outcomes

A key component of quality improvement (QI) is developing leaders who can implement QI projects collaboratively. A yearlong interprofessional, workplace-based, continuing professional development program devoted to QI trained 2 cohorts of teams (dyads or triads) to lead QI projects in their areas of work using Plan-Do-Study-Act methodology. Teams represented different specialties in both inpatient and outpatient settings. They spent 4 to 6 hours/week on seminars, online modules, bimonthly meetings with a QI coach, and QI project work. Evaluations conducted after each session included pre-post program QI self-efficacy and project milestones. Post-program participants reported higher levels of QI self-efficacy (mean = 3.47; SD = 0.39) compared with pre program (mean = 2.02, SD = 0.51; P = .03, Cohen's d = 3.19). Impact on clinical units was demonstrated, but varied. The coach was identified as a key factor for success. An interprofessional, workplace-based, continuing professional development program focused on QI increased QI knowledge and skills and translated to improvements in the clinical setting.

The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies

Background

Policy- and decision-makers seek to improve the quality of care in the health sector and therefore aim to improve quality through appropriate policies. Higher quality of care will satisfy service providers and the public, reduce costs, increase productivity, and lead to better organisational performance. Clinical governance is a method through which management can be improved and made more accountable, and leads to the provision of better quality of care. In November 2009, the Iranian Ministry of Health and Medical Education implemented new clinical guidelines to standardise and improve clinical services as well as to increase efficiency and reduce costs. The purpose of this study was to assess the challenges of implementing clinical governance through a meta-synthesis of qualitative studies published in Iran.

Methods

Ten databases, including ISI/Web of Sciences, PubMed/MEDLINE, Embase, PsycINFO, the Cochrane Library, CINAHL, Scopus, Barakatns, MagIran and the Scientific Information Database, were searched between January 2009 and May 2018. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool. This study was reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Thematic synthesis was used to analyse the data.

Results

Ten studies were selected and included based on the inclusion/exclusion criteria. In the first stage, 75 items emerged and were coded, and, following comparison and combination of the codes, 32 codes and 8 themes were finally extracted. These themes included health system structure, management, person-power, cultural factors, information and data, resources, education and evaluation.

Conclusion

The findings of the study showed that there exist a variety of challenges for the implementation of clinical governance in Iran. To successfully implement a health policy, its infrastructure needs to be created. Using the views and support of stakeholders can ensure that a policy is well implemented.

Trial registration

CRD42017079077. Dated October 10, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0399-5) contains supplementary material, which is available to authorized users.

How Theory Can Inform Our Understanding of Experiential Learning in Quality Improvement Education

It is widely accepted that quality improvement (QI) education should be experiential. Many training programs believe that making QI learning "hands-on" through project-based learning will translate into successful learning about QI. However, this pervasive and overly simplistic interpretation of experiential QI learning, and the general lack of empirical exploration of the factors that influence experiential learning processes, may limit the overall impact of project-based learning on educational outcomes.In this Perspective, the authors explore the opportunities afforded by a theoretically informed approach, to deepen understanding of the diverse factors that affect experiential QI learning processes in the clinical learning environment. The authors introduce the theoretical underpinnings of experiential learning more generally, and then draw on their experiences and data, obtained in organizing and studying QI education activities, to illuminate how sociocultural theories such as Billett's workplace learning theory, and sociomaterial perspectives such as actor-network theory, can provide valuable lenses for increasing our understanding of the varied individuals, objects, contexts, and their relationships that influence project-based experiential learning. The two theoretically informed approaches that the authors describe are amongst numerous others that can inform a QI education research agenda aimed at optimizing educational processes and outcomes. The authors conclude by highlighting how a theoretically informed QI education research agenda can advance the field of QI education; they then describe strategies for achieving this goal.

Development and implementation of a national quality improvement skills curriculum for urology residents in the United Kingdom: A prospective multi-method, multi-center study

BACKGROUND

Surgical quality improvement (QI) is a global priority. We report the design and proof-of concept testing of a QI skills curriculum for urology residents.

METHODS

'Umbrella review' of QI curricula (Phase-1); development of draft QI curriculum (Phase-2); curriculum review by Steering Committee of urologists (Attendings & Residents), QI and medical education experts and patients (Phase-3); proof-of-concept testing (Phase-4).

RESULTS

Phase-1: Six systematic reviews were identified of 4332 search hits. Most curricula are developed/evaluated in the USA; use mixed teaching methods (incl. didactic, QI exercises & self-reflection); and introduce core QI techniques (e.g., Plan-Do-Study-Act). Phase-2: curriculum drafted. Phase-3: the curriculum was judged to represent state-of-the-art, relevant QI training. Stronger patient involvement element was incorporated. Phase-4: the curriculum was delivered to 43 urology residents. The delivery was feasible; the curriculum implementable; and a knowledge-skills-attitudes evaluation approach successful.

CONCLUSION

We have developed a practical QI curriculum, for further evaluation and national implementation.

Concerns and Responses for Integrating Health Systems Science Into Medical Education

With the aim of improving the health of individuals and populations, medical schools are transforming curricula to ensure physician competence encompasses health systems science (HSS), which includes population health, health policy, high-value care, interprofessional teamwork, leadership, quality improvement, and patient safety. Large-scale, meaningful integration remains limited, however, and a major challenge in HSS curricular transformation efforts relates to the receptivity and engagement of students, educators, clinicians, scientists, and health system leaders. The authors identify several widely perceived challenges to integrating HSS into medical school curricula, respond to each concern, and provide potential strategies to address these concerns, based on their experiences designing and integrating HSS curricula. They identify two broad categories of concerns: the (1) relevance and importance of learning HSS-including the perception that there is inadequate urgency for change; HSS education is too complex and should occur in later years; early students would not be able to contribute, and the roles already exist; and the science is too nascent-and (2) logistics and practicality of teaching HSS-including limited curricular time, scarcity of faculty educators with expertise, lack of support from accreditation agencies and licensing boards, and unpreparedness of evolving health care systems to partner with schools with HSS curricula. The authors recommend the initiation and continuation of discussions between educators, clinicians, basic science faculty, health system leaders, and accrediting and regulatory bodies about the goals and priorities of medical education, as well as about the need to collaborate on new methods of education to reach these goals.

X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block

BACKGROUND

Meaningful resident engagement in quality improvement (QI) remains challenging. Barriers include a lack of time and of faculty with QI expertise. We leveraged our internal medicine (IM) residency program's adoption of an "X" (inpatient rotations) plus "Y" (ambulatory block) schedule to implement a QI curriculum for all residents during their ambulatory block.

OBJECTIVE

We sought to engage residents in interprofessional QI, improve residents' QI confidence and knowledge and application to practice, and create opportunities for QI scholarship.

METHODS

In July 2015, the program provided dedicated time for QI in the ambulatory block. All categorical IM residents and 11 voluntary faculty mentors were divided into 10 teams based on clinic site and "Y" block schedule. Teams participated in resident-led, interprofessional ambulatory QI projects. Resident QI knowledge and confidence were assessed before the curriculum and 11 months after using the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and surveys. QI project implementation and scholarship were tracked.

RESULTS

All categorical residents (N = 81) participated. Residents reported increased confidence in all QI skills, and they demonstrated increased knowledge, with mean QIKAT-R paired scores improving from 15.8 ± 4.6 to 19.1 ± 5.9 (n = 45 pairs, P < .001). A total of 9 of 10 teams implemented process changes, and 6 team project improvements have been sustained.

CONCLUSIONS

This ongoing curriculum engaged IM and IM-psychiatry residents in QI during their ambulatory block using volunteer clinic faculty mentors. Residents demonstrated improved QI confidence and knowledge. The majority of resident projects were sustained and generated scholarship.

Immediate and long-term effects of a team-based quality improvement training programme

Background

Although many studies of quality improvement (QI) education programmes report improvement in learners’ knowledge and confidence, the impact on learners’ future engagement in QI activities is largely unknown and few studies report project measures beyond completion of the programme.

Method

We developed the Academy for Quality and Safety Improvement (AQSI) to prepare individuals, across multiple departments and professions, to lead QI. The 7-month programme consisted of class work and team-based project work. We assessed participants’ knowledge using a multiple choice test and an adapted Quality Improvement Knowledge Assessment Test (QIKAT) before and after the programme. We evaluated participants’ postprogramme QI activity and project status using surveys at 6 and 18 months.

Results

Over 5 years, 172 individuals and 32 teams participated. Participants had higher multiple choice test (71.9±12.7 vs 79.4±13.2; p<0.001) and adapted QIKAT scores (55.7±16.3 vs 61.8±14.7; p<0.001) after the programme. The majority of participants at 6 months indicated that they had applied knowledge and skills learnt to improve quality in their clinical area (129/148; 87.2%) and to implement QI interventions (92/148; 62.2%). At 18 months, nearly half (48/101; 47.5%) had led other QI projects and many (41/101; 40.6%) had provided QI mentorship to others. Overall, 14 (43.8%) teams had positive postintervention results at AQSI completion and 20 (62.5%) had positive results at some point (ie, completion, 6 months or 18 months after AQSI).

Conclusions

A team-based QI training programme resulted in a high degree of participants’ involvement in QI activities beyond completion of the programme. A majority of team projects showed improvement in project measures, often occurring after completion of the programme.

Evaluation of a Distance Learning Curriculum for Interprofessional Quality Improvement Leaders

As health care systems move toward value-based care, training future leaders in quality improvement (QI) is essential. Web-based training allows for broad dissemination of QI knowledge to geographically distributed learners. The authors conducted a longitudinal evaluation of a structured, synchronous web-based, advanced QI curriculum that facilitated engagement and real-time feedback. Learners (n = 54) were satisfied (overall satisfaction; M = 3.31/4.00), and there were improvements in cognitive (immediate QI knowledge tests; P = .02), affective (self-efficacy of QI skills; P < .001), and skill-based learning (Quality Improvement Knowledge Application Tool; P < .001). There was significant improvement in affective transfer (interprofessional attitudes on the job; p < .01) but no significant change on cognitive (distal QI knowledge test; P = .91), or skill-based transfer (self-reported interprofessional collaboration job skills; P = .23). The findings suggest that this model can be effective to train geographically distributed future QI leaders.

Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning

BACKGROUND

Quality Improvement (QI) training for health professionals is essential to strengthen health systems. However, QI training during medical school is constrained by students' lack of contextual understanding of the health system and an already saturated medical curriculum. The Program for Improvement in Medical Education (PRIME), an extracurricular offered at the Michael G. DeGroote School of Medicineat McMaster University (Hamilton, Canada), addresses these obstacles by having first-year medical students engage in QI by identifying opportunities for improvement within their own education.

METHODS

A sequential explanatory mixed-methods approach, which combines insights derived from quantitative instruments and qualitative interview methods, was used to examine the impact of PRIME on first-year medical students and the use of QI in the context of education.

RESULTS

The study reveals that participation in PRIME increases both knowledge of, and comfort with, fundamental QI concepts, even when applied to clinical scenarios. Participants felt that education provided a meaningful context to learn QI at this stage of their training, and were motivated to participate in future QI projects to drive real-world improvements in the health system.

CONCLUSIONS

Early exposure to QI principles that uses medical education as the context may be an effective intervention to foster QI competencies at an early stage and ultimately promote engagement in clinical QI. Moreover, PRIME also provides a mechanism to drive improvements in medical education. Future research is warranted to better understand the impact of education as a context for later engagement in clinical QI applications as well as the potential for QI methods to be translated directly into education.