Attitudes of Pulmonary and Critical Care Training Program Directors toward Quality Improvement Education

Efficacy of a Longitudinal Project-Based Quality Improvement Curriculum in Pediatric Cardiology Fellowship

Quality improvement knowledge is a requirement of fellowship training. Our goal was to evaluate the efficacy of a 3-year quality improvement and patient safety (QI/PS) curriculum that gives fellows both didactic knowledge and first-hand experience with improvement science, and meets Clinical Learning Environment Review (CLER) requirements. Knowledge assessment is obtained through pre- and post-surveys. A secondary measure of success is academic products resulting from fellows' QI/PS work, and future participation in QI/PS efforts. Since 2019, 51 pre-tests and 36 post-tests were completed, showing improvement across all competencies. Fellows have produced one published manuscript, two poster presentations, and two oral presentations describing their improvement work. Additionally, mentoring faculty members have gone on to lead other QI work throughout the division. This longitudinal QI/PS curriculum provides both knowledge and experience in QI/PS work. It also creates opportunities for academic publications and presentations, builds faculty expertise, and most importantly, works to improve multiple aspects of patient care. This curriculum can serve as a model for other cardiology fellowships working to meet CLER requirements.

The Quality Improvement Fellow: Educating on Making the Difference

The critical care medicine (CCM) fellowship is an opportunity for advanced anesthesiology trainees to refine their quality improvement (QI) skills. However, the short training period and inconsistent curricula make this challenging. The QI fellow (QIF) is described as an education program to provide consistent QI training during the CCM fellowship. The QIF is a mentored position to help manage data review, QI conferences, and improvement efforts within the CCM Division. The curriculum is focused on a QI education framework and mentored experiential learning. The QIF program is an opportunity for education and mentorship in the role of a CCM operational leader.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Perspectives of hospital pharmacists on quality improvement initiatives in patient care: A pilot study from one healthcare system in Canada

Background

Quality Improvement (QI) is any systematic process that seeks to improve patient safety or clinical effectiveness in healthcare. Although hospital pharmacists positively contribute to QI initiatives, there is no information available regarding Canadian hospital pharmacists' involvement and perspectives with QI.

Objectives

The primary objective of the study was to describe the QI experiences (including attitudes, enablers and barriers) of hospital pharmacists employed by the Lower Mainland Pharmacy Services (LMPS) in British Columbia.

Methods

This research study used an exploratory cross-sectional survey. A 30-item survey was developed to measure QI experiences of hospital pharmacists including prior QI experiences, their attitudes towards pursuing QI initiatives, and their perceived enablers and barriers to participating in QI initiatives in hospital settings.

Results

Forty-one pharmacists responded (response rate of 14%). Thirty-eight participants (93%) indicated that they were familiar with the concept of QI. All participants (100%) reported that it was important for pharmacists to be involved with QI despite the general lack of formal QI training among the participants, and 40 participants (98%) agreed that QI was necessary to advance patient care. Moreover, 21 participants (51%) showed interest in leading QI initiatives, while 29 (71%) would participate in QI initiatives. Participants identified several individual and organizational barriers that hindered hospital pharmacists from pursuing QI initiatives.

Conclusion

Our findings suggest that hospital pharmacists in LMPS would like to be actively involved with QI initiatives; however, individual and organizational barriers must be addressed in order to facilitate widespread adoption of QI practices.

Teaching Quality Improvement: The Use of Education Theories Across the Medical Education Spectrum

It is well recognized that the principles and practices of patient safety and quality improvement (QI) need to be included in medical education. The implementation of patient safety and QI learning experiences at the undergraduate medical education (UME) and graduate medical education (GME) levels has been variable. Consistent teaching of QI across the UME-GME-continuing medical education (CME) spectrum may result in a systemic change of improved patient care and patient safety in clinical practice. We propose using education theories to frame the development of QI curricula for a longitudinal integration in medical education and clinical practice. The basic principles of four education theories, namely, reflective practice, deliberate practice, social constructivism, and organizational learning, are briefly described, and examples of their applications to QI teaching are discussed. The incorporation of education theory into the design and implementation of a longitudinal QI curriculum threaded across the UME-GME-CME spectrum may empower learners with a comprehensive and lasting understanding of QI principles and training in patient safety practice, which are essential prerequisites for the formation of a physician workforce capable of creating sustainable change in patient care.

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.

Feasibility and Effectiveness of a Quality Improvement Curriculum for Combined Medicine Subspecialty Fellows

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) requires training in quality improvement (QI) yet many programs struggle to incorporate appropriate content. Small fellowship programs may find it particularly difficult, limited by a lack of well-trained faculty. We report on the feasibility and effectiveness of a consolidated curriculum for subspecialty fellowship programs.

METHODS

Two QI experts were identified to design a curriculum. Interactive didactic sessions were created to guide development and implementation of fellow QI projects. All projects culminated in abstract/poster presentation.

RESULTS

Seven of 10 eligible fellowships participated. Twenty-four projects were completed with 70% reaching improvement in process measures. Trainees improved confidence in 11 of 12 QI domains. Program directors stated enhancement in QI education with 100% recommending program continuation.

CONCLUSIONS

Consolidating teaching efforts with existing QI experts can lead to an effective QI curriculum for fellowship programs. This model can be expanded to other graduate medical education trainees as a means to increase QI proficiency.

Expanding Training in Quality Improvement and Patient Safety Through a Multispecialty Graduate Medical Education Curriculum Designed for Fellows

INTRODUCTION

Although the Accreditation Council for Graduate Medical Education requires quality improvement and patient safety (QIPS) training for fellow-level trainees, this experience is often insufficient due to lack of faculty time and expertise within fellowship training programs. We developed a centralized GME curriculum targeted to an integrated, multispecialty audience of fellow-level trainees with the goal of promoting leadership and scholarship in QIPS.

METHODS

The University of Colorado implemented the Fellows' Quality and Safety Academy, a three-seminar curriculum in patient safety and health systems improvement. As most participants had prior training in QIPS during medical school or residency, educational strategies emphasized application of QIPS concepts through focused didactic content review paired with small-group case-based exercises and coaching of experiential project work to promote content mastery as well as practice of leadership and scholarship strategies.

RESULTS

Since the curriculum's inception in 2017, there have been 106 participants in the Foundations in Patient Safety seminar, 49 participants in the Adverse Events Into Quality Improvement seminar, and 48 participants in the Quality in Academics seminar. These participants represented 44 separate fellowship disciplines from both adult and pediatric subspecialties. Learners reported improved attitudes and confidence and demonstrated objective knowledge acquisition across QIPS content domains.

DISCUSSION

Our pedagogical approach of centralizing QIPS training and harnessing faculty expertise to teach fellow-level trainees across specialties through interdisciplinary collaboration and interactive project-based work is an effective strategy to promote development of QIPS competencies during fellowship training.

Educational Strategies for Training in Quality Improvement and Implementation Medicine

Education in quality improvement (QI) is endorsed by the Association of American Medical Colleges across the spectrum of undergraduate, graduate, and postgraduate training. QI training is also a required component of graduate medical training per the American College of Graduate Medical Education. Despite widespread recognition of the importance of QI education and high levels of trainee involvement in QI as reported by pulmonary and critical care fellowship program directors, significant barriers to the implementation of effective and meaningful QI education during training exist. This creates an opportunity for the promotion of successfully implemented QI programs. Research demonstrates that successful QI educational programs involve the teaching of key QI concepts, participation in QI projects, protected time for QI project development, and institutional support. Using QI models such as the Plan-Do-Study-Act cycle and the Standards for Quality Improvement Reporting Excellence framework for reporting new knowledge about healthcare improvements also enhances both the educational value of the QI project and prospects for wider scholarly dissemination. In this perspective article, three examples of QI projects are discussed that serve to illustrate effective strategies of QI implementation.

Faculty-Resident "Co-learning": A Longitudinal Exploration of an Innovative Model for Faculty Development in Quality Improvement

PURPOSE

To examine the effectiveness of co-learning, wherein faculty and trainees learn together, as a novel approach for building quality improvement (QI) faculty capacity.

METHOD

From July 2012 through September 2015, the authors conducted 30 semistructured interviews with 23 faculty participants from the Co-Learning QI Curriculum of the Department of Medicine, Faculty of Medicine, University of Toronto, and collected descriptive data on faculty participation and resident evaluations of teaching effectiveness. Interviewees were from 13 subspecialty residency programs at their institution.

RESULTS

Of the 56 faculty participants, the Co-Learning QI Curriculum trained 29 faculty mentors, 14 of whom taught formally. Faculty leads with an academic QI role, many of whom had prior QI training, reinforced their QI knowledge while also developing QI mentorship and teaching skills. Co-learning elements that contributed to QI teaching skills development included seeing first how the QI content is taught, learning through project mentorship, building experience longitudinally over time, a graded transition toward independent teaching, and a supportive program lead. Faculty with limited QI experience reported improved QI knowledge, skills, and project facilitation but were ambivalent about assuming a teacher role. Unplanned outcomes for both groups included QI teaching outside of the curriculum, applying QI principles to other work, networking, and strengthening one's QI professional role.

CONCLUSIONS

The Co-Learning QI Curriculum was effective in improving faculty QI knowledge and skills and increased faculty capacity to teach and mentor QI. Findings suggest that a combination of curriculum and contextual factors were critical to realizing the curriculum's full potential.

Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review

The Accreditation Council for Graduate Medical Education requires that trainees show progressive milestone attainment in the practice-based learning and systems-based practice competencies. As part of the Clinical Learning Environment Review, sponsoring hospitals must educate trainees in health care quality improvement, provide them with specialty-specific quality data, and ensure trainee participation in quality improvement activities and committees. Subspecialty-specific quality improvement curricula in nephrology training programs have not been reported, although considerable curricular and assessment material exists for specialty residencies, including tools for assessing trainee and faculty competence. Nephrology-specific didactic material exists to assist nephrology fellows and faculty mentors in designing and implementing quality improvement projects. Nephrology is notable among internal medicine subspecialties for the emphasis placed on adherence to quality thresholds-specifically for chronic RRT shown by the Centers for Medicare and Medicaid Services Quality Incentive Program. We have developed a nephrology-specific curriculum that meets Accreditation Council for Graduate Medical Education and Clinical Learning Environment Review requirements, acknowledges regulatory quality improvement requirements, integrates with ongoing divisional quality improvement activities, and has improved clinical care and the training program. In addition to didactic training in quality improvement, we track trainee compliance with Kidney Disease Improving Global Outcomes CKD and ESRD quality indicators (emphasizing Quality Improvement Program indicators), and fellows collaborate on a yearly multidisciplinary quality improvement project. Over the past 6 years, each fellowship class has, on the basis of a successful quality improvement project, shown milestone achievement in Systems-Based Practice and Practice-Based Learning. Fellow quality improvement projects have improved nephrology clinical care within the institution and introduced new educational and assessment tools to the training program. All have been opportunities for quality improvement scholarship. The curriculum prepares fellows to apply quality improvement principals in independent clinical practice-while showing milestone advancement and divisional compliance with Clinical Learning Environment Review requirements.

Synergy, Salary, and Satisfaction: Benefits of Training in Critical Care Medicine and Infectious Diseases Gleaned From a National Pilot Survey of Dually Trained Physicians

BACKGROUND

An increasing number of physicians are seeking dual training in critical care medicine (CCM) and infectious diseases (ID). Understanding experiences and perceptions of CCM-ID physicians could inform career choices and programmatic innovation.

METHODS

All physicians trained and/or certified in both CCM and ID to date in the United States were sent a Web-based questionnaire in 2015. Responses enabled a cross-sectional analysis of physician demographics and training and practice characteristics and satisfaction.

RESULTS

Of 202 CCM-ID physicians, 196 were alive and reachable. The response rate was 79%. Forty-six percent trained and 34% practice in the northeastern United States. Only 40% received dual training at the same institution. Eighty-three percent identified as either an intensivist with ID expertise (44%) or as equally an intensivist and ID physician (38%). Median salary was $265 000 (interquartile range [IQR], $215 000-$350 000). Practice settings were split between academic (45%) and community settings (42%). Two-thirds are clinicians but 62% conduct some research and 26% practice outpatient ID. Top reasons to dually specialize included clinical synergy (70%), procedural activity (50%), and less interest in pulmonology (49%). Although 38% cited less proficiency with bronchoscopy as a disadvantage, 87% seldom need pulmonary consultation in the intensive care unit. Median career satisfaction was 4 (IQR, 4-5) out of 5, and 76% would dually train again.

CONCLUSIONS

CCM-ID graduates prefer the acute care setting, predominantly CCM or a combination of CCM and ID. They find combination training and practice to be synergistic and satisfying, but most have had to seek CCM and ID training independently at separate institutions. Given these findings, avenues for combined training in CCM-ID should be considered.