Validity and Reliability of a Tool to Assess Quality Improvement Knowledge and Skills in Pediatrics Residents

A theoretical and practical approach to quality improvement education

Quality Improvement (QI) knowledge and skills are required at all levels of physician training. System improvement efforts need to include understanding of health disparities and design of interventions to reduce those disparities, thus health equity needs to be integrated into QI education. Payors, accreditation bodies and health systems' emphases on QI result in the need for QI curricula that meet the needs of diverse learners. This article presents a theoretical background and practical tools for designing, implementing, and evaluating a QI educational program across the spectrum of physician training with an emphasis on competency-based education and a goal of continuous practice improvement. Practice-based learning and improvement and systems-based practice are two core domains of competencies for readiness to practice. These competencies can be met through the health systems science framework for studying improvement in patient care and health care delivery coupled with QI science. Curricula should incorporate interactive learning of theory and principles of QI as well as mentored, experiential QI project work with multidisciplinary teams. QI projects often develop ideas and implement changes but are often inconsistent in studying intervention impacts or reaching the level of patient outcomes. Curriculum design should incorporate adult learning principles, competency based medical education, environmental and audience factors, and formats for content delivery. Key QI topics and how they fit into the clinical environment and teaching resources are provided, as well as options for faculty development. Approaches to evaluation are presented, along with tools for assessing learner's beliefs and attitudes, knowledge and application of QI principles, project evaluation, competency and curriculum evaluation. If the goal is to empower the next generation of change agents, there remains a need for development of scientific methodology and scholarly work, as well as faculty development and support by institutions.

Developing a tool to measure enactment of complex quality improvement interventions in healthcare

Quality improvement (QI) projects are common in healthcare settings and often involve interdisciplinary teams working together towards a common goal. Many interventions and programmes have been introduced through research to convey QI skills and knowledge to healthcare workers, however, a few studies have attempted to differentiate between what individuals 'learn' or 'know' versus their capacity to apply their learnings in complex healthcare settings. Understanding and differentiating between delivery, receipt, and enactment of QI skills and knowledge is important because while enactment alone does not guarantee desired QI outcomes, it might be reasonably assumed that 'better enactment' is likely to lead to better outcomes. This paper describes the development, application and validation of a tool to measure enactment of core QI skills and knowledge of a complex QI intervention in a healthcare setting. Based on the Institute for Healthcare Improvement's Model for Improvement, existing QI assessment tools, literature on enactment fidelity and our research protocols, 10 indicators related to core QI skills and knowledge were determined. Definitions and assessment criteria were tested and refined in five iterative cycles. Qualitative data from four QI teams in long-term care homes were used to test and validate the tool. The final measurement tool contains 10 QI indicators and a five-point scale. Inter-rater reliability ranged from good to excellent. Usability and acceptability among raters were considered high. This measurement tool assists in identifying strengths and weaknesses of a QI team and allows for targeted feedback on core QI components. The indicators developed in our tool and the approach to tool development may be useful in other health related contexts where similar data are collected.

A Scoring Rubric for the Knowledge Section of the Systems Quality Improvement Training and Assessment Tool

INTRODUCTION

Quality improvement (QI) competencies for health professions trainees were developed to address health care quality. Strategies to integrate QI into curricula exist, but methods for assessing interdisciplinary learners' competency are less developed. We refined the Knowledge section scoring rubric of the Systems Quality Improvement Training and Assessment Tool (SQI TAT) and examined its validity evidence.

METHODS

In 2017, the SQI TAT Knowledge section was expanded to cover seven core QI concepts, and the scoring rubric was refined. Three coders independently scored 35 SQI TAT Knowledge sections (18 pretests, 17 posttests). Interrater reliability was assessed by percent agreement and Cohen's kappa for individual variables and by Lin's concordance correlation for total scores for knowledge and application. Concurrent validity was assessed by comparing responses from two groups with different QI exposure and evaluating whether differences in exposure were measured.

RESULTS

Total-score interrater reliability average measures of concordance were .89 for all coders and >.70 for six of seven concept scores. The total score discriminated the two groups (p <. 05), and five of seven concept scores were higher for the group with more QI experience. Total scores were significantly higher posttest than pretest (p < .001), with improvement in posttest knowledge scores.

DISCUSSION

The SQI TAT Knowledge section provides a comprehensive assessment of QI knowledge. The scoring rubric was able to discriminate QI knowledge along a continuum. The SQI TAT Knowledge section is not linked to a clinical context, making it useful for assessing interprofessional learners and varying education levels.

Baseline Quality Improvement Capacity of 33 Endocrinology Centers Participating in the T1D Exchange Quality Improvement Collaborative

This article describes the evolution of the Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) and provides insight into the development and growth of a successful type 1 diabetes quality improvement (QI) program. Since its inception 8 years ago, the collaborative has expanded to include centers across the United States with varying levels of QI experience, while simultaneously achieving many tangible improvements in type 1 diabetes care. These successes underscore the importance of learning health systems, data-sharing, benchmarking, and peer collaboration as drivers for continuous QI. Future efforts will include recruiting additional small- to medium-sized centers focused on adult care and underserved communities to further the goal of improving care and outcomes for all people living with type 1 diabetes.

Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents.

BACKGROUND

There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery.

METHODS

We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully.

RESULTS

There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting.

CONCLUSIONS

The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.

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.

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.