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

Education Research: Sustained Implementation of Quality Improvement Practices Is Observed in Early Career Physicians Following a Neurology Resident QI Curriculum

Background and Objectives

The Accreditation Council for Graduate Medical Education and American Board of Psychiatry and Neurology expect engagement in quality improvement (QI) activities for all residents and practicing neurologists. Our neurology residency program instituted an experiential Neurology Residency QI Curriculum in 2015 for all residents. In this study, we aimed to characterize the role of QI engagement in the early-career paths of program graduates.

Methods

We distributed an online survey evaluating QI training, scholarship, and leadership (before, during, and after residency training) to all individuals who graduated from our residency program (graduation years 2017-2021). Primary outcomes were QI project leadership or mentorship and QI scholarship (projects, posters, and publications) after residency. Predictors of these outcomes were also evaluated using Fisher exact test.

Results

Twenty-nine of 50 graduates (58%) completed the survey. Median time from residency graduation was 3 years. Of the respondents, 14% actively participated in a QI project before residency, 83% during residency, and 48% after graduating. In addition, 41% had led or mentored a QI project and 34% had performed QI scholarship since residency. Fourteen percent of participants held formal roles in QI or patient safety, while 24% received formal full-time equivalents for QI work. Significant predictors (p < 0.05) of QI leadership included older age, time since graduation, rank, and participation in Clinical Effectiveness Leadership Training (CELT-an institutional QI faculty development course). Significant predictors (p < 0.05) of QI scholarship included older age, time since graduation, participation in CELT, and participation in QI scholarship during residency. QI training, participation, and/or project leadership before residency did not predict either QI leadership or scholarship after residency.

Discussion

Many neurology residency graduates continued to lead QI projects and produce QI scholarship in the early years after graduation. However, receiving protected time for leadership and academic work in this area is uncommon. Our findings suggest that more infrastructure, including training, career development, and mentorship, can foster neurologists interested in leading in quality and patient safety. In academic models, promotion pathways that support academic advancement for faculty leading in QI are needed.

Improving inpatient hyperglycaemia in non-critically ill adults in resident wards through audit and feedback

Inpatient hyperglycaemia is associated with an increase in morbidity and mortality, number of rehospitalisations and length of hospitalisation. Although the advantages of proper glycaemic control in hospitalised patients with diabetes are well established, a variety of barriers limit accomplishment of blood glucose targets. Our primary aim was to decrease the number of glucose values above 180 mg/dL in non-critical care hospitalised patients using an audit and feedback intervention with pharmacy and internal medicine residents. A resident-led multidisciplinary team implemented the quality improvement (QI) project including conception, literature review, educating residents, iterative development of audit and feedback tools and data analysis. The multidisciplinary team met every 5 weeks and undertook three 'plan-do-study-act' cycles over an 8-month intervention period (August 2022 to March 2023) to educate residents on inpatient hyperglycaemia management, develop and implement an audit and feedback process and assess areas for improvement. We performed 1045 audits analysing 16 095 accu-checks on 395 non-duplicated patients. Most audits showed compliance with guidelines. The monthly run-on chart shows per cent of glucose values above 180 mg/dL in our non-ICU hospitalised patients and an overall pre-to-post comparison of 25.1%-23.0% (p value<0.05). The intervention was well accepted by residents evidenced by survey results. We did not meet our primary aim to reduce hyperglycaemia by 30% and this combined with the audits showing mostly compliance with guidelines suggests that prescribing behaviour was not a key driver of inpatient hyperglycaemia in our population. This internal medicine resident and pharmacy interprofessional collaboration with audit and feedback for inpatient hyperglycaemia was feasible, well accepted and had a statistically significant yet small improvement in inpatient hyperglycaemia. The project may be helpful to others wishing to explore inpatient hyperglycaemia, interprofessional QI with pharmacists, resident-led QI and audit and feedback.

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.

The Implementation of X + Y Scheduling in Combined Internal Medicine-Pediatrics Residency Programs: Practical Considerations for Program Leadership

The X + Y scheduling approach, or block scheduling, is common among internal medicine residency programs. With the beginning of a pilot program through the American College of Graduate Medical Education in 2018, pediatrics and internal medicine-pediatrics (Med-Peds) residency programs have been able to adopt X + Y scheduling as well. The X + Y scheduling approach presents unique challenges and opportunities for combined Med-Peds residencies. This paper describes an early experience with X + Y scheduling in Med-Peds residencies and describes practical considerations for Med-Peds programs considering or planning a transition to the X + Y schedule. These considerations include strategies for gaining stakeholder support; selecting the appropriate block structure; opportunities for designing the ambulatory curriculum; and maximizing the clinical benefit in the residency continuity clinic.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Practical strategies to enhance resident engagement in clinical quality improvement

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality improvement education innovation: evaluation of Coursera MOOC 'Take the Lead on Healthcare Quality Improvement'

BACKGROUND

Massive open online courses have the potential to enable dissemination of essential components of quality improvement learning. Subsequent to conducting the massive open online course 'Take the Lead on Healthcare Quality Improvement', this paper is a report of the evaluation of the course's effectiveness in increasing healthcare professionals' quality improvement knowledge, attitudes, self-efficacy and systems thinking.

METHODS

Using the Kirkpatrick model for evaluation, a pretest-posttest design was employed to measure quality improvement knowledge, attitude, self-efficacy and systems thinking. Interprofessional learners across the globe enrolled in the 5-week online course that consisted of 10 modules (short theory bursts, assignments and assessments). The objective of the course was to facilitate learners' completion of a personal or clinical project. Of the 5751 learners enrolled, 1415 completed the demographic survey, and 88 completed all the surveys, assignments and assessments. This paper focuses on the 88 who completed the course.

RESULTS

There was a significant 14% increase in knowledge, a 3.5% increase in positive attitude, a 3.9% increase in systems thinking and a 21% increase in self-efficacy. Learners were very satisfied with the course (8.9/10).

CONCLUSIONS

Learners who completed the course 'Take the Lead on Healthcare Quality Improvement' had significant gains in learner outcomes: quality improvement knowledge, attitude, self-efficacy and systems thinking supporting this course format's efficacy in improving key components of students' quality improvement capabilities.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Re-thinking How We Teach Quality Improvement: Adding Meaning to an ACGME Requirement

BACKGROUND

Many residency programs have struggled to meaningfully meet the ACGME quality improvement (QI) requirements. Similarly, our residents were receiving limited QI education, and their longitudinal projects were ineffective.

AIM

Create an integrated didactic and experiential learning environment that equips residents to become leaders of QI.

SETTING AND PARTICIPANTS

Internal medicine (IM) residency program of 45 residents in a large community hospital.

PROGRAM DESCRIPTION

This curriculum included eight content areas. Games, real-life application, and project celebrations cultivated engagement. Sessions occurred during residents' 2-week outpatient rotations. Project development was standardized.

PROGRAM EVALUATION

The QI Knowledge Application Tool-Revised (QIKAT-R) and separate surveys were used before and after the curriculum's implementation to evaluate resident QI knowledge and confidence, respectively. We also tracked QI scholarship and faculty engagement. Mean QIKAT-R scores improved significantly from 7.0 (SD 2.9) at baseline to 16.6 (SD 4.7) post-curriculum (n = 37 pairs, p = 0.043). Residents' adverse event reporting increased from 44% (19/43) at baseline to 90% (28/31) post-curriculum. Seven presentations were accepted for local, regional, and national conferences, compared with one presentation the preceding year.

DISCUSSION

A QI curriculum can be successfully integrated in a "4 + 2" program.

Delivering the AAMC "Teaching for Quality" Program through a Community-Based GME Collaborative: Lessons Learned to Date

CONTEXT

To address scholarly activity (SA) accreditation standards, the Michigan State University's College of Osteopathic Medicine Statewide Campus System has offered the Association of American Medical Colleges' (AAMC) Teaching for Quality Program for two cohorts of community-based faculty. The purpose of this paper was to describe the design and delivery of the customized program, the authors' initial lessons learned, and their plans for further evaluation and dissemination.

METHODS

The authors customized the program to overcome the barriers typically faced by community-based program faculty learners through a graduate medical education (GME) consortium model. This was the first time this program was delivered in this manner.

RESULTS

The authors' initial cohort of 19 learners successfully developed 15 projects, with two pairs of learners collaborating on projects. The second cohort of 15 learners developed 11 projects, with one pair of learners collaborating. The authors present a series of principles for community-based GME leaders striving to develop SA projects in their respective GME environments.

CONCLUSIONS

The "consortium advantage" derived from entities such as the SCS may prove integral to efficiently coordinating SA project resources and knowledge across diverse GME systems.