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Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review. Ann Surg 2021; 274:e489-e506. [PMID: 34784666 DOI: 10.1097/sla.0000000000004751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Brown A, Lafreniere K, Freedman D, Nidumolu A, Mancuso M, Hecker K, Kassam A. A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts? BMJ Qual Saf 2020; 30:337-352. [PMID: 33023936 DOI: 10.1136/bmjqs-2020-010887] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 08/11/2020] [Accepted: 08/29/2020] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Allison Brown
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada .,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kyle Lafreniere
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - David Freedman
- Department of Psychiatry, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Aditya Nidumolu
- Department of Psychiatry, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Matthew Mancuso
- Undergraduate Medical Education, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Kent Hecker
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aliya Kassam
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Postgraduate Medical Education, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Sudan R, Olivere LA, Nussbaum MS, Dunnington GL. The business of educating the next generation of surgeons. Am J Surg 2018; 217:205-208. [PMID: 30249336 DOI: 10.1016/j.amjsurg.2018.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/28/2018] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
Surgical education community needs to be informed about how education is funded and how it is threatened. In order to explore these issues the Association of Surgical Education convened a panel with significant experience in managing surgery departments to discuss the business of surgical education. They specifically addressed methods to recognize and reward faculty, educate residents on safety, quality and cost, and increase departmental revenue. This information is important in the current educational environment where there is an increased need for institutions to find alternate revenue streams to sustain graduate medical education. It is also important to find additional revenue streams to fund new residency slots to accommodate the greater number medical students who have been admitted to medical schools in response to meet the projected shortage of physicians.
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Affiliation(s)
- Ranjan Sudan
- Duke University Medical Center, Durham, NC, USA.
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Ramanathan R, Duane TM, Kaplan BJ, Farquhar D, Kasirajan V, Ferrada P. Using a Root Cause Analysis Curriculum for Practice-Based Learning and Improvement in General Surgery Residency. JOURNAL OF SURGICAL EDUCATION 2015; 72:e286-e293. [PMID: 26111820 DOI: 10.1016/j.jsurg.2015.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/29/2015] [Accepted: 05/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe and evaluate a root cause analysis (RCA)-based educational curriculum for quality improvement (QI) practice-based learning and implementation in general surgery residency. DESIGN A QI curriculum was designed using RCA and spaced-learning approaches to education. The program included a didactic session about the RCA methodology. Resident teams comprising multiple postgraduate years then selected a personal complication, completed an RCA, and presented the findings to the Department of Surgery. Mixed methods consisting of quantitative assessment of performance and qualitative feedback about the program were used to assess the value, strengths, and limitations of the program. SETTING Urban tertiary academic medical center. PARTICIPANTS General surgery residents, faculty, and medical students. RESULTS An RCA was completed by 4 resident teams for the following 4 adverse outcomes: postoperative neck hematoma, suboptimal massive transfusion for trauma, venous thromboembolism, and decubitus ulcer complications. Quantitative peer assessment of their performance revealed proficiency in selecting an appropriate case, defining the central problem, identifying root causes, and proposing solutions. During the qualitative feedback assessment, residents noted value of the course, with the greatest limitation being time constraints and equal participation. CONCLUSION An RCA-based curriculum can provide general surgery residents with QI exposure and training that they value. Barriers to successful implementation include time restrictions and equal participation from all involved members.
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Affiliation(s)
- Rajesh Ramanathan
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Therese M Duane
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Brian J Kaplan
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Doris Farquhar
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Vigneshwar Kasirajan
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia.
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McCormick ME, Stadler ME, Shah RK. Embedding Quality and Safety in Otolaryngology–Head and Neck Surgery Education. Otolaryngol Head Neck Surg 2014; 152:778-82. [DOI: 10.1177/0194599814561601] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/06/2014] [Indexed: 11/17/2022]
Abstract
Education in patient safety (PS) and quality improvement (QI) helps both medical students and residents understand the health care environment in the United States, where these concepts are now incorporated into virtually every aspect of patient care. The Accreditation Council of Graduate Medical Education has made PS/QI a mandatory component of resident education, and a number of specialties have published their experiences with incorporating PS/QI into their training programs. In otolaryngology–head and neck surgery, a strong curriculum can be built by teaching residents about the principles of PS/QI through both didactic and experiential learning, and morbidity and mortality and QI conferences can serve as the cornerstone of this curriculum. Understanding the potential challenges in PS/QI education can allow training programs to plan their strategy effectively for successful incorporation into their existing curricula.
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Affiliation(s)
- Michael E. McCormick
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael E. Stadler
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rahul K. Shah
- Division of Pediatric Otolaryngology, Children’s National Medical Center, George Washington University, Washington, DC, USA
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Medbery RL, Sellers MM, Ko CY, Kelz RR. The unmet need for a national surgical quality improvement curriculum: a systematic review. JOURNAL OF SURGICAL EDUCATION 2014; 71:613-631. [PMID: 24813341 DOI: 10.1016/j.jsurg.2013.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/15/2013] [Accepted: 12/19/2013] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The Accreditation Council for Graduate Medical Education Next Accreditation System will require general surgery training programs to demonstrate outstanding clinical outcomes and education in quality improvement (QI). The American College of Surgeons-National Surgical Quality Improvement Project Quality In-Training Initiative reports the results of a systematic review of the literature investigating the availability of a QI curriculum. METHODS Using defined search terms, a systematic review was conducted in Embase, PubMed, and Google Scholar (January 2000-March 2013) to identify a surgical QI curriculum. Bibliographies from selected articles and other relevant materials were also hand searched. Curriculum was defined as an organized program of learning complete with content, instruction, and assessment for use in general surgical residency programs. Two independent observers graded surgical articles on quality of curriculum presented. RESULTS Overall, 50 of 1155 references had information regarding QI in graduate medical education. Most (n = 24, 48%) described QI education efforts in nonsurgical fields. A total of 31 curricular blueprints were identified; 6 (19.4%) were specific to surgery. Targeted learners were most often post graduate year-2 residents (29.0%); only 6 curricula (19.4%) outlined a course for all residents within their respective programs. Plan, Do, Study, Act (n = 10, 32.3%), and Root Cause Analysis (n = 5, 16.1%) were the most common QI content presented, the majority of instruction was via lecture/didactics (n = 26, 83.9%), and only 7 (22.6%) curricula used validated tool kits for assessment. CONCLUSION Elements of QI curriculum for surgical education exist; however, comprehensive content is lacking. The American College of Surgeons-National Surgical Quality Improvement Project Quality In-Training Initiative will build on the high-quality components identified in our review and develop data-centered QI content to generate a comprehensive national QI curriculum for use in graduate surgical education.
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Affiliation(s)
- Rachel L Medbery
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Morgan M Sellers
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency. JOURNAL OF SURGICAL EDUCATION 2014; 71:18-20. [PMID: 24411418 DOI: 10.1016/j.jsurg.2013.09.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 09/17/2013] [Accepted: 09/21/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To outline a structured approach for general surgery resident integration into institutional quality improvement and patient safety education and development. DESIGN A strategic plan to address Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. SETTING Gundersen Lutheran Medical Foundation is an independent academic medical center graduating three categorical residents per year within an integrated multi-specialty health system serving 19 counties over 3 states. RESULTS The quality improvement and patient safety education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. CONCLUSIONS Structured education regarding and participation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data.
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Affiliation(s)
- Colette T O'Heron
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, Wisconsin
| | - Benjamin T Jarman
- Department of General & Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin.
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