Teaching Quality Improvement in a Primary Care Residency

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.

A Longitudinal Ambulatory Quality Improvement Curriculum That Aligns Resident Education With Patient Outcomes: A 3-Year Experience

Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration-based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre-post survey assessed residents' confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly (P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.

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.

Review of Cognitive Biases in ACGME Milestones Training Assessments in Post-graduate Medical Education Programs

The course of study for young physicians for post-graduate training is an exciting and life-changing opportunity, one that is filled with the relentless optimism of intellectual discovery and personal growth and development. The American Council for Graduate Medical Education (ACGME) is a non-profit private council that evaluates and accredits internship, residency, and fellowship programs. The role of the ACGME is to oversee curriculums, training environments, and specialty evaluation standards to ensure satisfactory competency leading to board eligibility and certification in the respected field of study. The ACGME has the monumental task of guiding educational standards that are designed to both protect the public welfare and further educational programs. Many educational standards are objective, such as quantitative performance on examinations, involvement in research, and involvement in systems development and quality improvement. However, key clinical performance measures are based on prior training and experience. Over the last several years, studies examining rates of abuse and discrimination during post-graduate medical training in both the United States and Canadian studies, which have reported alarmingly high rates of 50%. With the increasing utility and availability of social media, such issues have become more transparent to the public. A plethora of studies has been conducted, examining physician biases towards patients, practice changes, insurance company regulations, and evolving healthcare systems. However, a significant amount of evaluation is merited when examining individual institutional cultures and the educational environments that harbor them. We wish to examine the role of ever-evolving specialty-specific ACGME-instituted educational milestones in Internal Medicine and Opthalmology in the context of potential cognitive biases and their implementation within post-graduate training programs.

Pediatrics Residents' Confidence and Performance Following a Longitudinal Quality Improvement Curriculum

BACKGROUND

Quality improvement (QI) training is an integral part of residents' education. Understanding the educational value of a QI curriculum facilitates understanding of its impact.

OBJECTIVE

The purpose of this study was to evaluate the effects of a longitudinal QI curriculum on pediatrics residents' confidence and competence in the acquisition and application of QI knowledge and skills.

METHODS

Three successive cohorts of pediatrics residents (N = 36) participated in a longitudinal curriculum designed to increase resident confidence in QI knowledge and skills. Key components were a succession of progressive experiential projects, QI coaching, and resident team membership culminating in leadership of the project. Residents completed precurricular and postcurricular surveys and demonstrated QI competence by performance on the pediatric QI assessment scenario.

RESULTS

Residents participating in the Center for Advancing Pediatric Excellence QI curriculum showed significant increases in pre-post measures of confidence in QI knowledge and skills. Coaching and team leadership were ranked by resident participants as having the most educational value among curriculum components. A pediatric QI assessment scenario, which correlated with resident-perceived confidence in acquisition of QI skills but not QI knowledge, is a tool available to test pediatrics residents' QI knowledge.

CONCLUSIONS

A 3-year longitudinal, multimodal, experiential QI curriculum increased pediatrics residents' confidence in QI knowledge and skills, was feasible with faculty support, and was well-accepted by residents.

Republished: Key characteristics of successful quality improvement curricula in physician education: a realist review

PURPOSE

Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI.

METHOD

Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality.

RESULTS

Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty.

CONCLUSIONS

This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Meeting Resident Scholarly Activity Requirements Through a Longitudinal Quality Improvement Curriculum

BACKGROUND

Quality improvement (QI) skills are learned during residency, yet there are few reports of the scholarly activity outcomes of a QI curriculum in a primary care program.

INTERVENTION

We examined whether scholarly activity can result from a longitudinal, experiential QI curriculum that involves residents, clinic staff, and faculty.

METHODS

The University of Pittsburgh Medical Center Shadyside Family Medicine Residency implemented a required longitudinal outpatient practice improvement rotation (LOPIR) curriculum in 2005. The rotation format includes weekly multidisciplinary work group meetings alternating with resident presentations delivered to the entire program. Residents present the results of a literature review and provide 2 interim project updates to the residency. A completed individual project is required for residency graduation, with project results presented at Residency Research Day. Scholarly activity outcomes of the curriculum were analyzed using descriptive statistics.

RESULTS

As of 2014, 60 residents completed 3 years of the LOPIR curriculum. All residents satisfied the 2014 Accreditation Council for Graduate Medical Education (ACGME) scholarly activity and QI requirements with a literature review presentation in postgraduate year 2, and the presentation of a completed QI project at Residency Research Day. Residents have delivered 83 local presentations, 13 state/regional presentations, and 2 national presentations. Residents received 7 awards for QI posters, as well as 3 grants totaling $21,639. The educational program required no additional curriculum time, few resources, and was acceptable to residents, faculty, and staff.

CONCLUSIONS

LOPIR is an effective way to meet and exceed the 2014 ACGME scholarly activity requirements for family medicine residents.

Connecting resident education to patient outcomes: the evolution of a quality improvement curriculum in an internal medicine residency

As part of the Accreditation Council for Graduate Medical Education's Next Accreditation System, residency programs must connect resident-physician education to improved patient care outcomes. Residency training programs, however, face multiple obstacles in doing so. Results from residency quality improvement (QI) curricula tend to show improvement in simple process-based measures but not in more complex outcomes of care such as diabetes or blood pressure control. In this article, the authors describe the evolution of their QI educational program for internal medicine residents at the University of Cincinnati Medical Center within the structure of a novel training model called the Ambulatory Long Block. They discuss a resident-run project that led to reduced rates of patients with uncontrolled diabetes as an example of improvement in outcome measures. Despite favorable results from that particular resident group, the successful intervention did not spread practice-wide. Using this example, they detail the phases of evolution and lessons learned from their curriculum from 2006 to 2014 within a framework of previously published general principles for successful QI education, including those of exemplary care and learning sites. Successful programs require leadership, faculty expertise and mentorship, data management, learner buy-in, and patient engagement. Their experience will hopefully be of help to others as they attempt to simultaneously improve care and education. Further research and innovation are needed in this area, including optimizing strategies for strengthening resident-driven projects through partnership with nursing, allied health, and longitudinally engaged faculty members.

The unmet need for a national surgical quality improvement curriculum: a systematic review

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.

Performance improvement: getting an early start

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the Surgical Care Improvement Program (SCIP) can be utilized to develop quality initiatives to improve surgical care. Understanding the fundamentals of quality measures provides insight to the six Accreditation Council on Graduate Medical Education (ACGME) competencies. Resident education needs a robust exposure to quality measures, such as NSQIP and SCIP to prepare surgeons for tomorrow's healthcare system.

METHODS

The resident champion (RC) position is a dedicated research year between the PGY-2 and PGY-3 as a way to introduce residents to NSQIP and the importance of quality improvement. The resident partners with the NSQIP clinical reviewer to analyze data, develop quality improvement projects, implement these initiatives, and re-examine quality performance.

RESULTS

Over the last 24 months, there have been numerous performance improvement initiatives and projects implemented at our facility as a direct result of the RC's efforts and their participation within the performance improvement committees. In addition, the projects led to multiple presentations at national conferences.

CONCLUSIONS

A dedicated year in performance improvement has benefited our residents with a working knowledge of quality measures and our institution with multiple projects that have yielded significant improvements in the quality of patient care.