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

Abstract

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 beforeafter 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.

Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals

“…Presentations on change management and leadership48 and provision of guidelines on office organisation14 helped improve nutrition care. Collaboration between education and care delivery leaders helped remove structural and systemic barriers 30. These created working environments that were conducive to the delivery of nutrition care.…”

Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning

“…The qualitative portion highlights that teamwork, autonomy in selecting an area for improvement,5 and access to program supports6 7 were key factors that underpinned student learning throughout the program. Although this was an education-focused curriculum, a common theme that emerged in the analysis of the interviews were that medical students were already making the connection to QI in the clinical environment and wanted to further their QI training through clinical applications that lead to real-world improvements.…”

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents

“…The ''learning while doing'' QI experience was well accepted by residents and nursing staff working in collaborative teams. This is an important educational model 1,3,4,7 because relying on ''protected time'' for QI dissociates care delivery from the improvement of care. The curriculum described here allows ''the resident''-not the individual resident, but the figurative ''resident''-to be a valuable member of QI efforts while on service (provided as online supplemental material).…”

“…[1][2][3][4] The new accreditation system builds on the 6 competencies by requiring sponsoring institutions to provide opportunities for resident engagement in QI and patient safety, as a required element of the common standards and a key component of the Clinical Learning Environment Review program. 5,6 Ideally, QI should be part of the usual workflow, allowing physicians to care for individual patients and improve the system of care delivery simultaneously.…”

“…5,6 Ideally, QI should be part of the usual workflow, allowing physicians to care for individual patients and improve the system of care delivery simultaneously. 7 The clinical microsystem and the exemplary care and learning site are 2 models to operationalize this integration. A microsystem is defined as a small group of individuals (health care professionals, patients, and families) who work together in a particular setting to deliver care for a defined population of patients.…”