HiQuiPs: Engaging Residents in QIPS – Current and Future Perspectives
Authors: Mankeeran Dhanoa, Fadi Bahodi, Taryn Lloyd, Justin Hall
Welcome to this HiQuiPs post on Quality Improvement in Residency Education where we will review the current status of Quality Improvement and Patient Safety (QIPS) education in postgraduate medical education and strategies to effectively engage trainees in QIPS.
CanMEDS and QIPS
In 2015, the updated CanMEDs framework broadend accreditation standards for residency programs across Canada.(1) As part of the CanMEDS roles, competencies in QIPS methodologies have been highlighted in each of the six domains and residency programs are required to integrate QIPS training into their curricula. Globally, incorporating QIPS competencies into residency training has been emphasized within the Accreditation Council for Graduate Medical Education (ACGME) and the General Medicine Council in the United Kingdom.(2,3)
Why is this Important?
Residency education is an important stakeholder in the QIPS realm for two reasons. First, residents are often the first point of contact for patient admissions, transfers, discharges, and handovers where safety issues are prone to occur (4). Second, residents are potential agents for change that will carry forward QIPS-focused practices into their careers.(4,5)
A 2020 national survey of both Royal College and Family Medicine (FM-EM) stream Emergency Medicine residents across Canada illustrated that while trainees reported a strong interest in QIPS curricula, only a third of Royal College and FM-EM programs incorporate formal QIPS teaching into their programs.(6) Specific barriers to QIPS engagement reported by residents included confusion regarding how QIPS could be practically translated into their clinical work and accessibility to opportunities and faculty with QIPS expertise.(6) These findings were consistent with surveys conducted in the United Kingdom and the United States, which also demonstrated that participation in a formalized curriculum enhances resident interest in participating in QIPS initiatives.(7-10) From a program standpoint, faculty surveys have identified barriers to QIPS curricula implementation that include limited access to faculty with QIPS expertise and resources to sustain a formal curriculum in the long-term.(11-14)
Which Way is the Best Way?
Currently, there is no consensus. QIPS curricula have included didactic lectures, web-based modules, individual projects, and case scenarios with reflective components.(15) At present, there are no studies that illustrate a direct comparison between methods of QIPS curriculum delivery.(15)
What can educators do? A couple review articles have shed some light on this topic.(15,16) When facilitating a QIPS curricula in the context of postgraduate education, there are some key considerations to keep in mind:
1. Facilitate Lifelong Learning
Within Competence by Design (CBD), residency training is no longer viewed as a finite period of time, but a series of transitions. The majority of QIPS curricula have focused on short-term evaluations, which limits trainees from revisiting and continuing to build QIPS competencies as they move towards transitioning to practice.(15) Potential solutions to this issue have included implementing a QIPS curriculum through longitudinal outpatient clinics or inpatient blocks that trainees return to throughout their residency.(17-20) Through these placements, residents form interprofessional teams that participate in the evaluation and reporting of various programs and outcome measures. The overall response from trainees has been positive, and residents reported an enhanced interest in QIPS participation.(17-20) Given that residents struggle to practically link QIPS teaching to their clinical work environments, longitudinal curricula may foster better engagement and practical experience in QIPS leadership.
2. Shape the Experience: Immersive Learning
Linking residents with QIPS and clinical work requires experiential learning. In order to be effective, experiential learning within a QIPS curriculum should be framed in educational theory.(15-21) A strong example is Kolb’s Experiential Learning Theory, which has been cited as a framework for best practices in experiential education.(15,22) Through Kolb’s theory, an experiential curriculum proceeds through a series of stages that starts with an introductory experience. This could be in the form of a simulation, role-play scenario, longitudinal rotation, or case-based project.(15,22) From this experience, learners take part in active reflection, discussion, and reinforcement of key concepts to apply to their future environments (Figure 1). (15,22) It has been suggested that providing residents with hands-on experience could provide a more engaging, effective modality of QIPS training in comparison to didactic teaching.(15,16)
3. Evaluate: Use the QI-KAT
In keeping with the myriad of QIPS curricula, there is wide variation in assessment methods. Many curricula have adopted resident evaluations that utilize a Kirkpatrick framework, which seeks to evaluate learner reactions, satisfaction, knowledge acquisition, and behavioural changes.(15,23) The challenge with this approach is that when used alone, the depth of the Kirkpatrick evaluation (i.e., individual-level changes vs. organizational changes) and question styles across survey questions have varied.(15,24,25) The use of an objective, validated assessment tool such as the Quality Improvement Knowledge Application Tool (QI-KAT) could offer a more robust, uniform analysis, quantifying competency over time and across cohorts or programs.(26) QI-KAT is an open-access educational resource that provides trainees with a patient case scenario and question prompts that are graded with a rubric. Given the variation in QIPS curricula assessments, the QI-KAT has potential as an adjunct to curricula evaluations (i.e., Kirkpatrick evaluation) and future academic work in QIPS teaching.(15,26)
QIPS in residency education comes with its own set of challenges, and there is a growing need to think critically about the way QIPS education is taught. Residents have an interest in learning QIPS methodologies, and residency programs will need to adapt and implement curricula that will foster and support key competency development.
Key Take-Home Points:
Facilitate Lifelong Learning: Residents fd the opportunity to revisit QIPS opportunities at each stage of their training.
Shape the Experience: Framing QIPSxperiences within Kolb’s Experiential Learning Theory facilitates an experiential curriculum to better engage trainees.
Evaluate: Adjuncts, such as the QI-KAT, are validated tools that can be used to strengthen curriculum evaluation.
Senior Editor: Ahmed Taher
Copyedited by: Fadi Bahodi
Frank J., Snell L., Sherbino J. CanMEDS 2015 Physician Competency Framework. Ottawa, ON: Royal College of Physicians and Surgeons of Canada; 2015. Available at: https://canmeds.royalcollege.ca/en/framework.
Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements; 2017. Available at: https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf.
General Medical Council. General Professional Capabilities Framework. 2017. Available at: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/generic-professional-capabilities-framework.
Lam P., Wong B. "Harnessing the power of residents as change agents in quality improvement." Academic Medicine 96.1 (2020): 21-23.
Clemo R., Parsons A., Boggan J., et al. “Learning by Doing: Practical Strategies to Integrate Resident Education and Quality Improvement Initiatives.” J Grad Med Educ 13.5 (2021): 631-634.
Trivedi S., Hartman R., Hall J., et al. "Residents’ perspective of quality improvement and patient safety education in Canadian emergency medicine residency programs." Canadian Journal of Emergency Medicine 22.2 (2020): 224-231.
Pallari E., Khadjesari Z., Biyani C., et al. "Pilot implementation and evaluation of a national quality improvement taught curriculum for urology residents: lessons from the United Kingdom." The American Journal of Surgery 219.2 (2020): 269-277.
Butler J., Anderson K., Supiano M., et al. “‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” Academic Medicine 92.7 (2017): 984-990.
Purnell S., Wolf L., Millar M., Smith K. "A national survey of integrated vascular surgery residents' experiences with and attitudes about quality improvement during residency." Journal of Surgical Education 77.1 (2020): 158-165.
Eisenberg M., Nagler J., Moses J., Paul R., Hudgins J."Development of a longitudinal quality and safety curriculum for pediatric emergency medicine fellows." Clinical Pediatric Emergency Medicine 18.2 (2017): 130-137.
Ziemba J., Matlaga B., Tessier C. "Educational resources for resident training in quality improvement: a national survey of urology residency program directors." Urology Practice 5.5 (2018): 398-404.
Chartier L., Vaillancourt S., McGowan M., Dainty K., Cheng A. “LO093: A national needs assessment survey for the development of a quality improvement and patient safety curriculum for Canadian emergency medicine residents.” Canadian Journal of Emergency Medicine 18.S1 (2016): S62.
Mann K., Craig M., Moses J. "Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors." Academic Pediatrics 14.1 (2014): 23-28.
Wolff M., Macias C., Garcia E., Stankovic C. "Patient safety training in pediatric emergency medicine: a national survey of program directors." Academic Emergency Medicine 21.7 (2014): 835-838.
Mondoux S., Chan T., Ankel F., Sklar D. “Teaching quality improvement in emergency medicine training programs: a review of best practices.” Academic Emergency Medicine Education and Training 1.4 (2017):301-309.
Wong B., Levinson W., Shojania K. “Quality improvement in medical education: current state and future directions.” Medical Education 46.1 (2012):107-119.
Pohl S., Van Hala S., Ose D., Tingey B., Leiser J. “A longitudinal curriculum for quality improvement, leadership experience, and scholarship in a family medicine residency program.” Family Medicine 52.8 (2020):570-575.
Simasek M., Ballard S., Phelps P., et al. “Meeting resident scholarly activity requirements through a longitudinal quality improvement curriculum.” Journal of Graduate Medical Education 7.1 (2015):86-90.
Tess A., Yang JJ., Smith C., et al. “Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine.” Academic Medicine 84.3 (2009):326-334.
Tentler A., Feurdean M., Keller S., Kothari N. “Integrating a resident-driven longitudinal quality improvement curriculum within an ambulatory block schedule.” Journal of Graduate Medical Education 8.3 (2016):405-409.
Ridout S., Ridout K., Theyel B., et al. “A novel experiential quality improvement training program during residency improves quality improvement confidence and knowledge: a prospective cohort study.” Academic Psychiatry 44.3 (2020):267-271.
Kolb D., Boyatzis R., Charalampos M. "Experiential learning theory: Previous research and new directions." Perspectives on thinking, learning, and cognitive styles. In Perspectives on Thinking, Learning, and Cognitive Styles. Sternberg R., Zhang L. (editors). Routledge, 2014. 227-248.
Kirkpatrick D., Kirkpatrick J. Evaluating Training Programs”: The Four Levels. 3rd edition. San Francisco: McGraw Hill; 2006.
Wong B., Etchells E., Kuper A., Levinson W., Shojania K. “Teaching quality improvement and patient safety to trainees: a systematic review.” Academic Medicine 85.9 (2010):1425-1439.
Kirkman M., Sevdalis N., Arora S., Baker P., Vincent C., Ahmed M. “The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review.” BMJ Open 5.5 (2015):1-17.
Singh M., Ogrinc G., Cox K., et al. “The quality improvement knowledge application tool revised (QIKAT-R).” Academic Medicine 89.10 (2014):1386-1391.