An educational improvement project to track patient encounters: toward a more complete understanding of third-year medical students' experiences.

BACKGROUND: At the University of Missouri School of Medicine (MUSOM), "commitment to improving quality and safety in healthcare" is one of eight key characteristics set as goals for our graduates. As educators, we have modelled our commitment to continuous improvement in the educational experiences through the creation of a method to monitor and analyse patient encounters in the third year of medical school. This educational improvement project allowed course directors to (1) confirm adequate clinical exposure, (2) obtain prompt information on student experiences, (3) adjust individual student rotations to meet requirements and (4) ascertain the range of clinical experiences available to students. DISCUSSION: Data illustrate high levels of use and satisfaction with the educational innovation. We are in our second year using the new Patient Log (PLOG) process and are now considering expanding the use of PLOG into the fourth year of medical school.

How an educational improvement project improved the summative evaluation of medical students.

BACKGROUND: At the University of Missouri-Columbia School of Medicine (USA) "commitment to improving quality and safety in healthcare" is one of eight key characteristics set as goals for our graduates. As educators, commitment to continuous improvement in the educational experience has been modelled through improvement of the Medical Student Performance Evaluation (MSPE) letter (formerly the Dean's letter). DISCUSSION: This educational improvement project decreased waste, increased collaboration and developed locally useful knowledge. By applying continuous improvement principles to the construction of the MSPE the overall efficiency of the process could be enhanced, and the MSPE committee was able to spend less cognitive energy on structure and format and focus more on the content of the letters. Four MSPE cycles have been completed using a new Web-based system; after each cycle, additional enhancements were identified and implemented. This work adds to the literature, as it describes the application of continuous improvement principles to an educational system.

Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach.

While most newly qualified physicians are well prepared in the science base of medicine and in the skills that enable them to look after individual patients, few have the skills necessary to improve care and patient safety continuously. We apply a systems analysis from the field of human error to identify ways in which medical school education can increase the number of graduates prepared to reflect on and improve professional practice. Doing so requires a systematic approach involving entrance requirements, the curriculum, the organizational culture of training environments, student assessment, and program evaluation.

Working and learning together: good quality care depends on it, but how can we achieve it?

Educating healthcare professionals is a key issue in the provision of quality healthcare services, and interprofessional education (IPE) has been proposed as a means of meeting this challenge. Evidence that collaborative working can be essential for good clinical outcomes underpins the real need to find out how best to develop a work force that can work together effectively. We identify barriers to mounting successful IPE programmes, report on recent educational initiatives that have aimed to develop collaborative working, and discuss the lessons learned. To develop education strategies that really prepare learners to collaborate we must: agree on the goals of IPE, identify effective methods of delivery, establish what should be learned when, attend to the needs of educators and clinicians regarding their own competence in interprofessional work, and advance our knowledge by robust evaluation using both qualitative and quantitative approaches. We must ensure that our education strategies allow students to recognise, value, and engage with the difference arising from the practice of a range of health professionals. This means tackling some long held assumptions about education and identifying where it fosters norms and attitudes that interfere with collaboration or fails to engender interprofessional knowledge and skill. We need to work together to establish education strategies that enhance collaborative working along with profession specific skills to produce a highly skilled, proactive, and respectful work force focused on providing safe and effective health for patients and communities.

Continuous self-improvement: systems thinking in a personal context.

BACKGROUND: Continuous quality improvement (CQI) thinking and tools have broad applicability to improving people's lives--in continuous self-improvement (CSI). Examples include weight loss, weight gain, increasing exercise time, and improving relationship with spouse. In addition, change agents, who support and facilitate organizational efforts, can use CSI to help employees understand steps in CQI. A STEP-BY-STEP APPROACH: Team members should be involved in both the definition of the problem and the search for the solution. How do everyday processes and routines affect the habit that needs to change? What are the precursors of the event? Clients list possible solutions, prioritize them, and pilot test the items selected. One needs to change the daily routines until the desired behavior is accomplished habitually and with little external decision. DISCUSSION: CSI is successful because of its emphasis on habits embedded in personal processes. CSI organizes support from process owners, buddies, and coaches, and encourages regular measurement, multiple small improvement cycles, and public reporting.

Understanding the value added to clinical care by educational activities. Value of Education Research Group.

In an era of competition in health care delivery, those who pay for care are interested in supporting primarily those activities that add value to the clinical enterprise. The authors report on their 1998 project to develop a conceptual model for assessing the value added to clinical care by educational activities. Through interviews, nine key stakeholders in patient care identified five ways in which education might add value to clinical care: education can foster higher-quality care, improve work satisfaction of clinicians, have trainees provide direct clinical services, improve recruitment and retention of clinicians, and contribute to the future of health care. With this as a base, an expert panel of 13 clinical educators and investigators defined six perspectives from which the value of education in clinical care might be studied: the perspectives of health-care-oriented organizations, clinician-teachers, patients, education organizations, learners, and the community. The panel adapted an existing model to create the "Education Compass" to portray education's effects on clinical care, and developed a new set of definitions and research questions for each of the four major aspects of the model (clinical, functional, satisfaction, and cost). Working groups next drafted proposals to address empirically those questions, which were critiqued at a national conference on the topic of education's value in clinical care. The next step is to use the methods developed in this project to empirically assess the value added by educational activities to clinical care.

Performance of third-year primary-care-track students in an integrated curriculum at Case Western Reserve University.

In 1994, Case Western Reserve University School of Medicine established a Primary Care Track (PCT) with an integrated curriculum as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. This study compared the performance of the first cohort of students to participate in the PCT third year with that of their classmates and determined student attitudes toward their experiences. The performances of 24 PCT and 81 traditional students on the Medical School Admissions Test (MCAT) and the United States Medical Licensure Examination (USMLE) Step 1 and 2 were compared using analysis of variance. Grades on the six core clerkships were compared using chi-square analysis. Performances of the PCT students and a subset of traditional students on the generalist school's objective structured clinical exam (OSCE) were compared using multivariate analysis. The students reported their perceptions on a questionnaire. The traditional students had significantly higher scores on the physical science section of the MCAT and on the USMLE Step 1, but at the end of year three, their USMLE Step 2 scores did not differ. Grade distributions in the core clerkships did not differ, except in psychiatry, where the PCT students received honors significantly more often. The PCT students had a lower mean score on the internal medicine National Board of Medicine Examiners shelf exam but performed better on the generalist OSCE exam. A majority of PCT students reported that they would choose the integrated third year again and recommend it to others.

Using PDSA (Plan-Do-Study-Act) to establish academic-community partnerships: the Cleveland experience.

The Schools of Medicine and Nursing at Case Western Reserve University and the Program in Health Administration at Cleveland State University have created an interdisciplinary course in continuous improvement that emphasizes learning through experience, accommodates a large number of students, and has created new partnerships with Cleveland area health care organizations. An approach that respects these partners as customers and refines the relationships with serial tests of change (e.g., PDSA) has contributed significantly to this program's success.

Collaborating for improvement in health professions education.

Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Teaching medical faculty how to apply continuous quality improvement to medical education.

BACKGROUND: An eight-hour workshop was conducted at a professional meeting in 1996 to introduce medical faculty to the principles of continuous quality improvement (CQI) as they relate to change in medical education and to provide participants with opportunities to use specific tools for applications to education. Four two-hour sessions focused on an introduction to CQI, understanding and mapping processes, identifying change ideas, and testing a change for improvement. TESTING A CHANGE FOR IMPROVEMENT: The goals of the final session were to plan a pilot test of an improvement, identify the steps of the plan-do-study-act (PDSA) cycle, and consider change for improvement in the context of one's own organization. Working in small groups, participants chose a specific change one might try in the following example: improving student performance in a neuroscience course. POSTSESSION EVALUATION AND FOLLOW-UP: Immediately following the workshop sessions, participants represented by administrators in medical education and clinical and basic science teaching faculty completed evaluations on the usefulness and likelihood of their using CQI tools. One year later, of the 32 workshop registrants who were mailed surveys, 15 respondents rated their change in understanding of CQI and their use of CQI techniques. More than 60% of the respondents reported application of CQI principles at their organizations. CQI methods used most frequently included structured team meetings, prioritizing opportunities, and brainstorming. CONCLUSION: The significant application of CQI principles and methods reported by participants one year after a brief intervention supports a need and utility for CQI principles and tools in medical education.

Rapid improvement teams.

BACKGROUND: Suggestions, most of which are supported by empirical studies, are provided on how total quality management (TQM) teams can be used to bring about faster organizationwide improvements. SUGGESTIONS: Ideas are offered on how to identify the right problem, have rapid meetings, plan rapidly, collect data rapidly, and make rapid whole-system changes. Suggestions for identifying the right problem include (1) postpone benchmarking when problems are obvious, (2) define the problem in terms of customer experience so as not to blame employees nor embed a solution in the problem statement, (3) communicate with the rest of the organization from the start, (4) state the problem from different perspectives, and (5) break large problems into smaller units. Suggestions for having rapid meetings include (1) choose a nonparticipating facilitator to expedite meetings, (2) meet with each team member before the team meeting, (3) postpone evaluation of ideas, and (4) rethink conclusions of a meeting before acting on them. Suggestions for rapid planning include reducing time spent on flowcharting by focusing on the future, not the present. Suggestions for rapid data collection include (1) sample patients for surveys, (2) rely on numerical estimates by process owners, and (3) plan for rapid data collection. Suggestions for rapid organizationwide implementation include (1) change membership on cross-functional teams, (2) get outside perspectives, (3) use unfolding storyboards, and (4) go beyond self-interest to motivate lasting change in the organization. CONCLUSIONS: Additional empirical investigations of time saved as a consequence of the strategies provided are needed. If organizations solve their problems rapidly, fewer unresolved problems may remain.

Continuous improvement learning for residents.

Physicians must be ready to assume an active role in the design, implementation, and improvement of emerging models of health care delivery. Knowledge and skill in continuous improvement prepare them to engage seriously in the processes of change, on the basis of the same scientific principles they always have relied on in the use of evidence to improve outcomes. This includes include the ability to 1) identify the health needs of the individuals and communities for which they provide health services; 2) assess the impact of current practice with appropriate outcome measures; 3) discover what in the process of health care may be contributing to less than desired outcomes; 4) design and test interventions to change the process of care to improve outcomes; 5) act as an effective member of the interdisciplinary team required to complete these tasks; and 6) consider ethical principles and professional values when making decisions about change in health services delivery. Graduate medical education presents special opportunities and challenges for learning about continuous improvement. Early experiences at Rainbow Babies and Children's Hospital in Cleveland and Children's Hospital in Boston suggest how we might prepare pediatricians and other physicians to create positive change and continually improve health care.

National Asthma Education and Prevention Program working group report on the quality of asthma care.

The quality of asthma care is the second topic of the National Asthma Education and Prevention Program Task Force Report on the Cost Effectiveness, Quality of Care, and Financing of Asthma Care. This working group recommended an asthma continuous quality improvement model as an appropriate framework for examining the quality of asthma care. This model can be implemented by various organizations and providers of care in a variety of settings. The framework consists of four steps: (1) define the opportunity for improvement, (2) set the asthma quality improvement goals (outcomes), (3) characterize the process of care, and (4) begin the improvement cycle. Several case studies are presented to illustrate the use of this model in various settings, including managed care facilities, emergency departments, teaching hospitals, physician's offices, schools, workplaces, and communities. In addition, the appendix provides an overview of asthma outcome measures in the framework of patient-centered versus organizationally based perspectives.

A multisite collaborative for the development of interdisciplinary education in continuous improvement for health professions students.

In 1994, The Institute for Healthcare Improvement, in Boston, Massachusetts, formed the Interdisciplinary Professional Education Collaborative (the Collaborative). The mission of the Collaborative is to create an interdisciplinary teaching and learning environment in which future health professionals learn to work together to improve health care delivery. Apart from emphasizing interdisciplinary collaboration, the Collaborative focuses on teaching the methods of continuous improvement (CI), a system of management first developed for manufacturing industries that is increasingly being used in the management of health care delivery. The Collaborative consists of four local interdisciplinary teams (LITs): the Cleveland LIT, the "George" LIT (a collaboration between George Washington University in Washington, D.C., and George Mason University in Fairfax, Virginia), the South Carolina LIT, and the Pennsylvania LIT; and a coordinating committee. This paper describes each LIT's approach to achieving the Collaborative's commitment to give health professions students the opportunity to work in interdisciplinary teams to learn about and practice CI methods, training the Collaborative believes will enable them to be effective providers in a variety of health care systems. The paper describes the overall goals of the Collaborative, presents reports from the four LITs, and discusses common lessons learned.

Working from upstream to improve health care: the IHI interdisciplinary professional education collaborative.

BACKGROUND: Recognizing the need to find new models for educating health professionals, the Institute for Healthcare Improvement (IHI) initiated the Interdisciplinary Professional Education Collaborative in April 1994. The goal of the Collaborative is to improve health care by working from upstream, to address the health professions workforce changes demanded by the need to deliver better care at a lower cost. With support and advice from IHI and others, faculty leaders in health professions education from the disciplines of medicine, nursing, and health administration framed a vision of the future in which "health professions education has evolved into an integrated teaching/learning environment in which health professionals are working together across discipline boundaries, using the best knowledge for improvement to continuously improve health care". This article describes the first year of the three-year project. SUMMARY: The 1994-1995 pilot year of the Collaborative involved more than 60 learners and 50 faculty members, across multiple disciplines. At each of the four sites, education was integrated with efforts to improve health care delivery. Education-oriented outcomes include assessment of student learning (applied knowledge and skills) and program evaluation (student and faculty feedback on the effect of the project on community-based experiential learning sites). Even at this early stage, there is evidence of change in participating institutions. The Collaborative in now planning how to increase the number of students and faculty involved in such a way that a deeper understanding of how to prepare new health professionals to improve health care may be determined.