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.

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.

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.

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.

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.

The PDSA cycle at the core of learning in health professions education.

BACKGROUND: The Plan-Do-Study-Act (PDSA) cycle lies at the heart of continuous improvement and is a redefinition of the scientific method for application to the world of work. HEALTH CARE AS A CONTEXT FOR HEALTH PROFESSIONS LEARNING: Educational institutions could create the best "quality learning" environments for students by relating closely to health care organizations that create improvement environments for workers. When both become "learning" organizations and develop a relationship with each other, an important product will be the integration of processes for individual and organizational learning. THE PDSA CYCLE AS LEARNING THEORY: The PDSA cycle can be an integrating theory for both individual and organizational learning. It shares basic features of well-accepted theory about individual and organizational learning, including the concepts of change and action/reflection. EVALUATING LEARNING THROUGH PDSA CYCLES: An illustration is given of one set of implications of the PDSA cycle as learning theory. It describes an alternative way of thinking about the evaluation of learning, which surpasses the traditional emphasis on judgment in evaluation. CONCLUSIONS: The potential to place the PDSA cycle at the core of learning in health professions education is great. Contributing factors to this potential include the historical emphasis on the scientific method in health care, the relationship between clinical education and practice, recent improvements in our capacity to define and measure health outcomes, emergent pressures for change in health care and education, and compatible multiple functions of the PDSA cycle.

Quality health care.

Health professionals are reporting progress in the application of improvement principles and methods to clinical care. Clinical quality improvement efforts have decreased unnecessary intravenous catheter use, improved preventive services, and decreased hospital costs for patients with chest pain.

Medical students in a time of HIV: education and the duty to treat.

This article concerns medical education about the ethics of professional duties and treatment of HIV-infected patients. The issue at hand is not whether medical students have a duty to treat HIV-infected patients, since it is a matter of consensus that they do. Medical schools have reasserted that risks are inherent in medicine, and that medical school admission should be based on the willingness to accept some risks, in addition to intelligence and personal skills. Those who wish to avoid risks are free to enter other professions. While it is imperative to assert a duty to treat, this requires thoughtful explanation to match the understandably high anxiety levels of many medical students.

Continuous quality improvement and the education of the generalist physician.

The new health care environment--centered on patients, focused on health, and managed by generalists--requires new competencies for the generalist physician. Among these are knowledge and skills for the continuous improvement of health care. In many areas, generalist physicians already use quality improvement methods and principles to improve the health and health care of their communities. Efforts to teach medical students and residents to improve quality continuously in health care are beginning. Early lessons are: (1) quality improvement is most effectively learned in the context of real work; (2) initial emphasis must be on the basics; (3) the focus is on the needs of those we serve; (4) interdisciplinary skills are essential and best learned during clinical training; and (5) the best learning environment for future generalist physicians, one which results in optimism about the future and the ability to make things better, is an environment that is continuously improving.

Quality health care.

Despite a long history in industry, the principles and methods of continuous improvement are new to medicine. Continuous improvement led to a 73% drop in the number of inadequate cervical smears in a large urban health center.

Efforts to improve compliance with the National Cholesterol Education Program guidelines. Results of a randomized controlled trial.

STUDY OBJECTIVE: We compared three approaches for improving compliance with the practice guidelines of the National Cholesterol Education Program (NCEP). DESIGN: A randomized controlled trial. SETTING: Academic group practices of a major urban teaching hospital. PARTICIPANTS: Study physicians were three equivalent groups of PG-2 and PG-3 residents (N = 33) seeing patients in equivalent outpatient clinics. Continuity patients of these residents were included (N = 240) if they were younger than 66 years, saw their primary physician during the intervention period, were not pregnant, and had no serious life-shortening noncardiac illnesses. INTERVENTIONS: Three interventions were implemented over a 5-week period. Control group physicians (group 1) were offered only a standard lecture provided through the Physician Cholesterol Education Program (PCEP). Group 2 physicians were offered the PCEP lecture and also received generic chart reminders of the NCEP guidelines on each eligible patient's chart. Group 3 physicians were offered the PCEP lecture and also received timely patient-specific feedback, including acknowledgement of recent lipid values and management, and explicit recommendations for further action. Knowledge of lipid disorders was tested before and after the PCEP lecture, and physicians' attitudes were surveyed following the intervention period. MEASUREMENTS AND MAIN RESULTS: The three groups were similar in baseline (preintervention) compliance with NCEP recommendations (average, 39%) and physicians' knowledge. Patients were similar across groups in number of coronary artery disease risk factors and cholesterol values. Significant within-group improvements in compliance were noted for groups 2 and 3 (7.6% and 10.6%, respectively), but not for group 1 (4.5%). Importantly, there were no differences observed in improvements across groups. In exploratory analyses, however, there was a significant correlation between improved compliance and the number of patients seen by each provider in group 3 that was not observed in groups 1 or 2. Notably, changes in compliance were unrelated to PCEP lecture attendance (8.6% vs 8.1% for attenders vs nonattenders, respectively), level of postgraduate training, baseline or later tests of knowledge, or patient factors. The postintervention survey revealed marked overestimation by physicians of their personal compliance with NCEP guidelines, although there was strong support for clinic efforts that would screen patients for lipid disorders independent of physician initiative. CONCLUSIONS: This study raises questions about the effectiveness of education alone for improving compliance with NCEP guidelines. The effectiveness and efficiency of timely, individualized feedback should be explored in studies over a longer period. Innovative alternative approaches are suggested by the responses to our survey and other research in preventive practices.