Shaping a Culture for Continuous Quality Improvement in Undergraduate Medical Education.

PURPOSE: This study sought to identify key features of an organizational quality culture and explore how these features contribute to continuous quality improvement of undergraduate medical education. METHOD: Between July and December 2018, researchers from Maastricht University in the Netherlands conducted a multicenter focus group study among 6 education quality advisory committees. Participants were 22 faculty and 18 student representatives affiliated with 6 medical schools in the Netherlands. The group interviews focused on quality culture characteristics in relation to optimizing educational development, implementation, evaluation, and (further) improvement. Template analysis, a stepwise type of thematic analysis, was applied to analyze the data. RESULTS: Five main themes resembling quality culture constituents to continuous educational improvement were identified: (1) fostering an open systems perspective, (2) involving stakeholders in educational (re)design, (3) valuing teaching and learning, (4) navigating between ownership and accountability, and (5) building on integrative leadership to overcome tensions inherent in the first 4 themes. A supportive communication climate (which can be fueled by the organization's leaders) contributes to and is integrated within the first 4 themes. CONCLUSIONS: The results call for a shift away from static quality management approaches with an emphasis on control and accountability toward more flexible, development-oriented approaches focusing on the 5 themes of a culture for continuous quality improvement. The study provides new insights in the link between theory and practice of continuous quality improvement. Specifically, in addition to quality management systems and structures, faculty's professional autonomy, collaboration with peers and students, and the valuing of teaching and learning need to be amplified.

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

Reflective learning in a patient safety course for final-year medical students.

BACKGROUND: Patient safety has become an important topic over the last decade and has also been increasingly implemented in the undergraduate curriculum. However, the best timing and method of teaching still remains to be decided. AIMS: To develop and evaluate a patient safety course for final-year students. The course is based on reflective learning and personal experiences to improve the transfer of theory into practice. METHODS: We performed a mixed method evaluation study of the course. An evaluation questionnaire and the number of completed incident report cards were analyzed using descriptive statistics. Focus groups, organized two and four weeks after the course, were analyzed using template analysis; the Theory of Planned Behaviour (TPB) was used to interpret the results. RESULTS: Students found the course overall instructive and reacted positively towards many elements of the course. Focus group analysis showed that an increase in knowledge about patient safety topics resulted in a change of attitudes towards these subjects and in an increase in awareness of patient safety. This influenced students' behavioral intention and their behavior. CONCLUSIONS: A course based on students' personal experiences enables them to transfer theory on patient safety issues into their own practice and has an effect on their awareness, attitudes and behavior. This could have a large impact on their future role as resident.

Poor professionalism identified through investigation of unsolicited healthcare complaints.

AIM: To determine whether analysis of unsolicited healthcare complaints specifically focusing on unprofessional behaviour can provide additional information from the patients' perspective. METHODS: A qualitative study with content analysis of healthcare complaints and associated judgements using complaints filed from 2004 to 2009 at the complaints committee of a tertiary-referral centre. Subsequent comparison of the resulting categories of poor professionalism to categories perceived relevant by physicians in a previous study was performed. RESULTS: 137 complaints (98%) yielded 46 different unprofessional behaviours grouped into 18 categories. The element 'perceived medical complications and error' occurred most commonly (n=77), followed by 'having to wait for care' and 'insufficient or unclear clarification' (n=52, n=48, respectively). The combined non-cognitive elements of professionalism (especially aspects of communication) were far more prominently discussed than cognitive issues (knowledge/skills) related to medical error. Most categories of professionalism elements were considered important by physicians but, nevertheless, were identified in patient complaints analysis. Some issues (eg, 'altruism', 'appearance', 'keeping distance/respecting boundaries with patients') were not perceived as problematic by patients and/or relatives, while mentioned by physicians. Conversely, eight categories of poor professionalism revealed from complaint analysis (eg, 'having to wait for care', 'lack of continuity of care' and 'lack of shared decision making') were not considered essential by physicians. CONCLUSIONS: The vast majority of unprofessional behaviour identified related to non-cognitive, professionalism aspects of care. Complaints pertaining to unsatisfactory communication were especially noticeable. Incongruence is noted between the physicians' and the patients' perception of actual care.

A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

BACKGROUND: Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. METHODS: The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier "Incident type", described as odds ratios (OR) and proportional similarity indices (PSI). RESULTS: A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). CONCLUSIONS: IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

Students' perceptions of patient safety during the transition from undergraduate to postgraduate training: an activity theory analysis.

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.

Bad apples spoil the barrel: Addressing unprofessional behaviour.

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

Enhancing diagnostic accuracy among nonexperts through use of video cases.

OBJECTIVE: The goal was to determine whether the diagnostic accuracy of nonexperts in selected learning environments would improve with the use of patient video cases (PVCs). METHODS: We designed a stepwise, team-based, learning approach with a (1) text-based patient presentation, (2) first review of a PVC, (3) small-group discussion, (4) second review of a PVC, and (5) large-group discussion and listening to think-aloud modeling by a content expert. Four pediatric neurology PVCs were analyzed by 44 physicians. After each step, the diagnostic accuracy was assessed with a questionnaire with open-ended questions measuring the frequency of relevant diagnoses and clinical diagnostic reasoning processes. RESULTS: The first review of the PVC was followed by a large number of relevant clinical diagnostic reasoning processes. Small-group discussions and listening to a think-aloud procedure with an expert were particularly effective in increasing the diagnostic accuracy of the nonexperts. CONCLUSIONS: The diagnostic accuracy of nonexperts was clearly enhanced by interaction in small-group discussions and subsequent listening to a think-aloud procedure with a content expert. Learning through PVCs in clinical settings thus is improved through the interactive participation of junior and senior clinicians. Such an environment (a "virtual examination room") may be introduced at grand rounds, case conferences, or morning rounds, to stimulate the development of diagnostic accuracy in nonexperts.

Fellows' in intensive care medicine views on professionalism and how they learn it.

INTRODUCTION: The emphasis on the importance of professionalism in a recent CoBaTrICE-IT paper was impressive. However, insight into the elements of professionalism as perceived relevant for intensivists from the fellows' view, and how these are taught and learned, is limited. OBJECTIVES AND METHODS: A nationwide study was performed in 2007-2008. All ICM fellows (n = 90) were sent a questionnaire containing the following questions regarding training in professionalism (7-point Likert scale (1 = very inadequate, 7 = very adequate)): which are the elements perceived to be important in intensivists'' daily practice (38 items, cat. I)? Which methods of learning and teaching are recognised (16 items, cat. II)? Which methods of teaching and learning are considered especially useful (16 items, cat. III)? Finally, the perceived quantity and quality of formal and informal learning methods, as well as the responsible organisational body was studied. Data were analysed using SPSS 15.0. RESULTS: Response was 75.5 % (n = 68), mean age 34 years. Regarding Elements, scores on virtually all items were high. The factor 'striving for excellence' explained half the variance. Two other aspects, 'Teamwork' and 'Dealing with ethical dilemmas', were identified. Regarding Methods, three dimensions, 'formal curriculum'', 'private and academic experiences' and 'role modelling', proved important. The factor 'formal curriculum' explained most of the variance. Regarding Usefulness the same factors, now mainly explained by the factor Private and academic experiences, emerged with variance. In both categories the items 'observations in daily practice' and 'watching television programmes like ER and House' were the highest- and lowest-scoring items (5.99 and 5.81, and 2.69 and 2.49, respectively). Mean scores regarding the quantity of formal and informal teaching were 4.06 and 4.58 (range 1.841 and 1.519). For the quality of teaching, the figures were 4.22 and 4.52 (range 1.659 and 1.560, respectively). 54 suggestions for improvement of teaching were documented. The need for some form of formal teaching of professionalism aspects as well as for feedback was most frequently mentioned (n = 19 and 16). The local training centres are considered and should remain pivotal for teaching professionalism issues (n = 17 and 28). CONCLUSIONS: Almost all elements of professionalism were considered relevant to intensivists' daily practice. Although formal teaching methods regarding professionalism aspects are easily recognised in daily practice, learning by personal experiences and informal ways quantitatively plays a more important, and more valued role. Qualitative comments, nevertheless, stress the need for providing and receiving (solicited and unsolicited) feedback, thereby requesting expansion of formal teaching methods. The local training centres (should continue to) play a major role in teaching professionalism, although an additional role for the (inter)national intensive care organisations remains.

Professionalism beyond medical school: an educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Professionalism: evolution of the concept.

The concept of professionalism has undergone major changes over the millennia in general and the last century specifically. This article, the first in a series of articles in this Journal on professionalism, attempts to provide the reader with a historical overview of the evolution of the concept of professionalism over time. As a result of these changes, medical school curricula, and contemporary specialist training programs are increasingly becoming competence based, with professionalism becoming an integral part of a resident's training and assessment program.

Training and learning professionalism in the medical school curriculum: current considerations.

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.

Perceptions of learning as a function of seminar group factors.

CONTEXT: Small-group learning is advocated for enhancing higher-order thinking and the development of skills and attitudes. Teacher performance, group interaction and the quality of assignments have been shown to affect small-group learning in hybrid and problem-based curricula. OBJECTIVES: This study aimed to examine the perceptions of student groups as to how teacher performance, group interaction and the quality of assignments are related to one another and to learning effects in seminars of 15-30 students in a hybrid curriculum. METHODS: We constructed a 28-item questionnaire and administered it to 639 students attending 32 seminars in Years 1-4 of an undergraduate veterinary curriculum. We performed factor analysis and reliability analysis of the questionnaire. We used correlation and regression analyses to explore the interactions of the four-factor model, with teacher performance, group interaction and quality of assignments as independent variables and the perceived learning effect of the seminars as the dependent variable. RESULTS: The response rate was 99%. Teacher performance (beta = 0.78) and group interaction (- 0.28) significantly influenced the perceived learning effect. The total effect of the quality of assignments (through effects on teacher performance and group interaction) was 0.47. DISCUSSION: The strong relationship between teacher performance and learning effect suggests that students rely strongly on their teachers. The negative effect of group interaction may reflect poor alignment of teaching and assessment and poor organisation of group processes. This should be further examined. Comparative studies on seminars are also recommended.

Teachers' interactions and their collaborative reflection processes during peer meetings.

Teachers' reflections are often narrowly focused on technical questions ('how to') and less on the underlying moral, political and emotional aspects of their functioning. However, for a better understanding of teaching practice it is important to uncover beliefs and values that usually remain implicit. Meeting with others is considered crucial for enhancing the quality of teachers' reflections. However, little is known about how any beneficial effects of such meetings are brought about. We explored the relationship between medical teachers' interactions and collaborative reflection processes during peer meetings. Five experienced teachers and a teacher trainer participated in the study. Three peer meetings were videotaped and transcribed. Teachers' interactions and collaborative reflective processes were analysed. The interactions promoted reflection not only on technical questions but also on moral, political, and emotional issues. 'Guiding/directing', 'proposing an alternative' and 'exploring an alternative' appeared to be the principal interactions. The results may be useful for teachers and trainers who are considering organising and/or improving peer meetings.

Factors inhibiting assessment of students' professional behaviour in the tutorial group during problem-based learning.

CONTEXT: We addressed the assessment of professional behaviour in tutorial groups by investigating students' perceptions of the frequency and impact of critical incidents that impede this assessment and 5 factors underlying these critical incidents. METHODS: A questionnaire asking students to rate the frequency and impact of 40 critical incidents relating to effective assessment of professional behaviour on a 5-point Likert scale was developed and sent to all undergraduate medical students in Years 2-4 of a 6-year undergraduate curriculum. RESULTS: The response rate was 70% (n = 393). Important factors underlying critical incidents are: lack of effective interaction; lack of thoroughness; tutors' failure to confront students with unprofessional behaviour; lack of effort to find solutions, and lack of student motivation. Confirmatory factor analysis showed a good model fit. Because the relationship between frequency of occurrence and degree of impediment varies, the best information about the true impact of critical incidents and the underlying factors is provided by the product of frequency and degree of impediment. Frequency of occurrence remains stable and degree of impediment increases in Years 2-4. CONCLUSIONS: The results of this study can be used to design and improve faculty development programmes aimed at improving assessment of professional behaviour. Training programmes should motivate tutors by providing background information as to why and how sound assessment of professional behaviour is to be performed and encourage tutors to confront students with and discuss all aspects of professional behaviour, as well as provide appropriate feedback.

Student perceptions about the characteristics of an effective discussion during the reporting phase in problem-based learning.

To explore student perceptions of factors contributing to the effectiveness of discussions in the reporting phase of the problem-based learning (PBL) process, where students report and synthesise the results of self-study. Forty-eight Year 1 and 2 medical students participated in 6 focus group interviews about the characteristics of effective group discussions and possible improvements. The data were analysed qualitatively in several stages. The analysis yielded 4 main characteristics of effective discussions: asking for, giving and receiving explanations; integrating and applying knowledge; discussing differences with regard to learning content, and guiding and monitoring the content and the group process of the discussion. Integrating and applying knowledge included structuring, relating and summarising information and providing examples from practice. Discussing different opinions included discussing a variety of literature resources and disagreements. The main learning effects mentioned by the students were retention, understanding, integration and application of knowledge. Students have clear ideas about what promotes effective discussions during the reporting phase. Their PBL experience has provided them with some insights that are in line with theory and research on collaborative learning. Future research should examine differences between student and tutor perceptions of the quality of discussions. Introductions to PBL for students and tutors should include training in asking open but focused questions, supporting explanations with arguments and dealing with conflicts about learning content. Tutors should be trained in giving effective and personal feedback. Collaborative creation of external knowledge representations (i.e. concept maps) should be advocated, as should variety of literature resources.

Portfolio as a tool to stimulate teachers' reflections.

Portfolios are increasingly being used to stimulate teachers' reflections. Frameworks for reflection on teaching often emphasize competencies and behaviours. However, other aspects of teacher functioning are also important, such as the teaching environment and individual teachers' beliefs, professional identity and mission. In a study among five medical school teachers, we explored how a portfolio stimulated reflections on the various aspects of teaching functioning. Outcomes of written portfolio assignments were collected and analysed to identify examples of reflections on the various aspects of teacher functioning. Examples of reflections on all aspects of teacher functioning were found, although examples of reflections on competencies were easier to find than those on beliefs, identity and mission. This study might help teachers and their trainers and coaches to recognize different aspects of teacher functioning when discussing portfolios for professional development purposes. However, further development of assignments and other methods to stimulate reflections on beliefs, identity and mission are needed. Furthermore, apart from the content of teachers' reflections, teachers' reflection processes should be researched, as well as the effects of portfolio meetings with peers and coaches.

Participants' opinions on the usefulness of a teaching portfolio.

BACKGROUND: Whether teaching portfolios achieve their aim of stimulating teachers' professional development is favourably affected by the incorporation of a balanced structure and effective social interactions, such as coaching. We explored teachers' experiences with a teaching portfolio that was structured by teaching roles, portfolio assignments and conversation protocols. The related social interactions consisted of meetings with peers and personal coaches. Teachers' and coaches' opinions were sought about the benefits and the enabling and disabling factors of the portfolio structure and the social interactions involved. METHOD: Five teachers and their personal coaches were individually interviewed about their experiences with the portfolio. Protocols were analysed using a top-down strategy. RESULTS: The teaching roles were helpful in analysing teaching, but the assignments and the conversation protocols were too detailed and directive. The social interactions were perceived as very valuable for professional development, particularly the meetings with personal coaches. CONCLUSIONS: The portfolio structure and social interactions, especially personal coaching, appeared to be helpful for teachers in analysing their teaching practice. The assignments and protocols, however, were too detailed and directive. This may be resolved by using assignments and conversation protocols more flexibly and enabling adjustment to personal learning needs. The high appreciation of personal coaching might be related to the freedom for teachers to choose their own coach. The results can be used by portfolio designers as guidelines for how to achieve a balanced structure and effective social interactions and how these might be combined to increase the benefits of working with a portfolio to teachers.

Education research at the Faculty of Medicine, University of Maastricht: fostering the interrelationship between professional and education practice.

An academic department of education serving the entire university and a strategic choice by the Faculty of Medicine to support educational innovation through education research are the historical cornerstones of the education research program of the University of Maastricht. Over the years, the department's initial exclusive research focus on the evaluation of problem-based learning has widened to include theory-based applied research covering the broad domain of education. The program focuses on themes: the learning of students and teachers, characteristics of powerful learning environments, and assessment and evaluation of learning and teaching. Although modest in terms of resources, the program is firmly anchored within the Faculty's organizational structure. Educational relevance and professional alignment are the most prominent determinants of the success of the program. These features sustain the institutional mission of educational excellence as well as the high ranking of the Faculty of Medicine's medical training program among the training programs of the Netherlands' medical schools. A break in this self-perpetuating mechanism--due either to internal politics or to staffing problems--forms the main risk factor for the continuation of the department.

Trends in research on the tutor in problem-based learning: conclusions and implications for educational practice and research.

The tutor role in problem-based learning (PBL) has attracted the interest of many researchers and has led to an abundance of studies. This article reports on major trends in studies investigating the tutor during the past 10 years. Three major trends were observed by the authors while analysing the studies conducted: studies on the differential influence of content expert and non-content expert tutors on student achievement, studies on process variables, and studies on the relationship between tutor characteristics and differential contextual circumstances. The aim of this article is to summarize the main findings of the studies conducted so far within the three trends observed, to provide directions for educational practitioners and policy makers, and to suggest directions for future research questions. The studies included were selected by conducting a literature search in medical journals, which was complemented with the personal archives of the authors. The results of the studies conducted within the three trends of research have led to advanced insights in tutoring. The outcomes revealed that content expert tutors tend to use their subject-matter expertise more to direct the discussion in the tutorial group, whereas non-content expert tutors tend to use their process-facilitation expertise more to direct the tutorial group. Furthermore, a tutor's performance is not a stable characteristic but is partly situation specific. It is concluded that a tutor should both know how to deal with the subject matter expertise and should know how to facilitate the learning process. Faculty and policy makers should put substantial efforts into designing curricula and cases and developing tutors' skills by faculty development strategies that stimulate reflection. The research agenda should be driven more by modern educational theories of learning in which tutoring is a process aimed at stimulating constructive, self-directed, situated and collaborative learning by students. Furthermore, more qualitative studies should be conducted to gain better insights in teachers' conceptions about the tutor role and student learning to better understand their behaviours.