Providing quality improvement workplace-based professional development to Australian general practice clinical educators: findings from a feasibility study

Figures & data

Figure 1. Research design – embedded multiple case study.

Table 1. Intervention stages.

Step	Outline
Priming task	The principal supervisor completes the priming task, generating a list of areas of that are perceived as priorities for development.
The scoping meeting	Identifying and clarifying the ‘problem’; deciding what to change. A learning conversation with the supervisor focused on the priorities identified in the priming task. The key outcome is the identification of the teaching and learning area that will be the focus of the QI activity. The supervisor’s preferred focus determines whether other training post employees are invited to participate.
The planning meeting	Designing and negotiating achievable changes. The aim of the meeting is to: i) articulate the changes in practice (actions) that are intended to lead to the hoped-for improvement(s), and ii) decide what evidence should be gathered to determine if those changes have happened.
Taking action	The participants undertake the actions and collect associated data.
The review meeting	Reflection-on-action conversation. Monitoring what happened, facilitating reflection, drawing out what was learnt and encouraging further experimentation.
Evaluating the intervention	Participants are invited to comment on the medical educator’s performance and the intervention.

Table 2. Demographic details of the supervisor participants.

Case	Name	Sex	Australian or International Medical Graduate (IMG)	Years as a GP	Years as a supervisor	Formal teaching qualification	Geographical location of practice^a
C1	S1	F	IMG	24	6	No	MM1 not rural/regional
C2	S2	M	Australian	29^b	31	No	MM5 rural/reginal
C3	S3^c	F	IMG	28	5	No	MM4 rural/regional
	S4	M	Australian	30	5	No	MM4 rural/regional
	S5	M	Australian	22	5	No	MM4 rural/regional
C4	S6	F	Australian	12	7	No	MM4 rural/regional

^aThe Modified Monash Model is an Australian geographical classification system that categorises the country into seven remoteness categories. The higher the number, the greater the degree of remoteness. ^bS2 obtained his Fellowship 29 years ago, but practiced as a general practitioner and as a supervisor prior to obtaining Fellowship. ^cS3 was the point-of-contact for the intervention, but was not the principal supervisor at the training post. She was the de facto ‘lead’ for the intervention.

Table 3. Outline of the four QI projects: questions, interventions, actions, evidence, and outcomes.

Case	QI questions	Interventions	QI Actions	Evidence	Duration and Outcomes
1	How can I improve the interactivity of my protected teaching sessions? How can I improve the integration of my expert knowledge^a into my protected teaching sessions? How can I improve the pace of my protected teaching sessions? How can I improve (i.e. decrease) the amount of time that I spend preparing for protected teaching sessions?	The questions arose from the supervisor and medical educators reviewing a videorecording of the supervisor’s protected teaching session – a structured post-event learning conversation (aka debriefing) (see Bearman et al. 2019) – where performance concerns and strategies for improvement were discussed.	Run a protected teaching session using case-based discussion. Prime the registrar about the topic and set expectations around preparation and how the session is going to run. Contribute more expert knowledge (as opposed to declarative knowledge). Slow down the pace of the session.	Pre – post surveys completed by supervisor and registrar. Supervisor to request feedback from registrar at end of the session. Interview with registrar. Self-report at debriefing with medical educators.	12 weeks ✔ Registrar survey showed positive changes in session effectiveness, value, and activeness. Interview confirmed priming, slower pace, more interactivity, better engagement with content, and greater expert knowledge input. ✔ Supervisor survey showed more satisfied with interactivity of the teaching session. × No changes in supervisor’s satisfaction regarding proportion of declarative and expert knowledge, pace, and registrar’s engagement. ✔ Debriefing confirmed actions had been implemented.
2	How can I improve the quality of information about [a registrars’] performance to use in a learning conversation with him? How can I use that information to have an improved learning conversation with him?	Discussion of ways to review a registrar’s performance, settling on a review of medical records as a pragmatic and suitable data source. Discussion of ‘concerning cases’ with medical educator and role play of how to raise these concerns in a feedback conversation.	Review registrar’s medical records. Prime registrar for protected teaching session based on ‘concerns’ gleaned from those records. Rehearse how to address these concerns. Run protected teaching session with registrar.	Number of medical records reviewed, and concerns identified. Post-intervention survey. • Self-report at debriefing with medical educators.	11 weeks ✔ Reviewed 13 records Selected three cases of concern. ✔ Primed registrar and ran teaching session. ✔ Survey reported improved rapport with registrar. ✔ Survey reported good confidence to assess patient safety (4/5). ✔ Survey reported good comfort and ability in giving corrective feedback (4/5).
3	How can I improve my use of random case analysis (RCA)?^b How can I improve my use of RCA through judicious use of ‘What if’ questions? How can I improve my use of RCA through the application of greater structure? How can I improve my use of RCA through exploring the registrar’s knowledge (rather than imparting information)?	One supervisor shared a videorecording of her use of RCA with two colleagues. Pre-reading on RCA (Morgan and Ingham, 2013) that outlines a process and framework for using it. Structured post-event learning conversation using shared videorecording with three supervisors and medical educations identified strategies for improvement. From the overarching question, each supervisor identified one question (a – c).	Use RCA in a protected teaching session. Employ ‘What if’ questions to more deeply explore the registrar’s clinical reasoning and decision making. Follow the Set, Clarify, Explore, Assess process. Experiment with ‘Ask before tell’ to get a sense of the registrar’s knowledge (and avoid being didactic).	Supervisors to request feedback from registrars at end of the protected teaching sessions. Self-reports at group debriefing with medical educators, three supervisors and three registrars.	9 ½ weeks ✔ RCA had been employed by all three supervisors. ✔ Supervisor 4 had generated more ‘What if’ questions. ✔ Questions reflected broader use of the five domains of general practice. ✔ Supervisor 5 made better use of the Clarify and Explore process elements. × Little use of the Assess element: assessment and feedback; identification of learning needs and opportunities, and expectations and follow up. ✔ Supervisor 6 facilitated a less didactic, more interactive session.
4	How can I improve the way in which I facilitate feedback conversations when the focus is an adverse incident?	Pre-reading on the impact of emotions in feedback conversations (see Molloy et al. 2013). Ratification of nine-point framework to structure a feedback conversation after a registrar error.	(Sensibly) apply elements of the framework in feedback conversations with registrars and students.	• Self-report at debriefing with medical educators	5 weeks × No opportunities to use the framework in relation to adverse incidents. Limited opportunities to use the framework. ✔ Supervisor articulated knowledge of the framework in debriefing. ✔ Obtained a registrar’s version of events before giving her perspective in relation to error. ✔ Primed registrar for the feedback conversation.

^aExpert knowledge is the deep, practical knowledge that an expert GP would know. ^bMorgan and Ingham (2013) describe random case analysis as a specific method of chart stimulated recall where records are selected at random by the supervisor, not the learner.

Table 4. Demographic details of the medical educator participants.

Name	Sex	Australian or International Medical Graduate (IMG)	Years as a GP	Years as a supervisor	Years as a medical educator	Formal teaching qualification
Author	M	Australian	32	30	25	Graduate Certificate in Health Professions Education
ME1	F	Australian	2	0	4 + 16 years of tertiary education experience	No
ME2	F	Australian	43	20	20	Certificate IV Training and Assessment
ME3	M	Australian	10	7	8	No
ME4	F	Australian	33	20	12	No

Bearman, M., Eppich, W., and Nestel, D., 2019. How debriefing can inform feedback: practices that make a difference. In: M. Henderson, et al., eds. The impact of feedback in higher education: improving assessment outcomes for learners. London: Palgrave Macmillan, 165–188.

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Morgan, S. and Ingham, G., 2013. Random case analysis: a new framework for Australian general practice training. Australian Family Physician, 42 (1–2), 69–73.

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Molloy, E., Borrell-Carrió, F., and Epstein, R., 2013. The impact of emotions in feedback. In: D. Boud and E. Molloy, eds. Feedback in higher and professional education. London: Routledge, 50–71.

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