A Tale of Four Programs: How Residents Learn About Quality Improvement during Postgraduate Medical Education at the University of Calgary

Abstract

Phenomenon: Quality Improvement (QI) has become increasingly incorporated into competency frameworks for physician learners over the past two decades. As contemporary medical education adapts competency-based models of training, learners will be required to demonstrate competency in QI. There is a need to explore how various residency programs are currently teaching QI, including how residents might participate in experiential QI activities, and the various outcomes of these strategies. Approach: A collective case study examined how residents in four postgraduate programs at a single academic institution have learned about QI since the formal integration of QI as a cross-cutting competency. Data from surveys, interviews, observations, and archival records were collected in order to develop a comprehensive understanding of each case in its real-life context and explore current and historical trends and patterns within and across the four programs. Findings: Teaching and resident involvement in QI projects increased across all four programs since its formal integration into the national physician competency framework. Two programs had a longitudinal, hybrid QI curriculum involving didactic and experiential components. Two programs had didactic-alone QI curricula, with minimal resident engagement in applied QI activities. Between-program differences were quantified with regards to learning climate, safety climate, QI knowledge, skills, and attitudes, attitudes toward research during residency, and quality of mentorship for scholarly activities. Residents in programs with experiential learning reported higher knowledge, skills, and attitudes toward QI were motivated to lead improvement efforts in their future practice. Residents in programs with didactic-only QI teaching perceived that the historical operationalization of the scholarly project as research was a barrier to their involvement in QI, as it was not valued or legitimized in their academic and clinical contexts. Common barriers and facilitators to engagement with QI across all programs included time, mentorship, motivation, and competing demands such as feeling pressure to conduct research in order to obtain competitive fellowship positions or employment. Common across all programs was the perception of the residency scholarly project requirement as a “checkbox.” Associations were quantified between the constructs of learning climate with safety culture, and safety culture with QI knowledge, skills, and attitudes. Insights: While hybrid QI curricula with experiential learning remains an effective curriculum strategy, tensions between research and QI may be a critical barrier to learner engagement in experiential activities. In addition to providing learners with support, time, mentorship, and explicitly communicating the value QI by the program, the local safety culture may impact QI learning beyond the core curriculum. Reconceptualization of the scholarly project requirements to normalize QI activities and recognizing the potential influence of the local organizational culture on QI learning and how trainees can positively or negatively shape these cultures warrants consideration.

Keywords:

• Quality improvement
• case study
• postgraduate medical education
• scholarship

Additional information

Funding

The research team would like to thank the Office of Health and Medical Education Scholarship (OHMES) for providing financial support for this study through the OHMES Health and Medical Education Research Funding grant competition; Alberta Innovates for providing the lead author financial support during their doctoral studies through the Training and Early Career Development award; Dr. Nishan Sharma and Dr. Deirdre McCaughey for their support as members of the lead author’s doctoral committee; and finally, the numerous staff and faculty at the University of Calgary Cumming School of Medicine for their help facilitating various aspects of this study, including Dr. Steve Mintsioulis, Dr. Maeve O’Beirne, Dr. Marcy Mintz, Dr. Sarah Glaze, Dr. Paula Pearce, Dr. Paul Davis, Stefania Sleiman, Joy Hodgson, Veronica Anderson, Camille Baguio, Karen McKeon, Jill Vaughan, and Megan Mercia.