Interprofessional student teams focus on staff issues while learning about quality improvement

ABSTRACT

There is a well-known gap between what we know and what we do within healthcare service processes. Models that facilitate quality improvement (QI) have seen used to eliminate these gaps. Knowledge and competence in QI work are necessary for every professional within the healthcare system and are ideally learned through interprofessional collaboration and introduced during undergraduate studies. To meet these competence needs, Linköping University, Sweden, in collaboration with the main healthcare provider in the region, implemented a 2-week interprofessional QI learning module, which is mandatory for all undergraduate healthcare students. Ideas for practice-based QI projects were introduced to all the students who studied theory in the relevant domains of QI while working on these projects. A content analysis of students’ written reports was conducted to investigate the focus of the projects. The analysis showed that most projects (65%) concerned staff-related issues, while 35% had patient perspectives. This distribution changed over time, increasing the number of patient centered projects.

KEYWORDS:

• Quality improvement
• interprofessional
• healthcare
• student
• qualitative

Introduction

Healthcare systems face challenges in the organization and delivery of efficient and effective services. In addition to dealing with treatment-related injuries, fatalities and logistics, the exponential growth of scientific evidence and knowledge contributes to the complexity of professional practice. Healthcare managers and professionals introduce ways of “working on the work”, and healthcare organizations focus on teaching and learning about Improvement of Quality and Safety (IQS) (Berwick, 1989) in order to achieve improved patient safety. In Sweden, these requirements are described in guidelines from Socialstyrelsen (2012), in the joint publication from the Swedish Society of Nursing and the Swedish Society of Medicine “Teamwork and Quality improvement knowledge” (Kvarnström et al., 2017), and, at the national level, in the learning outcomes for healthcare undergraduates (Högskoleförordningen, 1993). Person centered care has been promoted to improve patient safety and value of care (Olsson et al., 2016). However, earlier studies have reported that it is common for healthcare professionals to focus on staff-related issues while doing quality improvement (QI) projects (Andersson, 2013; Olsson et al., 2003).

Background

It is suggested that knowledge in IQS should be introduced at the undergraduate level (Kyrkjebø & Hanestad, 2003), preferably as an interprofessional learning module (Barr, 2007; Ladden et al., 2006), and ideally in an authentic context, i.e. within the healthcare organization, both at hospitals and with care providers such as primary healthcare centers and community care centers. This means that educators should adapt the curriculum accordingly. To achieve this, another level of challenge is created for the university that depends on the close collaboration between the academy and the healthcare providers. At the Faculty of Medicine and Health Sciences (FMHS), Linköping University, Sweden, problem-based learning (PBL) and interprofessional education (IPE) were established as pedagogical corner-stones in 1986 (Wilhelmsson et al., 2009). The benefits of integrating PBL and IPE were described by Dahlgren (2009). Over the years, an IPE curriculum including three different modules was developed; today this corresponds to a total of 8 weeks of full-time studies (Lindh Falk et al., 2015). The first module, over 4 weeks, takes place in the first semester. Students are introduced to and learn about fundamental concepts of health and disease, health promotion and prevention, ethics, and evidence-based practice. The purpose is for students to develop a common ground of values. The second module, 2 weeks in semester four or five, concerns quality improvement (QI) knowledge, the QI module and the subject of this paper. In the third module, students from the different programmes are scheduled into teams who undertake a clinical placement during 2 weeks at the Interprofessional Training Ward (IPTW). Currently, approximately 2,800 undergraduate students in seven programmes (biomedical laboratory sciences, medical biosciences, nursing, occupational therapy, medicine, physiotherapy, and speech and language therapy) are participating in these mandatory modules of IPE (Abrandt Dahlgren et al., 2012; Lindh Falk et al., 2015).

The QI module

In 2011, the content of the second module of the IPE curriculum was changed from sexual health (personal information) to knowledge and skills in QI, motivated by the argument of the synergic advantage between interprofessional competence and IQS (Barr, 2007). The new learning outcomes (Box 1) concern methods and tools of IQS, the ability to analyze the complexity of quality improvement processes, and how interprofessional collaboration affect the result of quality improvement work. Student evaluation of the QI module showed that students were positive to learning QI in an interprofessional setting (Gjessing et al., 2014).

Box 1. The learning outcomes of The QI module.

Learning outcomes to apply methods and tools from models of IQS, to analyze the complexity of quality improvement processes, to value how one’s own and others’ professional knowledge and approaches in collaboration affect the result of quality improvement work, and to value one’s own professional role in relation to professional competences’ in students from other undergraduate programmes in order to describe one’s own interprofessional competence

The QI module was developed and organized in close collaboration with the County Council of Östergötland, the main healthcare provider in the region. Since FMHS applies PBL, where the scenarios are created from real-life cases and are the starting point for learning, ideas for authentic quality improvement projects were collected from clinical practice to be used as scenarios. Quality managers at healthcare centers or hospital clinics were involved in the process of collecting and selecting appropriate QI projects. These projects could be the round process, hygiene compliance, accessibility and availability, etc. The overall criteria to be defined as a “suitable project” were the sense of urgency from the clinic, to have a balance in complexity of the project in relation to knowledge level of the students, the limited time the students had, and the probability that the outcome of the project would improve quality of care and patient safety. The student groups were not able to choose projects.

The period of full-time studies over 2 weeks started with an introductory day with lectures from experts in quality improvement theory and methods, theory in interprofessional collaboration, and knowledge of the healthcare system. The interprofessional student groups of eight to nine students used the authentic QI project ideas as scenarios to problematize and identify their learning needs according to the principles of PBL. The groups were supervised by an academic tutor, providing guidance within the theoretical frameworks of QI as well as the PBL process. The clinical supervisor was responsible for the presentation of the idea of a QI project, guiding the students in relation to clinical challenges. The final focus of the QI-projects was identified and decided by the students.

Working on the QI-project, students made site visits where issues related to the project were investigated. To illustrate the progress and data of the QI project, students used Ishikawa diagrams, flow charts, questionnaires, and made data collections appropriate to the QI project. Due to the limited time, student did not have the opportunity to test any suggestions for improvement themselves. This is a recurring complaint from students, not knowing what happens after the report to the clinic (not published). At the end of the QI module, the students presented their acquired theoretical knowledge, findings regarding the QI project, and suggested interventions for improvements to the staff at the specific clinical site of the QI project. The students also deliver a written report or poster. Knowing that healthcare professionals focus on staff-related issues doing QI projects (Olsson et al., 2003), the question was raised whether the students had a different perspective on healthcare quality improvement work. The aim of this study was to investigate the focus of students’ QI projects.

Methods

Data collection

The full-scale introduction of the QI module in 2011 has generated almost 650 projects up to the end of 2018, which is between 35 and 45 QI projects each semester. Here we present an analysis of reports or posters representing approximately 1250 students from all healthcare programmes (biomedicine, physiotherapy, occupational therapy, nursing, medicine, and speech and language therapy). The written reports/posters were produced as feedback to the clinical staff and for assessment. A convenience sample was selected between 2011 and 2016 by choosing reports from six semesters over three different years (2012, 2014, and 2016). In total, there should have been 230 reports, but all of them were not accessible as all reports were not saved on the learning platform, uploading to the platform was optional. All available reports from the six semesters (n = 155) were analyzed.

Data analysis

A conventional content analysis (Hsieh & Shannon, 2005; Krippendorf, 2013) was performed by two of the authors (ALF and PT) who independently read all the project reports, with emphasis on how the students conceived the suggested QI project and how they had specified the focus. Meaning units related to the specified focus were collected as a first step and then condensed to preserve the core content. These condensed meaning units were coded independently with labels close to the text in the project reports without losing the core content (Krippendorf, 2013). Thereafter, the two authors collaboratively merged the codes into manifest categories (Graneheim & Lundman, 2004). The latent content was also used to identify themes (by ALF, PT). All the projects for the selected years were assessed according to the themes and the distribution among the themes was calculated. In the analysis process, when discrepancies were identified between the two authors, a decision regarding the classification into categories was negotiated. Thereafter, the coauthors (JD, MH) read and commented on the suggested codes and categories. As a member check, a common discussion with all the authors took place with the aim of reaching a mutually exclusive category system.

Ethical considerations

The Regional Ethical Committee was consulted about the need for ethical approval, and it was determined that such approval was not required. The Helsinki declaration was followed to protect participants in the student groups. The reports were anonymized before analysis.

Findings

Of the expected number of projects, we were able to collect 155 reports or posters (67%). The missing 33% could be explained by the fact that submission to the learning platform was not compulsory and was only performed by 155 out of 230 project groups. Seventeen different codes were identified in the content analysis of the reports (Table 1). In instances when students described how the procedures for hygiene were investigated, how patients were informed about the processes planned, or how the environment in the ward or healthcare center was managed, etc, the authors labeled the focus of the QI project as codes accordingly. These codes were merged into five categories, i.e. illustrating the manifest content close to the text formulated by students. The inference of the five categories illustrated the latent content, i.e. the underlying meanings interpreted by the researchers. The categories were grouped into two themes (Table 1): patent-related or staff-related issues. In Findings, the categories and codes are presented first, then the themes, and finally the distribution of the IQS problems.

Table 1. Analysis of student projects resulted in five categories illustrating the main orientations of the students’ QI project

	Theme: PATIENT-RELATED ISSUES	Theme: STAFF-RELATED ISSUES
CATEGORIES	CODES	CODES
Care flow		Within clinics Between clinics Waiting time/delays Students’ clinical practice
Routines	Patient safety	Hygiene Efficiency
Information, communication, dialogue	Information to patients	Between staff Between clinics Staff education
Environment	Care environment	Work conditions Equipment
Patient satisfaction	Care visit/stay Accessibility Encounter

Categories

The five categories illustrated the main orientation of the students’ QI projects. Every category contained a variation of QI problems illustrated by the codes. The five categories are presented below.

Care flow

The codes within the category of care flow contain different processes within and between clinics according to organization, coordination and transport. All projects in this category were staff-related issues. The code care flow “within clinics” represented projects concerning the preparation of patients for radiography examinations, dealing with canceled surgery, and organization of vaccination programmes. In the code “between clinics” projects dealt with referring and reporting patients from one clinic to another. The code “waiting time and delays” included QI problems concerning waiting time at a clinic affecting e.g., transporting time which interrupted the staff working schedule. A few QI projects dealt with students’ clinical placements in relation to the care flow.

Routines

A common issue for QI projects concerned compliance with hygiene routines, mostly related to staff washing hands, but a few projects focused on patients’ compliance with hygiene routines. Routines regarding patient safety, such as misregistration in medical records, and positioning patients on the operation table to prevent complications post-surgery, were other QI problems investigated by the students. The code “efficiency” dealt with shortages of technical devices such as computers, double documentation, or the environment in the special room dedicated to storage of medicines.

Information, communication and dialogue

This category concerns communication issues such as handover/reporting between staff members and between clinics, but also information to patients, and finally dialogue for staff education. Examples of projects included how information was distributed within the organization, during the ward rounds, in follow-up dialogue before discharge from a ward, or other issues such as patients’ privacy during the ward rounds or in waiting rooms.

Environment

The work conditions categorized as “environment” concerned stress-related factors for the staff, such as long queues of patients either on the telephone or in waiting rooms. There were also problems dealing with staffs’ use of equipment in their work, i.e. the spaces dedicated to computer work, and other issues regarding technical aids. The physical environment is related to the patients’ opinions on how the waiting rooms are designed and the influence of art in the ward.

Patient satisfaction

In this category, projects focused on issues where the students identified problems related to patients’ experiences of care. Patients were interviewed and/or answered a questionnaire. The problems related to accessibility, encounters with healthcare professionals and patients’ experiences of care. Accessibility focused on patients calling from home for an appointment, and how to improve the availability of services.

Themes

The latent content analysis revealed two themes: patient-related and staff-related issues. Staff-related issues seemed to focus mostly on improving the quality of daily work for the staff, i.e. increased efficiency, decreased cancellation of patients’ visits, and improved communication. It was mainly about how the healthcare system was organized. Patient-related issues had a focus on improving the patients’ situations, i.e. to ensure that patients were well informed and safe, with high accessibility to care. The total distribution of the projects over the 3 years illustrated a prevalent focus on staff-related issues (n = 104, 65%), compared with fewer patient-related issues (n = 51, 35%), even though the proportion of patient-related projects increased in 2016 (Table 2).

Table 2. The latent content in a distribution of the QI projects illustrated as themes

	Themes
Year	PATIENT-RELATED ISSUES	STAFF-RELATED ISSUES
2012	16 (25%)	48 (75%)
2014	13 (29%)	31 (71%)
2016	22 (47%)	25 (53%)
Total	51 (35%)	104 (65%)

Discussion

Continuous professional development, which contributes to increased patient safety and quality of care, requires motivation and time. This need has been described by Batalden and Foster (2012) who have suggested three target areas for quality improvement work: i) patient centredness, ii) focus on learning within the healthcare system, and iii) organization of the healthcare system. Elg et al. (2011) also stressed that patients’ needs and complaints are important issues to address by using the tools of QI work. Involving patients in QI work can enhance the quality of care (Gremyr et al., 2018). Andersson (2013) found that staff satisfaction was the top-ranked driving force for quality improvement work, while issues regarding patients’ experiences of care and patient safety came second and third. In our study, we have shown that most QI projects performed by students were related to staff’s daily work. These findings are in line with an early report made by Olsson et al. (2003), which found that improvement work is often driven by good ideas from members of the local healthcare setting which focus on dysfunctions related to daily work and the environment. We believe there is a notion, both among staff and students, that staff-related issues are usually beneficial, in the end, for patient processes and improved patient care. However, this is not clearly expressed by the students in their QI projects. Elg et al. (2011) have shown that the scope for improvement work has widened over the years. As well as the importance of contributions from single members of the team, there is now awareness of the importance of the patient´s voice and the involvement of higher management (Andersson & Olheden, 2012).

A couple of years after the start of the QI module of FMHS, based on the impression of the reports, clinical and academic supervisors supported the initiative that the students must highlight how the patients would benefit from the QI project, as it is not good enough focusing on staff satisfaction. We believe this is the reason for the shift from staff-related issues to patient-related issues, which explains how the focus of the QI projects changed over the years (Table 2).

Few of the students’ projects focused the learning process within the healthcare system. One of the learning outcomes of the QI module “to value how own and others’ professional knowledge and approach in collaboration affect the result of quality improvement work”, are in line with Batalden and Foster (2012) target area: “focus on learning within the healthcare system”. Our students are used to reflecting critically on their own learning processes, since this is a recurrent part of every tutorial group session in PBL. However, the students may have difficulty in becoming aware of professionals’ learning processes. On the other hand, the collaboration with clinical practice during the QI module and the report back to the clinic was acknowledged as an important learning opportunity for the staff (from evaluations with the clinical supervisors). It is a challenge for everybody to engage in this learning experience to shift the focus from a profession-specific into an interprofessional perspective. Students reached the learning outcome regarding “applying methods and tools from models of QI”, and “analyzing the complexity of quality improvement processes” based on the reports assessed. However, there is a challenge to reach the learning outcome concerning interprofessional competence, and the complexity of the project and the level of interprofessional teamwork required needed to be addressed (Gjessing et al., 2014). It is not always evident that QI work could be done by an interprofessional team. However, it is our experience that QI based on a real clinical challenge inspires the students to participate in improving healthcare services.

Although we see many ways to develop our QI module, we are pleased to note that the results from a recurrent questionnaire from the Swedish Medical Association show that 75% of medical doctors who had graduated from FMHS think they are well prepared for continuous quality improvement work, and 90% think they are prepared for teamwork, which is a much larger proportion than reported from students at other medical schools in Sweden (Rydberg Stale et al., 2015).

In general, it is not likely that the interventions identified and suggested during only a 2-week period would create measurable changes, but feedback from recurring meetings between faculty and clinical staff showed that many of the students’ QI projects influenced everyday clinical practice. For example, one of the projects inspired the healthcare provider to start a mobile cervical screening team, increasing the accessibility for women to participate in cervical screening for viral infections, abnormal cervical cells, and cancer. Overall, we suggest that the close collaboration between FMHS and the health care provider stimulated continuous and increasing efforts of professionals in the healthcare system to work with QI. It is argued that undergraduate professional healthcare programmes need to develop students’ capacities of interprofessional collaboration and person-centered care in order to meet the challenges and the changing conditions for future healthcare (Frenk et al., 2010; World Health Organization [WHO], 2010; Costanza, 2015). Our design of the IPE curriculum is constructed to meet this challenge and we believe that QI knowledge plays an important role in this development. We emphasize the need to include QI in a modern curriculum for all undergraduate student programmes within healthcare, in accordance with the evolving needs for such skills among healthcare professionals. We also stress the value of offering such education in interprofessional student groups, in order to mimic the interprofessional collaboration needed to improve healthcare processes, patient safety, and efficiency in everyday clinical work.

Conclusion

A curriculum including IPE and QI will provide tomorrow’s healthcare professionals with the necessary knowledge and skills for the best use of evidence-based healthcare, all for the benefit of patients. However, students tended to apply the same approach to QI work as staff, dealing mostly with staff-related issues that did not obviously improve direct care of patients, something that might be prevented by means of proper introduction and supervision during the students’ learning process.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.

Acknowledgments

The authors are indebted to Paul Batalden, Ebba Berglund, Staffan Pelling, Tommy Skau, and all the clinical supervisors and quality improvement managers supporting the students’ learning.

Additional information

Notes on contributors

Annika Lindh Falk

Annika Lindh Falk, senior lecturer, MSc in Occupational Therapy and PhD in Medical Education. Involved in higher education and is Programme Director for Interprofessional Education. Her research interest is interprofessional learning and collaboration in Health Care.

Pia Tingström

Pia Tingström, ass professor, RN. Main research area is patient education and interprofessional collaborative practice in care settings of frail elderly. Also, students' interprofessional clinical placements is a research area of interest.

Mats Hammar

Mats Hammar, professor emeritus in obstetrics and gynecology, has been involved in education, mainly the medical programme and has published a number of papers on education, e.g. on interprofessional learning.

Johanna Dahlberg

Johanna Dahlberg, senior lecturer, IPE-coordinator. Johanna is engaged in interprofessional education, and the Medical programme. She is doing research in interprofessional education and collaborative practice, mainly in simulation.