Quality improvement (QI) in health care entails activities ranging from enhancing one's personal practice to reforming the larger health care system.1,2 The Accreditation Council for Graduate Medical Education (ACGME) recognizes this broad definition of QI in its mandate that physicians-in-training demonstrate competence in practice-based learning and improvement (PBLI) and systems-based practice (SBP).3 PBLI involves improving care in a physician's personal practice, whereas SBP requires understanding and improving care within the health care system.1,3,4 Although these competencies have been described as separate but related,1 educational theories that effectively link these competencies are lacking. Educational frameworks describing relationships between competency domains are needed to direct the development of effective curricula and appropriate teaching methods.
Transformative learning is an educational theory that states individuals must critically reflect on life events in order to change their beliefs or behaviors.5 We propose that the critical reflection that occurs during transformative learning can conceptually link PBLI and SBP. In this article, we discuss the PBLI and SBP competencies, review the transformative learning process, and describe how transformative learning can be used to teach and assess the improvement competencies. We envision educators will be able to use this framework to design meaningful learning experiences for residents as they progress from enhancing personal practice to improving the health care system.
Understanding PBLI and SBP
In 1999, the ACGME adopted its six general competencies for residents in training, which included PBLI and SBP. The ACGME states that PBLI requires residents to “investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning,” and that SBP is “an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”3 Researchers have observed that these competencies are not entirely intuitive and can be difficult to explain to residents and faculty.1 In simple terms, residents can achieve these competencies by answering two questions: (1) How can I change my own practice to improve patient care? (PBLI); and (2) How can I work with the health care system to improve patient care? (SBP).
Ziegelstein and Fiebach1 used creative metaphors of “the mirror” and “the village” to teach PBLI and SBP to residents. They explained PBLI as holding a mirror to one's personal practice to identify opportunities for improvement, whereas they likened SBP to many individuals (i.e., the “village”) collaborating to improve health care systems. Although these metaphors may help residents and faculty understand the individual meanings of the competencies, conceptual frameworks have not been elaborated to explain the important relationships between PBLI and SBP.
We believe that transformative learning theory, a conceptual framework developed by adult education scholar Jack Mezirow,5–7 can be used to understand and explain the relationship between PBLI and SBP competencies. Fundamentally, transformative learning is a process whereby individuals engage in critical reflection to develop new perspectives, skills, and behaviors.8
Specifically, the process of transformative learning begins with experiencing a disorienting dilemma, which is a life event that causes the learner to pause and question underlying beliefs and assumptions. The next and perhaps the most important phase is critically reflecting on the disorienting dilemma to expose the learner's limitations and areas for improvement. The learner then addresses these limitations by acquiring new knowledge, skills, or attitudes.9 Ultimately, these newly developed skills will transform the learner by providing him or her with fresh perspectives and powerful means for enacting improvement.
Critical reflection as the decision point
We believe that the critical reflection component of transformative learning is a decision point that leads to PBLI and SBP (see Figure 1). As previously described, transformative learning begins with a disorienting dilemma that leads to critical reflection, which results in perspective transformation. In clinical practice, a disorienting dilemma is a situation in which care of an individual patient does not go as planned. This may be an adverse event, a “near miss,” or simply a circumstance in which the achieved outcome was not as expected. Critical reflection on the disorienting dilemma may reveal deficiencies at the personal or system level that need to be addressed to improve patient care. If critical reflection reveals personal practice deficits, then the physician could be prompted to fill knowledge, behavior, or attitude gaps,10 resulting in transformed personal practice (i.e., PBLI). Alternatively, if critical reflection reveals system deficits, then the health care system could be changed by the physician's working to implement QI methodologies (i.e., SBP).2
The following hypothetical example demonstrates how critical reflection links the PBLI and SBP competencies.
A 75-year-old man with obesity and diabetes is admitted to the hospital for the treatment of lower extremity cellulitis. The patient is cared for by a first-year internal medicine resident. The resident feels uneasy because he performed a yearly examination on this patient in his continuity clinic four weeks ago, and he wonders if he may somehow be responsible for the patient's complication of diabetes (cellulitis).
The resident begins to reflect on the care that he provided to the patient. On reviewing the patient's case, he finds that the patient's HbA1c (glycated hemoglobin level) was 11% four weeks ago. He realizes that he had not appreciated the significance of this value and that he had not known how to counsel the patient on therapeutic lifestyle changes or how to appropriately adjust the patient's diabetes medications. He becomes embarrassed by the realization that instead of asking for help or reading about diabetes management, he had simply neglected the patient's HbA1c. Subsequently, he reviews the electronic appointment system and learns that the patient had not been seen for eight months prior to the recent clinic visit and has not scheduled any future follow-up appointments.
The resident's critical reflection uncovers his knowledge deficit regarding the care of patients with diabetes mellitus. At this point, the resident may engage in PBLI to change his practice. In this case, the resident reviews evidence-based guidelines and learns about the American Diabetes Association's recommendations for HbA1c monitoring and goals and the medical management of diabetes. He then reviews the medical records of 15 of his own diabetic patients and determines that their average HbA1c levels are suboptimal. Consequently, he sets a personal goal to improve the glycemic control of his diabetic patients and reaudit his charts in about six months.
Reflecting on the suboptimal care his patient received leads the resident to consider the impact of broader systems on the safety of diabetic patients. Specifically, he notices that the patient's appointment schedule is fragmented and that there is no system in place to ensure adequate and regular follow-up visits. Additionally, he notes that the laboratory order-entry system is poorly designed, requiring multiple key strokes to request HbA1c levels. This realization motivates and empowers the resident to tackle a QI project—as part of the residency program's SBP curriculum—to improve follow-up for diabetic patients. He applies QI methodologies to these problems and eventually creates a computerized reminder system based on ICD-9 codes to ensure patients with diabetes receive good continuity of care. He also simplifies the laboratory order-entry system.
As this example illustrates, the phases of transformative learning and the processes of PBLI and SBP are parallel. Critical reflection is the branch point at which PBLI or SBP can develop. If personal issues are identified during reflection, PBLI occurs. Alternatively, if systems issues are uncovered, SBP may ensue (see Figure 1).
Applying the Framework to Teaching and Assessing PBLI and SBP
Multiple curricula addressing elements of PBLI and SBP have been reported in the literature in recent years.11 PBLI competency has been demonstrated using numerous methods, including reviewing charts of continuity clinic patients for preventive services and advance health care directives,1 using electronic medical databases to improve personal practice,12 applying evidence-based medicine (EBM) to improve personal practice,13 and using practice improvement methodologies to enhance practice.14 The mainstay for assessment of resident competency at PBLI has been determination of adherence to EBM guidelines with chart or electronic reviews. Additional PBLI assessment methods have included use of the American Board of Internal Medicine Practice Improvement Modules,15 instruments to measure reflection on personal practice,16–18 and chart review of residents' preventive care performance.19,20
Residents' competency in SBP is commonly demonstrated by participation in QI initiatives.1,11,21,22 Curricula to teach SBP have focused on underserved populations, the cost of care, and patient advocacy.23 Assessment methods have included evaluation of written QI proposals,24 knowledge of QI25 and managed care,26 QI objective structured clinical examinations,4 and awareness of costs of care.27,28
Although numerous PBLI and SBP curricula exist, those that have used critical reflection to directly link residents' observations concerning their personal practice to systematic improvement initiatives are lacking. Yet, reflection is known to be an important method by which physicians become mindful of the art and science of medicine.29,30 Relative to QI, reflection represents a critical link between identifying opportunities for improvements in one's personal practice and system-wide changes in health care. We believe the transformative learning framework presented in this article will alert educators to the importance of reflection and guide them in the development of learning experiences that emphasize reflection as an essential step in the translation of practice-based observations to QI projects. Indeed, QI curricula and assessments that encompass critical reflection16,18 may hold greater potential to change future physician behaviors than those that emphasize knowledge alone.
At the Mayo Clinic internal medicine residency program in Rochester, Minnesota, we have instituted a formal curriculum regarding reflection on improvement opportunities that is based on a transformative learning framework. Every six months, resident physicians complete structured logs in which they describe events from their personal practices where patient care was not as expected. They then reflect on these events from personal and systems perspectives. The ideas generated from these logs have resulted in numerous personal practice and system improvements. Additionally, we have developed and validated an assessment instrument to rate the quality of these reflections; in the near future, we will create a program for rating the quality of all resident reflections, reviewing these ratings with residents, and inserting them into their QI portfolios.18
Transformative learning is a conceptual framework that helps residents and faculty understand and make connections between the improvement competencies via critical reflection. Educators may use this educational framework to design meaningful learning experiences for residents as they reflect on suboptimal patient care events and use those critical reflections to enhance their personal practice by addressing personal limitations (PBLI) or working to apply QI methodologies to improve the larger health care system (SBP).
Although the transformative learning framework has important implications for teaching the PBLI and SBP competencies, it also raises questions. For example, will highly reflective physicians who are skilled at identifying limitations in personal practice also be adept at transferring31 lessons learned to the next step of improving health care systems? Furthermore, will motivated and well-intentioned physicians be able to create positive systems changes without adequate training in improvement methodologies? We anticipate that addressing these issues will require medical educators to develop robust PBLI and SBP curricula that encourage residents to be reflective and empower them with QI skills. Future research is needed to determine relationships between a practitioner's level of reflection and variables to measure PBLI or SBP competency.
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