Purpose: To create a framework for teaching the knowledge and skills of practice-based learning and improvement to medical students and residents based on proven, effective strategies.
Method: The authors conducted a Medline search of English-language articles published between 1996 and May 2001, using the term quality improvement (QI), and cross-matched it with medical education and health professions education. A thematic-synthesis method of review was used to compile the information from the articles. Based on the literature review, an expert panel recommended educational objectives for practice-based learning and improvement.
Results: Twenty-seven articles met the inclusion criteria. The majority of studies were conducted in academic medical centers and medical schools and 40% addressed experiential learning of QI. More than 75% were qualitative case reports capturing educational outcomes, and 7% included an experimental study design. The expert panel integrated data from the literature review with the Dreyfus model of professional skill acquisition, the Institute for Healthcare Improvement's (IHI) knowledge domains for improving health care, and the ACGME competencies and generated a framework of core educational objectives about teaching practice-based learning and improvement to medical students and residents.
Conclusion: Teaching the knowledge and skills of practice-based learning and improvement to medical students and residents is a necessary and important foundation for improving patient care. The authors present a framework of learning objectives-informed by the literature and synthesized by the expert panel-to assist educational leaders when integrating these objectives into a curriculum. This framework serves as a blueprint to bridge the gap between current knowledge and future practice needs.
Dr. Michaels notices a pile of mail as he returns from precepting residents. Being the program director has mostly been enjoyable over the past few years, but keeping up with the rules and regulations can sometimes feel overwhelming. He opens correspondence from the Accreditation Council for Graduate Medical Education (ACGME). More changes in residency accreditation … bummer. He finally felt that he was getting ahead with his curriculum and now the rules are changing.
Two of these new competencies are particularly troublesome. He's heard of quality improvement and medical systems, but now he's supposed to certify residents are competent in practice-based learning and improvement and systems-based practice? How in the world … He reaches to the bookshelf and grabs the curriculum folder. Perhaps these elements are already part of the residents' learning? Maybe the appropriate learning objectives are already being taught?
As he scans the index of the curriculum, he realizes that the traditional framework does not address practice-based learning and improvement. Looking through the curriculum at this point is like trying to fish without a pole or bait-he has no tools available to find what he needs. Questions overwhelm him. What are appropriate objectives? Are the residents ready for this learning? What have they learned about this in medical school? How can I understand practice-based learning and improvement for my own patients? Can I just add another lunchtime lecture or are there skills that must be practiced? So many questions, and no reliable way to get them answered.
This scenario illustrates one possible reaction to the ACGME's recent shift to competency-based accreditation. Significant concern seems to center on the practice-based learning and improvement and systems-based practice competencies. In this paper, we review the current literature for teaching practice-based learning and improvement to residents and medical students and make recommendations based on review.
Recent successes in clinical improvement highlight the importance of teaching medical students and residents about the improvement of health care. For example, using improvement knowledge combined with clinical knowledge, teams have improved mortality after coronary artery bypass graft surgery,1 reduced infant mortality in a high-risk Native American population,2 and decreased cost and increased staff satisfaction on a general medicine inpatient unit.3
The ACGME's new approach to accreditation includes practice-based learning and improvement and systems-based practice as two of six core competencies that all residents must achieve.4 In addition, the Association of American Medical Colleges' Medical Student Outcomes Project Quality of Care committee has called for experience-based learning in the improvement of health care during medical school.5 These recommendations and changes in policy are on the heels of similar reports and recommendations from the Pew Health Professions Commisssion,6 the Institute of Medicine,7,8 and the Council on Graduate Medical Education.9
Against this backdrop of current successes in improvement work and recent policy changes, medical educators-at both undergraduate and residency levels-face significant challenges. What should we teach? How should we teach the improvement of health care? How will we measure success? To answer these questions, we reviewed the evidence in the literature and developed recommendations for teaching practice-based learning and improvement in medical school and residency.