Engagement In Quality Improvement Research Articles

Customised knowledge-sharing platform to foster resident quality improvement activities, tracking and scholarship

IntroductionMeeting accreditation requirements to train resident physicians in quality improvement (QI) may require more than education. Barriers to resident QI engagement underscore the need to demonstrate the impact and value...

Challenges and promising solutions to engaging patients in healthcare implementation in the United States: an environmental scan

BackgroundOne practice in healthcare implementation is patient engagement in quality improvement and systems redesign. Implementers in healthcare systems include clinical leadership, middle managers, quality improvement personnel, and others facilitating changes or adoption of new interventions. Patients provide input into different aspects of health research. However, there is little attention to involve patients in implementing interventions, especially in the United States (U.S.), and this might be essential to reduce inequities. Implementers need clear strategies to overcome challenges, and might be able to learn from countries outside the U.S.MethodsWe wanted to understand existing work about how patients are being included in implementation activities in real world U.S. healthcare settings. We conducted an environmental scan of three data sources: webinars, published articles, and interviews with implementers who engaged patients in implementation activities in U.S. healthcare settings. We extracted, categorized, and triangulated from data sources the key activities, recurring challenges, and promising solutions using a coding template.ResultsWe found 27 examples of patient engagement in U.S. healthcare implementation across four webinars, 11 published articles, and seven interviews, mostly arranging patient engagement through groups and arranging processes for patients that changed how engaged they were able to be. Participants rarely specified if they were engaging a population experiencing healthcare inequities. Participants described eight recurring challenges; the two most frequently identified were: (1) recruiting patients representative of those served in the healthcare system; and (2) ensuring processes for equitable communication among all. We matched recurring challenges to promising solutions, such as logistic solutions on how to arrange meetings to enhance engagement or training in inclusivity and power-sharing.ConclusionWe clarified how some U.S. implementers are engaging patients in healthcare implementation activities using less and more intensive engagement. It was unclear whether reducing inequities was a goal. Patient engagement in redesigning U.S. healthcare service delivery appears similar to or less intense than in countries with more robust infrastructure for this, such as Canada and the United Kingdom. Challenges were common across jurisdictions, including retaining patients in the design/delivery of implementation activities. Implementers in any region can learn from those in other places.

Physician engagement in quality improvement: A cross-sectional study

Objective: The positive impact of quality improvement (QI) on organizational and system outcomes has the potential to contribute to a high-performing health system. Physician engagement in QI has been linked to the success and sustainability of improvement initiatives. An informed overview of physicians’ interests in QI, opportunities to be involved in QI efforts, and insights into physicians’ experiences of participation, both in hospital and general practice is critical to understanding the challenges and opportunities for physician engagement in QI. The purpose of this study was to gain insight into both the number of physicians currently trained and participating in QI and identify key barriers preventing physicians from being trained and participating in QI.Methods: A cross-sectional online survey was used to evaluate physician engagement in QI. A total of 231 physicians across Ontario, Canada, participated in the study.Results: Results indicate that leadership should continue to make Quality Improvement (QI) training opportunities available to physicians.Conclusions: If more physicians are to be engaged in QI, there is a need to clearly identify and communicate opportunities for QI projects.

A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum.

There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. We applied foundational QI methods, including process mapping, plan-do-study-act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident-reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator's checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.

Original Research: Exploring Frontline Nurses' Self-Perceived Levels of QI Engagement and QI Competence.

Nurse engagement in quality improvement (QI) is critical in the delivery of safe high-quality care, yet few studies have evaluated frontline nurses in this area. The purpose of this study was to identify and compare levels of self-reported QI engagement and QI competence among frontline nurses and nurse leaders. This study used a cross-sectional descriptive design. A convenience sample of frontline nurses (bedside RNs and advanced practice nurses) and nurse leaders from acute and ambulatory care sites completed the Nursing Quality Improvement in Practice (NQuIP) tool, which measures engagement and competence (knowledge, skills, and attitudes) in QI. Data from 6,351 surveys completed by frontline nurses and nurse leaders representing 66 sites nationwide were analyzed. Only 52.5% of all respondents reported participating in QI. Knowledge scores were relatively high, while skills scores-especially those related to using QI tools-were low. Overall attitudes toward QI were positive. Nurse leaders scored significantly higher in engagement and competence than the frontline nurses they supervise. The study findings indicate that nurse engagement in QI is limited. Although nurses' knowledge levels appear to be high, their limited competency in QI-related skills may contribute to low QI engagement. Leaders must make efforts to increase nurse engagement in order to attain high-quality outcomes. Using the NQuIP tool will allow leaders to evaluate nurses' self-perceived QI competence and engagement, which will aid in identifying target areas and developing effective strategies for improvement.

The Influence of Anti-LGBTQIA+ Legislation on Graduate Medical Education

More than 400 state bills that discriminate against lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender diverse identities (LGBTQIA+) are active or have passed in the 2023 US legislative session.1 Across the United States, 70% of state legislatures, largely concentrated in the Midwest and South, are considering at least one anti-LGBTQIA+ policy.1 These bills target the rights of LGBTQIA+ people, who represent over 7% of US adults, in essential areas of life: health care, education, public space, free speech and expression, credit, and federally funded programs.2 Examples include censoring of LGBTQIA+ content in education and media, restricting transgender students from participating in school activities, prohibiting individuals from using public bathrooms concordant with their gender identity, criminalizing gender-affirming care, allowing religious exemptions for discrimination against LGBTQIA+ persons, and restricting free speech and gender expression.1 Accordingly, patients living in affected regions face outright discrimination in everyday life and are fearful about their access to health care.3-6 Effects of anti-LGBTQIA+ legislation are relevant not only to patients but also to the health care workforce. Residents are an especially vulnerable population given their clinical and educational responsibilities and reporting roles.7 In response to the evolving sociopolitical landscape, we aim to describe the influence of anti-LGBTQIA+ legislation on graduate medical education (GME) and offer solutions for GME leaders to support their trainees and to advocate for change.Educators and academic institutions should not underestimate the consequences and insidiousness of anti-LGBTQIA+ legislation. While it may seem that efforts to oppress LGBTQIA+ people affect only a minority of the workforce, most LGBTQIA+-identifying residents are not “out” to their peers, mentors, and supervisors.8 Meanwhile, physicians who do not identify as LGBTQIA+ will have patients, children, other family members, and friends who are affected by these policies. The constitutional ambiguity of many of these laws leaves enforcement at the discretion of subjective and bias-prone policing. For example, the Tennessee Senate Bill 0003 regarding “male or female impersonators” can be interpreted to broadly outlaw gender expression that is discordant from one's sex assigned at birth.9 Therefore, a resident assigned male at birth who wears traditionally feminine clothing, such as heels or a cropped shirt, could be charged with a misdemeanor or felony—risking their future medical license and hospital credentials. Such expression is part of the rich history and culture belonging to the LGBTQIA+ community. Because free speech and expression are protected US rights, it is unacceptable for residents to sacrifice their identity for their training and careers.Bills aimed at silencing LGBTQIA+ voices and advocacy in education are also highly relevant to GME. Florida's proposed House Bill 999 law would force postsecondary institutions to restrict funding for and remove LGBTQIA+ affinity organizations, and any majors, minors, or concentrations related to diversity, equity, and inclusion.10 Furthermore, restrictions on LGBTQIA+-related health care, including bans on gender-affirming care, require programs to offer alternative training opportunities, such as simulations or clinical experiences in other states, for trainees in various medical (eg, primary care, endocrinology, infectious disease) and surgical (eg, urology, plastic surgery) specialties.Although highly rewarding, practicing medicine is a high pressure, often stressful occupation that changes continuously in response to patient and societal expectations. In recent years, attention on physician mental health has increased with efforts underway to improve well-being throughout medical training.11 Despite these efforts, mental illness is pervasive in health care—nearly one-third of physicians have clinically significant depressive symptoms, and suicide risk is at least 3 times greater than the general population.12 Amid anti-LGBTQIA+ legislation, LGBTQIA+ residents face stressors associated with not only their physician roles, but also their gender and sexual identities. As a result of mistreatment and stigmatization in society, the risk of suicide in these individuals is 4 times higher than the general population.13 For an LGBTQIA+ resident, the intersection of roles and identities amplifies the already unacceptable mental illness burden in the physician population. Studies surveying residents and medical students show that LGBTQIA+ trainees report disparate rates of discrimination, mistreatment, and burnout compared with their heteronormative peers.8 Although we prioritize physician and trainee well-being to improve patient care, attrition and burnout are also financially devastating for health care institutions. A recent analysis found the annual cost of turnover and reduced clinical hours associated with burnout was approximately $7,600 per employed physician for an estimated total of $4.6 billion nationally.14 These findings demonstrate that supporting LGBTQIA+ residents and improving advocacy for LGBTQIA+ identities in GME have benefits beyond personal and patient care-related outcomes.Lifestyle is increasingly important to senior medical students when choosing residency programs.15 Considering safety and mental health consequences, we expect many LGBTQIA+ medical students will avoid ranking programs in geographies with restrictive and discriminatory policies, such as the Midwest and the South.16 Even without legislation, there are serious threats to the safety of LGBTQIA+ individuals in many states and cities. Surveys show that up to 19% of lesbian women and gay men have been assaulted because of their sexual orientation, 40% have been threatened with physical violence, and 94% have experienced some type of victimization, including verbal abuse.17 Because no studies have examined how anti-LGBTQIA+ policy has influenced the Match process in recent years, further research should investigate whether LGBTQIA+ medical students are disproportionately more likely to avoid certain specialties or remain unmatched as a result of limited acceptable positions. This reality is harmful to students who are thus restricted in rank options, patients who deserve and benefit from a diverse health care workforce, and programs that seek to attract diverse and talented residents and fellows to advance their specialties. The consequences amplify an already limited pipeline to the diversification of faculty within academia and GME leadership positions. GME offices and program directors should consider several institutional- and systems-level actions, as the rights of their LGBTQIA+ workforce are increasingly threatened.Faculty mentoring is important for trainee wellness, especially as part of a structured program.18 By providing residents an opportunity to form longitudinal relationships with faculty, a safety net of community support within the residency program is created that can extend beyond the clinical environment.19 Some mentor-trainee relationships are substantially strengthened by concordant interests and identities; however, it may be difficult for LGBTQIA+ trainees to find a faculty mentor with similar identities and experiences. Active efforts should be made to recruit diverse and inclusive faculty who can offer this mentorship and to train allies to bolster this mentorship. Additionally, residents may feel less vulnerable and more supported if there is representation of LGBTQIA+ identities in program and institutional leadership. Faculty members are better equipped to educate peers, leaders, and trainees about the LGBTQIA+ experience in ways residents cannot in their subordinate roles. Although legislation in some states targets the formation of affinity groups for people with LGBTQIA+ identities, creating an institutionally backed organization to give a voice to LGBTQIA+ residents and faculty should be prioritized wherever possible. Finally, our institution developed a 1-year fellowship program in LGBTQIA+ health to provide focused clinical expertise, research experience, and leadership training.Unfortunately, the politicization of LGBTQIA+ rights has created several barriers to supporting LGBTQIA+ trainees.20 To remain apolitical or maintain certain partnerships, health care institutions may avoid committing to a formal stance on anti-LGBTQIA+ legislation, especially in states where these policies are strongly promoted by state leaders. However, GME offices that serve as liaisons between residents and the medical center administration have a responsibility to optimize the safety and well-being of residents and patients—all of whom are threatened by discriminatory policies. This is not a political issue but rather a public health concern.Residents should be offered a reasonable amount of protected time to participate in advocacy activities and speak out about these issues. For example, legislators and activist organizations often invite medical trainees and other physicians to serve as experts in discussions of new policy. LGBTQIA+ trainees should be encouraged to form partnerships with local community organizations, which can be mutually beneficial through the exchange of resources and support. Moreover, trainees who are targeted by extremists because of their identity or advocacy should be connected with resources, such as institutional security, to ensure that they feel safe.21When visiting rotations and in-person interviews were limited during the COVID-19 pandemic, residency and fellowship applicants relied heavily on online information about GME programs. Recent studies show that content about diversity, equity, and inclusion on program websites is often absent or provides little useful information about the program or GME office's commitment to sponsoring trainees who identify as LGBTQIA+.22,23 Updating these resources to include efforts by GME to protect and empower LGBTQIA+ residents may help attract residents and foster community. Allocating funds for visiting student rotations, research, or other experiential learning opportunities at the institution should also be considered.22To achieve its mission to accredit programs that train physicians who will provide high-quality care to patients, the Accreditation Council for Graduate Medical Education (ACGME) uses several outcome measures for program evaluation. These measures include the assessment of resident well-being, workforce diversity, engagement in quality improvement and patient safety, and recruitment and retention.24 While some metrics may be objective, most measures are subjective, with programs having the ability to self-assess their achievement in reaching their aims. Accordingly, the ACGME should encourage GME stakeholders to develop, evaluate, and implement evidence-based performance metrics to assess programs in efforts to improve the quality of life for LGBTQIA+ people and other marginalized communities. If performance measures are determined, implementation through the ACGME Common Program Requirements and/or specialty-/subspecialty-specific Program Requirements are potential next steps. Supporting programs and GME institutions in improving the quality of life for LGBTQIA+ residents and fellows is an essential goal.In addition, the ACGME should ensure that relevant training in LGBTQIA+ health is included as appropriate within program curricula (eg, sexual health, gender-affirming hormone therapy and surgery, expected radiological findings). Similar to obstetrics and gynecology programs in areas where abortion is banned that send residents to pursue rotations at other institutions, the same strategy may be necessary for gender-affirming care in many states.25There have been discussions and proposals for increased transparency in GME funding, with calls for shifts in how funds are allocated to improve workforce diversity and health equity.26 GME programs are supported using federal, state, and independent funds. However, the primary source of funding is from the Centers for Medicare & Medicaid Services, which provides direct GME payments to cover direct teaching costs (eg, resident and faculty salaries) and indirect GME adjustments, which are designed to support teaching hospitals in providing care and learning opportunities in higher cost settings and to underserved populations.26 With the implementation of performance-based metrics for GME programs, funding might be allocated, as appropriate, to support institutions and programs that are actively working to dispel misinformation about LGBTQIA+ health, promote inclusive attitudes and health equity in the community, and oppose anti-LGBTQIA+ legislation. Such activities could have powerful, lasting effects to improve public health.National mandates for employee assistance programs for LGBTQIA+ trainees are needed, particularly in states with restrictive laws. LGBTQIA+ populations experience a disproportionate burden of mental illness and minority stress, and anti-LGBTQIA+ policy and attitudes have been shown to exacerbate these disparities.27 A healthy workforce will require access to confidential counseling and resources for personal and professional challenges.The rights of LGBTQIA+ people, which include both those of our workforce and our patients, should not be a partisan issue but rather a public health concern. As state legislatures introduce laws that seek to oppress LGBTQIA+ individuals, resident and fellow safety and quality of life are threatened, which affects recruitment, retention, and patient care. In addition to advocating for federal nondiscrimination protections, GME leaders and faculty have a duty to create learning environments in which all trainees have an equal opportunity to thrive. Such efforts may need to extend beyond medical centers to community, state, and national advocacy.

Expanded role of nurses in Swiss nursing homes and their engagement in quality improvement: A cross-sectional study.

To report on the engagement of Swiss nursing homes and of nurses in expanded roles in quality improvement. A cross-sectional study (2018-2019). Survey data from a sample of 115 Swiss nursing homes and 104 nurses in expanded roles. Descriptive statistics were used. Most participating nursing homes reported carrying several quality improvement activities (median of eight out of 10 activities surveyed) but some were only engaged in five activities or less. Nursing homes working with nurses in expanded roles (n = 83) showed greater engagement in quality improvement than those working with none. Nurses with more advanced qualifications (Bachelor's or Master's degree) engaged more in quality improvement than nurses with standard training. Specifically, higher educated nurses were more involved in data-focused activities. Using nurses in expanded roles can be a way forward for nursing homes seeking to actively carry out quality improvement in their facilities. Although a large proportion of nurses in expanded roles surveyed were implementing quality activities, their level of engagement depended on their educational level. Our findings support the principle that higher level competencies are a key aspect of data-based quality improvement in nursing homes. However, as Advance Practice Registered Nurses will remain difficult to recruit in nursing homes, using nurses in expanded roles might contribute to quality improvement.

Factors influencing family physician engagement in practice-based quality improvement: Qualitative study.

To explore the experiences of family physicians leading quality improvement (QI) efforts and to better understand facilitators and barriers related to advancing QI in family practice. Qualitative descriptive study. The Department of Family and Community Medicine at the University of Toronto in Ontario. The department launched a quality and innovation program in 2011 with the dual goals of teaching QI skills to learners and supporting faculty in leading QI efforts in practice. Family physician faculty who held QI leadership roles at any of the department's 14 teaching units between 2011 and 2018. Fifteen semistructured telephone interviews were conducted over 3 months in 2018. Analysis was informed by a qualitative descriptive approach. Consistency of responses across the interviews was suggestive of thematic saturation. Substantial variation was found in the level of engagement with QI in practice settings despite the common training, forms of support, and curriculum the department provided. Four factors influenced the uptake of QI. First, committed leadership across the organization was fundamental to developing an effective QI culture. Second, external drivers such as mandatory QI plans sometimes motivated engagement in QI but sometimes were barriers, particularly when internal priorities conflicted with external demands. Third, at many practices, QI was widely perceived as extra work rather than as a way to enable better patient care. Finally, physicians described lack of time and resources as a challenge, particularly in community practices, and advocated for practice facilitation as a mechanism to support QI efforts. Advancing QI in primary care practice will require committed leaders, a clear understanding among physicians of the potential benefits of QI, alignment of external demands with internal drivers for improvement, and dedicated time for QI work along with support such as practice facilitation.

Clinician Perspectives on the New Offloading Announcement in British Columbia: An Interview with Dr. John Hwang

In this interview, Dr. John Hwang shares his vision for persons living with diabetes in the province of British Columbia and across Canada. Dr. Hwang is a general surgeon and physician lead at the Fraser Health, Complex Wound Centre in British Columbia. He has specific interests in the optimal delivery of interprofessional wound care, as well as physician and wound care team engagement in quality improvement.

Role of patient and family engagement in quality improvement for pediatric surgery

In recent decades, the role of quality improvement (QI) in pediatric surgery has grown substantially. Patient and family engagement can help to maximize the impact of QI by enhancing safety and patient outcomes. Yet, broader, systematic efforts to actively involve patients and families in QI initiatives remain a persistent gap in pediatric surgery. To address this gap, we propose an agenda centered on three key goals for future quality improvement efforts: (1) building partnerships with patients and their families; (2) expanding the use of patient-reported outcomes (PROs) and novel, cross-disciplinary research methods; and (3) engaging patients and families consistently across all stages of pediatric surgical care. Fulfilling this agenda will be essential in shifting our mindset to view QI as a collective that involves patients, families, clinicians, and payers in continuous, system-wide opportunities to evaluate and improve care. Actively listening to and collaborating with patients and families may also help renew our focus on narrowing the gap between current practice and the best possible practice for children undergoing surgery.

Challenges to Engaging Women Veterans in Quality Improvement From Patient Care to Policy: Women's Health Managers' Perspectives.

Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman etal.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.

How did healthcare professionals define patient engagement in quality management? A survey study

BackgroundPatient and family engagement (PFE) can positively impact the patient experience and care process outcomes. There is no unique type of PFE, and the process is usually defined by the quality management department or professionals responsible for this process in the hospital. The objective of this study is to define PFE in quality management based on the professional’s perspective.MethodA survey was carried out with 90 professionals from Brazilian hospitals. There were two questions aimed at understanding the concept. The first was a multiple-choice question to identify synonyms. The second was an open-ended question to develop the definition. A content analysis methodology was employed by applying techniques for thematic and inferential analysis.ResultsThree words were classified as synonyms by more than 60% of respondents: involvement, participation, and centered care. The participants described patient participation at both the individual (related to the treatment) and organizational levels (related to quality improvement). The PFE in the treatment is related to the development, discussion and decision-making about the therapeutic plan, participation in each step of care, and knowledge of the institution's quality and safety processes. At the organizational level, engagement in quality improvement includes the involvement of the P/F in all processes of the institution, from strategic planning to the design or improvement processes, as well as active participation in institutional committees or commissions.ConclusionThe professionals defined engagement in two levels (individual and organizational) and the results suggest that their point of view can influence the practice in the hospitals. Professionals of hospitals that implemented mechanisms of consult defined PFE more in the individual level. On the other hand, professionals of hospitals that implemented mechanisms of involvement considered PFE more focus in the organizational level.

Applying a Rural Lens to Physician Leadership in Quality Improvement: A Scoping Review

Looking at physician engagement in quality improvement through a rural lens highlights both the increased need for and challenges to the involvement of physician leaders in rural settings. There is accentuated need for a “rural voice” in quality improvement leadership. This review considers best available evidence on the impact of physician leadership on QI and health system transformation and examines this evidence through a rural lens.

Using Project-Based Learning to Teach Advanced Practice Nurses About Quality Improvement

The universal challenge for clinicians worldwide is to provide safe and quality patient care that is based on the best available evidence. Despite current studies indicating that patients who receive evidence-based care have better outcomes, it is well documented that current care performed at the bedside is not based on the best current available evidence because of the delay from “bench to bedside.”1 Clinical inquiry aims to improve patient safety and quality of care through methodical exploration of a clinically significant phenomenon. So why are advanced practice nurses (APNs) not routinely formulating clinical inquiries in their daily clinical practice?Advanced practice nurses play a critical role in clinical inquiry, as we are able to identify local gaps in practice, processes, or systems that have the potential to negatively affect patient outcomes. Through curiosity about best available evidence, APNs can effectively guide clinical decision-making. Advanced practice nurses also have a perspective from patients about best care given their position at the bedside, bringing the literature and the patient perspective into alignment. Accordingly, a wide range of literature documents improvements in patient care and safety using quality improvement (QI) initiatives that have been developed and implemented by APNs. Therefore, with access to the right tools and education on how to best engage in and perform QI, APNs are poised to improve the quality of care and safety of patients. Despite adequate education, most APNs remain inexperienced in executing clinical inquiry independently in the clinical practice setting. Literature is still lacking on how to most effectively teach APNs in the clinical practice setting about clinical inquiry, specifically QI. Project-based learning (PjBL) is one teaching methodology, based in experiential adult learning theory and grounded in the notion that we as APNs learn better by doing; seeing and participating as a case unfolds in the form of PjBL provides important insights and demonstrates how to succeed in conducting a QI.The purpose of this column is to provide evidence for teaching QI to APNs in the clinical practice setting through the use of PjBL as a teaching methodology for facilitating more effective QI education.Quality improvement uses a systematic approach to distinguishing current practice from best practice and evidence-based practice (EBP). Quality improvement is about identifying gaps in performance in practice, process, or systems within an organization and implementing strategies to improve outcomes related to cost and productivity of work and care, quality of care, patient satisfaction, provider satisfaction, and ultimately patient outcomes. Advanced practice nurses are vital to QI given their presence at the bedside within the clinical practice setting. Regardless of widespread acknowledgement of the importance of QI in the clinical practice setting, it is likely not being used as effectively as possible. The Essentials: Core Competencies for Professional Nursing Education cite necessary competencies related to QI in the nursing scope of practice within broader domains at each education level.2 Among entry-level and advanced-level nursing education, nurses are prepared to participate in and develop initiatives that are aimed at quality and safety. If nurses have the knowledge and skills to participate in and develop QI, why is it not being done or done better?Despite their educational preparation, most APNs are unclear on how to successfully take a QI project from an idea to implementation. Education beyond the academic setting is needed even among doctor of nursing practice (DNP)-prepared nurses.3 To carefully construct a QI project, APNs must accurately identify a gap in their practice, engage with members of the interdisciplinary team and key stakeholders, evaluate the literature to determine best practice, develop a well-constructed plan, implement their plan, evaluate outcomes, and disseminate their findings internally to the organization and externally. Little guidance can be found in the literature on how to teach APNs about QI, particularly in the context of their clinical practice. Studies have shown that a lack of available continuing education and on-the-ground training about QI processes and a lack of mentorship within the practice setting remain barriers to nurses commencing projects.4-6Other barriers to QI exist at the provider and health-system levels; therefore, it is imperative that barriers to engagement in QI be addressed and overcome. Within the literature, barriers to engagement at the provider and health-system levels have included time constraints, heavy workload, lack of educational opportunities and mentorship, and the unique hospital or clinic-based culture.6-8 In addition, there is a notable lack of knowledge and skills among those who are practicing.9 Continuing education and training have been identified as facilitators of QI,4,8,10 and yet, these resources can be difficult to find. Education about QI has been associated with increased knowledge, skills, competency, and QI implementation and is urged by leading professional nursing organizations including the American Nurses Association and its subsidiaries.11Over the past decade, the number of APNs pursuing DNP degrees has grown exponentially. In a recent publication by the American Association of Colleges of Nursing, DNP graduates endorsed applying requisite skills in QI improvement to improve practice, processes, and systems in the clinical practice setting.12 All APNs, regardless of degree, can benefit from continuing to build skills and confidence for executing QI studies. The clinical practice arena provides an opportune setting to support APNs in pursuing advanced skills for improvement science through continuing education—education that provides APNs in the practice setting with the tools necessary to succeed. There is a need to promote the development, engagement, and mentorship of APNs interested in engaging in QI.6Quality improvement education with APNs new to QI at the bedside needs to be fostered, using teaching methodologies that encourage participation in existing projects in collaboration with mentorship with experienced colleagues.3,13 Several methods for teaching QI have been explored in the literature.14 Most methodologies for teaching QI have been explored in the academic setting with little evidence for teaching methodologies that can be applied in the clinical practice setting. Methodologies range from simple to complex, isolated to blended. Those that use active learning have been found to be more effective than traditional teaching methods such as didactic lectures.15Project-based learning is one teaching approach that has the potential to be used in the clinical practice setting to allow APNs to develop the knowledge and skills to execute QI more effectively, thus improving the development, design, and rigor of QI initiatives (Figure). Project-based learning encourages APNs who are novices in QI to collaborate with colleagues who have expertise in the clinical problem of interest. Through a standardized process, APNs obtain guidance and feedback on how to best facilitate nurse-led, evidence-based best practice initiatives. Rooted in constructivism, PjBL is a learner-focused teaching methodology that uses active learning and immersion to convey new knowledge (Figure). Project-based learning challenges the learner to apply theoretical knowledge and skills to real-world experiences in collaboration with faculty and others with expertise in the clinical problem.18 Through experiential learning, students engage in “learning by doing,” using an approach that is hands-on, clinically relevant, and culturally meaningful in the hospital setting.Advanced practice nurses curious about how to successfully develop, implement, and evaluate a QI project using PjBL can adopt a mentor-APN and learner-APN relationship through a professional nursing organization or several practice-based national networks (eg, the American Association of Critical-Care Nurses or the American Association of Nurse Practitioners). Project-based learning in the context of a QI project follows the EBP model with the intention of targeting specific learning goals through formal teaching principles and methods. The 7 steps for implementing PjBL can be sequentially followed, as depicted in the Figure. Through the steps, the mentor-APN provides support and guidance to accomplish successful transfer of knowledge, understanding, and skills while promoting learner-APN independence.19 Operationalization of learning goals for PjBL in QI projects can be found in the Table.Defining the problem is the foundation upon which to develop the QI project. The problem should be an important practice, process, or system issue that is identified, through discussion with other APNs and organizational leadership at different levels, as relevant within the context of the organization. After identification of the problem to be addressed, a broad clinical question should be developed that the learner-APN intends to answer. The initial clinical question will help drive subsequent steps.Sustained inquiry entails a deeper dive into the problem through the discovery and interpretation of relevant literature and iterative revision of the initial clinical question based on the literature.19 The learner-APN should appraise and synthesize the body of evidence related to the identified clinical problem. Accordingly, the learner-APN will formulate substantial conclusions of the most effective approaches to address the clinical problem that is based on the best evidence available. The learner-APN may propose alternative or complementary clinical questions.Quality improvement should be based on conclusive evidence. A key characteristic of authenticity is ensuring applicability within the real-world context.19 Real-world context can be related to quality and safety standards as deemed by regulatory or quality agencies, significance within the organization, relevance to current clinical practice, and vested interest in the clinical problem by the learner-APN.Integration of learner-APN input in the QI project is the basis for voice and choice.19 Development and implementation of the QI project should be based on the ideas of the learner-APN with guidance from the mentor-APN. Voice and choice fosters better learner-APN engagement and accountability within the QI project.Reflection involves learner-APN and mentor-APN self-evaluation of their role and performance within the QI project and evaluation of the outcomes associated with the QI project.19 Self-evaluation may involve specific knowledge and skill attained, quality of work, and barriers encountered with interventions implemented. Analysis of outcome data to determine the effectiveness of the practice, process, or system improvement should also be reflected upon.Methodical assessment of the learning process and the QI project is necessary to evaluate initial goals. Critique allows learner-APN views to be shared and acknowledged.19 Subsequently, the learner-APN is able to apply learned views to the revision of the QI project, resulting in an iterative process of improvement to both the learning process and the QI project.Dissemination of the QI project findings should take place within the organization and externally to achieve learner-APN knowledge translation and practice change. Internally, dissemination of the findings to organizational stakeholders, from unit leadership to hospital leadership, should take place. Externally, dissemination of outcomes can take place through presentation at professional meetings or publication within peer-reviewed journals to contribute to the current literature.Project-based learning is an innovative, evidence-based strategy by which learners are exposed to opportunities and challenges in the health care environment that may not be appreciated using other teaching methodologies. Project-based learning has been associated with improved learning outcomes, critical thinking and problem-solving skills, and competence by solving actual problems in an educational environment using dialogue between faculty and nursing students.20-25 Although little evidence exists regarding its use in the clinical practice setting in the nursing profession, PjBL specifically for QI has been shown to be an effective teaching strategy and increases knowledge and confidence in the academic setting.16,26 Current literature has demonstrated positive effects for PjBL on knowledge, critical thinking, problem-solving, and teamwork, among others.Project-based learning has been used infrequently by APNs in the clinical practice setting. Most QI learning tools offered in the clinical practice setting are executed through isolated didactic lecture rather than “learn by doing.” In contrast to the project-based, layered learning that takes place with PjBL, other QI tools for use in the clinical setting offer “micro-learning” in small, app-based segments.21 One example, BiteSizedQI, a mobile application developed for use by both clinicians and patients, offers small “sound bites” to provide the language and skills necessary for QI in clinical settings.27 Based on principles of Lean Six Sigma, the app shows a series of videos that build low-literacy, user-friendly questions and answers to reinforce content and evaluate learning. Similarly, the Institute for Healthcare Improvement web-based tools offer web-based skills development and online certification using learning modules and post-test quizzes.28 Unlike PjBL, these web-based programs deliver content and validate knowledge achievement without the added benefit of clinical context. Providing the clinical context adds meaningful learning and insight for APNs practicing in the clinical setting. Integration of PjBL into the clinical practice setting for APNs learning about QI should be a considered procedure to ensure accurate and standardized execution of QI can be achieved.Substantial evidence exists for the use of PjBL in the academic setting for teaching QI to nursing students; this experience may be applied in the clinical practice setting when teaching QI to APNs. Project-based learning is an effective teaching methodology for practicing APNs, in that it promotes the transfer of knowledge into clinical practice in a contextually and culturally meaningful way, addressing both the cognitive and psychomotor domains. Successful implementation of PjBL in the clinical practice setting engages the novice and expert APN together in QI and may be particularly advantageous for APNs pursuing clinical inquiry.

Patient Experience Feedback In Rehabilitation Quality Improvement And Codesign Activities: Scoping Review

<h3>Research Objectives</h3> To characterize the literature, including reported enablers and gaps, on the use of patient experience (Px) feedback in rehabilitation codesign and quality improvement (QI) activities. <h3>Design</h3> Scoping review. <h3>Setting</h3> Data sources: Scientific databases (PubMed, CINAHL, Rehabdata, Scopus, Web-of-Science, ProQuest); Greylit database, website searches (e.g., Beryl Institute), snowballing, and key-informant recommendations. <h3>Participants</h3> Study Selection: Two independent reviewers performed title-and-abstract screenings and full-text reviews. Eligibility criteria focused on English-language, peer-reviewed (all time) and grey literature (last 5 years) that engage Px feedback in rehabilitation QI or codesign activities. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Data extraction: The QI aims, settings, methods, patient engagement strategies, findings, implications, and reported limitations were extracted, followed by a content analysis identifying reported enablers and gaps. <h3>Results</h3> Data synthesis: Of 851 unique references and 50 full texts reviewed, ten papers were included: six used codesign to engage patients in QI activities; four used Px survey data to inform and evaluate QI activities. Implementation enablers included securing managerial support, having a designated methodology and facilitator - including for balancing power in codesign, using efficient processes, engaging staff experience feedback, and using appreciative inquiry. Gaps included limited follow-up, low sample sizes, analytical limitations, difficulties engaging patients with severe limitations, or lack of reported limitations. <h3>Conclusions</h3> Conclusion: Few examples of Px feedback engagement in QI or codesign activities were found in the rehabilitation literature, either scientific or grey. Px improvement activities were merely informed by Px survey data, not qualitative or participatory approaches which are often more actionable. The identified enablers and gaps can support the design, use, evaluation, and report of person-centered QI activities that meaningfully engage and use Px feedback. <h3>Author(s) Disclosures</h3> The authors declare no conflict of interest.

Examining QI Knowledge Among Frontline Nurses and Nurse Leaders.

Frontline nurses deliver direct patient care and by participating in quality improvement (QI) can have an impact on health care quality and safety. Unfortunately, nurses are not participating in QI, which may be due to a lack of QI knowledge. The purpose of this study was to evaluate nurses QI knowledge utilizing the revised Quality Improvement Knowledge Application Tool (QIKAT-R), with newly created nursing scenarios, among frontline nurses and nurse leaders. Using a cross-sectional design, this study evaluated nurses QI knowledge utilizing the QIKAT-R. Overall, QI knowledge among nurses was low. The frontline nurses (n = 44) scored higher than nurse leaders (n = 11) on overall QI knowledge scores, although not significant. Frontline nurses scored higher in QI knowledge related to aim and measure, whereas nurse leaders scored higher in change. Understanding frontline nurses QI knowledge, such as with the QIKAT-R with newly created nursing scenarios, can assist with creating targeted strategies for improving overall engagement in QI.

See one, do one, teach one: a flipped classroom to make quality improvement experiential in surgical residency

PurposeWe aimed to improve resident knowledge and engagement in quality improvement by developing a longitudinal experiential curriculum for all years of residency. We aimed to develop a flipped classroom in which content teaching happened prior to each session via short instructional videos the author team created, to maximize learner–faculty interactions around QI applications to real-world problems.MethodsFive 70-min interactive flipped-classroom sessions were devoted to the curriculum over a 12-month period. To evaluate the effect of the curriculum on resident knowledge, we used previously validated tools to assess QI skills and knowledge. We used both the Quality Improvement Knowledge Assessment Tool (QIKAT) and the QI self-assessment questionnaire of QI proficiency. The study was conducted at a large academic quaternary care center. All residents in the Department of Surgery at an academic teaching institution were involved by attending the surgical education sessions at the regularly scheduled time.ResultsTwo distinct QI projects were developed and implemented through the QI curriculum. These projects were both successful locally and generated academic productivity for the residents. We found an increase in QI self-assessment qualities which were statistically significant in the domains of knowledge and skills. Using the QIKAT, we found a non-statistically significant increase in knowledge after the intervention.ConclusionsThe QI curriculum developed for surgical residents has been successful in engaging residents in QI on an annual basis, improving QI knowledge and skills and has persisted in the official residency education schedule past its inaugural year.

Employee Engagement in Quality Improvement and Patient Sociodemographic Characteristics in Federally Qualified Health Centers.

Quality improvement (QI) work is critical, particularly in federally qualified health centers (FQHCs) that treat underserved populations. In a national sample of 45 FQHCs, we examined how patients' sociodemographic characteristics were associated with employee engagement in QI, via innovation contests that solicited ideas for improving care and offered opportunities to vote on ideas. We posited that patients' sociodemographic characteristics influence the complexity and intensity of clinical work and thus employees' capacity to engage in QI. Regression results indicated that the percentage of patients living in poverty was negatively associated with employee participation in idea submission and voting. Moreover, the percentage of Hispanic patients was negatively associated with participation in voting. The percentage of Black patients, however, was not associated with either outcome. FQHCs that serve a higher share of low income and/or Hispanic patients may face resource and personnel constraints that reduce employees' capacity to contribute to QI efforts.

Employee Engagement in Quality Improvement and Patient Sociodemographic Characteristics in FQHCs

Improving the quality of care is of paramount importance in federally qualified health centers (FQHCs). One strategy is to engage frontline employees by encouraging them to generate and share ideas for quality improvement. In a national sample of 54 FQHCs, we explore the relationship of employee engagement in quality improvement—via participation in innovation contests that sought ideas to improve patient care and offered opportunities to vote on shared ideas—and patients’ sociodemographic characteristics. Although all FQHCs deliver care to underserved populations, we find considerable variation in patients’ socioeconomic status in our sample. Furthermore, employees in FQHCs that serve a higher percentage of patients living in poverty and/or a higher percentage of Hispanic patients were less likely to participate in idea submission and voting. Our findings suggest that sociodemographic characteristics of the patients served in FQHCs may be important determinants of success when implementing quality improvement initiatives.

Impact of Point of Care Quality Improvement Training and Coaching on Quality Perceptions of Health Care Workers: Implication for Quality Policy.

BackgroundThe quality of infant healthcare service is one of the essential factors in preventing infant mortality. The purpose of the study was to analyze the quality performance in primary healthcare centers (PHC) and hospitals before and after the point of care quality improvement (POCQI) training for Infant Healthcare Services (IHS).MethodsThis is a mixed-method study design with convergence triangulation strategy, conducted at six public PHCs and four hospitals in two districts of West Java Province, Indonesia. One hundred health care workers (HCWs) were involved for quantitative study at baseline and end of intervention. An additional 40 patients participated as informants for qualitative study. Quantitative data analysis was performed by Rasch modeling and independent t-test for all variables, followed by content analysis for qualitative data.ResultsThere were significant changes in the variables of POCQI skill (mean diff: 5.14, p=0.001), quality improvement (QI) understanding (mean diff: 1.2; p=0.001), and QI engagement (mean diff: 1.7; p=0.001) in the PHC group. Although there was an increase in process and outcome variables, the changes were not significant. There was a significant change in all variables in the hospital group which were outcome (mean diff: 2.32 (p=0.19); POCQI skill (mean diff: 2.80, p=0.001); process (mean diff: 1.48, p= 0.01); QI understanding (mean diff: 1.01; p=0.01), and QI engagement (mean diff: 1.52; p=0.03). Patient perception in the qualitative study showed that PHCs and Hospitals’ services improved. Moreover, health care workers found they have a better understanding of service quality and created quality changes and improved POCQI steps.ConclusionImplementation of POCQI in PHC and hospitals improved the performance of the quality of his, therefore assuring that POCQI is an appropriate approach and tool to be adopted in the policy for strengthening the health system.