Team-based Quality Improvement Projects Research Articles

Optimizing Education to Improve COVID-19 Vaccination Rates in a Federally Qualified Health Center.

COVID-19 vaccination hesitancy is prevalent in underserved communities, and family medicine clinics can combat hesitancy with vaccine education. However, due to general misinformation, physicians hesitate to educate patients because doing so can create conflict. A series of resident-run, team-based quality improvement projects were conducted at a federally qualified health center every 4 months between June 2021 and May 2022. First, staff documentation of vaccine status was addressed. Second, physician and staff education about COVID-19 vaccines was completed along with motivational interview training to avoid conflict with patients. Third, patient COVID-19 vaccine education was addressed. After Cycle 1, COVID-19 vaccine documentation status increased the number of patients who completed the vaccination series from 1% to 22%. Cycle 2 showed an increase in COVID-19 vaccination rate after health care team education. This reflected an increase from 35% to 76% of residents reporting that they discussed COVID-19 vaccines with unvaccinated patients after the intervention. Cycle 3 fought vaccine misinformation by educating patients. Most patients heard information about COVID-19 vaccines from friends and family (95%), social media (90%), and the news (80%). Physician confidence in providing COVID-19 vaccine education to patients increased from 2.8 (< somewhat confident) to 4.3 (moderately confident) out of 5 over 3 plan-do-study-act cycles. Vaccination rates were tracked alongside physician surveys regarding the experience of offering the vaccine to patients. Vaccination rates steadily increased over time, and physicians became more confident in COVID-19 vaccine discussions with patients. Primary care physicians are needed to approach public health concerns, such as vaccination completion, but ongoing education is also needed to promote confidence in health care pathways.

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Improving Cervical Cancer Screening Rates at an Urban Federally Qualified Health Center Family Medicine Residency Clinic.

Background Family medicine residency clinics and underserved Federally Qualified Health Center clinics often have lower rates of cervical cancer screening (CCS). Methods A series of resident-run, team-based quality improvement projects were conducted to iteratively improve CCS rates in an urban Federally Qualified Health Center in a high-need and high-demand region. Results The authors were able to improve CCS rates from 52.2% to 66.3% through 6 quality improvement projects. Conclusion Improving the clinical workflows and systems to promote better rates of CCS likely requires a series of changes, however, promoting CCS in the usual clinic workflow, regardless of the reason for visit, demonstrated the greatest gains in CCS in our setting.

Hypersensitivity Reactions: Practice Recommendations for Paclitaxel Administration.

Paclitaxel is a high-alert IV oncology medication that causes hypersensitivity reactions (HSRs) in 10%-40% of infusions, predominantly during the first or second infusion. Although paclitaxel has been a common medication in cancer treatment regimens for decades, the literature fails to address the safest approach for administration to minimize HSRs. Oncology teams may implement different methods of administration. To address safety concerns and inconsistent findings in the literature, an advanced oncology clinical nurse specialist initiated a team-based quality improvement project. This retrospective study included chart reviews to assess organizational outpatient practices and documentation for paclitaxel administration. Results from this project were the basis for reinstating a standard order set, which includes titration during the first and second paclitaxel infusions to maximize patient safety.

National implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of ‘theory-of-change’ methodology

BackgroundThere is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the ‘Education in Quality Improvement’ program (EQUIP) in UK urology residencies. Materials & methodsTheory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation ‘Logic Model’ in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis. ResultsCore elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents’ QI projects). ConclusionsToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.

The Student Navigator Project (SNaP): Preparing Students Through Longitudinal Learning.

Early medical school education has historically focused on teaching basic medical sciences. More recently, medical schools are encouraged to incorporate health systems science (HSS) into early curricula. Addressing all of these components in an overcrowded curriculum remains challenging. We report on the Student Navigator Project (SNaP), a pre-clinical experience where students engage longitudinally with medically and socially complex patients. SNaP is built on a foundation of trust, responsibility, and ownership in the student-patient relationship. Early learners take an active role in navigating, advocating, and coaching for their patients. In addition, students are integrated as medical assistants into a primary care clinic; complete a mentored, team-based quality improvement project; and engage in evidence-based medicine, teaching, and handoff activities. As a result of these activities, students learn firsthand about HSS, contribute meaningfully to their patients' care, and are immersed in a systems-based practice approach early in their medical school education. Preliminary outcomes (2016-2019) show satisfaction with the program and knowledge of program focus areas. The authors are engaged in improvement cycles to modify program structure and curriculum in order to promote dissemination in diverse clinical settings. Ultimately, we plan to measure longer-term outcomes, including clerkship and residency preparation, career choice, and practice setting.

A New Quality Improvement Toolkit to Improve Opioid Prescribing in Primary Care.

The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This article summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing. The authors developed a list of opioid-prescribing best practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over 3 trials in the form of a toolkit. Outcome measures included pre- and postproject surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation. Ten clinics participated in trial 1, completing the QI project on average in 3 months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in trials 1 and 2 focused on regulatory compliance (35% to 36%), whereas in Trial 3 there was a strong move toward peer support (81%). Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support. Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.

A resident-led project to improve documentation of overweight and obesity in a primary care clinic

ABSTRACTBackground: Although the prevalence of overweight and obesity (OW/OB) has increased in the last three decades, studies show that these conditions are sub-optimally documented by physicians. Health information technology tools have varying effects on improving documentation of OW/OB but often have to be complemented with other interventions to be effective.Objective: Upon identifying low rates of documentation of diagnoses of overweight and obesity by resident and attending physicians, despite the use of an electronic health record (EHR) with automated BMI calculations, we performed a quality improvement (QI) project to improve documentation of these diagnoses for patients in our community hospital primary care clinic.Methods: The EHR was reviewed to determine documentation rates by resident and attending physicians between 1 March 2018 and 31 September 2018. We collected pre-intervention data, developed interventions, and implemented tests of change using Plan-Do-Study-Act (PDSA) cycles to improve documentation of OW/OB.Results: Documentation of overweight and obesity diagnoses increased from a baseline of 46% to 79% over a 20-week period after initiation of our project.Conclusion: We demonstrate the successful implementation of resident-led, multi-faceted interventions in a team-based QI project to optimize documentation of OW/OB in the EHR.

Multilevel Quality Improvement Teams: An Alternative Approach for Surgical Academic Training Programs to Meet ACGME Core Competency Milestones

Quality improvement (QI) activities are an integral part of residency training. We started the process to implement team-based, multilevel QI project streams within our academic surgical residency by studying resident perceptions. Our residency carried out 6 QI projects in line with the American Council for Graduate Medical Education competencies. A resident survey was completed in 2016 to measure resident perceptions of an individual versus team-based QI project approach. This was a descriptive study looking at resident's preference for team projects and ongoing projects within the training program. We started in 2014 utilizing Wait's Team Action Projects in surgery paradigm to conduct 6 QI projects. After initiation of projects, we allotted 2 full years to pass prior to assessing resident perceptions via a 12-item survey. Notably, this was a descriptive study aiming to capture resident perceptions on team-based QI and the foundational elements necessary to create and sustain such projects by integrating into our curriculum from the intern year. In 2016, 40 residents completed surveys (72.7% response rate), all (100%) opined that they preferred team-based approaches over individual ones, and 75% were on board to move forward with only a team-based approach in the future. This was a pivotal start to adopting a team-based QI project strategy in the future and laid a solid foundation to build upon. We found residents in our program desire to work within teams early on to develop effective solutions to clinical problems. Residents perceived that the team-based model resulted in an improved resident experience with the QI process and improved patient care. We hope to publish a series of articles updating our progress as we move forward in this endeavor.

A Project-Based, Resident-Led Quality Improvement Curriculum Within a Pediatric Continuity Clinic.

Participation in quality improvement (QI) projects is required of pediatric residents, and evidence-based medicine has highlighted the importance of providing residents with experiential practice in this realm. Embedding QI projects within a continuity clinic provides residents an opportunity for meaningful involvement in QI efforts. A QI curriculum was implemented within a pediatric residency program that included an introductory lecture on QI principles and participation in resident-led, team-based QI projects at an outpatient clinic. Residents designed, implemented, and analyzed projects beginning in their intern year. Projects operated on an accelerated, 6-month time frame, allowing residents to complete multiple projects over the course of their residency. Resident QI knowledge was assessed before and after an introductory lecture with the Quality Improvement Knowledge Application Tool (QIKAT). Resident feedback was solicited 1 year following curriculum implementation via anonymous online surveys. Residents completed four QI projects that produced meaningful improvements in clinic processes and patient care. QIKAT scores significantly increased after the introductory lecture. Residents reported that the curriculum afforded them increased confidence to implement plan-do-study-act cycles and improve patient care in their future practices. Qualitative feedback highlighted the team-based structure, participation in multiple projects, and visible direct impacts on patient care as strengths of the curriculum. Increased involvement of clinic staff, scheduling concerns, and improved communication were areas for improvement. Our model for integrating resident-led QI projects into an ambulatory clinic rotation is feasible and has been well received by residents and impactful on clinic processes and care.

Detailed Findings From the CLER National Report of Findings 2018.

Detailed Findings From the CLER National Report of Findings 2018.

Teaching Quality Improvement in Graduate Medical Education: An Experiential and Team-Based Approach to the Acquisition of Quality Improvement Competencies.

An emerging priority in medical education is the need to facilitate learners' acquisition of quality improvement (QI) competencies. Accreditation bodies in both Canada and the United States have included QI and patient safety in their core competencies. In 2010, the Department of Family Medicine at Queen's University designed a graduate medical education curriculum to engage residents in a clinical QI program that would meet accreditation requirements. Monthly didactic sessions were combined with an experiential, team-based QI project that aligned with existing clinic priorities. The curriculum spans the first year of residency and is divided into three stages: (1) Engaging, (2) Understanding, and (3) Improving and translating. In Stage 1, teams of residents select a clinical QI topic, engage stakeholders, and collect baseline data related to their topic. In Stage 2, they focus on understanding their problem, interpreting their results, and applying QI tools. In Stage 3, they develop change ideas, translate their knowledge, and prepare to hand over their project. This QI curriculum aided residents in effectively acquiring QI competencies and allowed them to experience real-world challenges, such as securing project buy-in, negotiating with peers, and developing solutions to problems. Unlike in many QI programs, residents learned how to improve quality rather than about QI; thus, they formed the necessary foundation to carry out QI work in the future. The curriculum will be evaluated using a knowledge assessment and satisfaction tool and postproject resident interviews. Facilitators will focus more on improving faculty develop ment in QI.

Implementation of Quality Improvement Skills by Primary Care Teams

Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams. We obtained qualitative and quantitative information about existing primary care team QI initiatives. Eleven interdisciplinary primary care teams and 4 facilitators/coaches. We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators. In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Impact of a competency based curriculum on quality improvement among internal medicine residents

BackgroundTeaching quality improvement (QI) principles during residency is an important component of promoting patient safety and improving quality of care. The literature on QI curricula for internal medicine residents is limited. We sought to evaluate the impact of a competency based curriculum on QI among internal medicine residents.MethodsThis was a prospective, cohort study over four years (2007–2011) using pre-post curriculum comparison design in an internal medicine residency program in Canada. Overall 175 post-graduate year one internal medicine residents participated. A two-phase, competency based curriculum on QI was developed with didactic workshops and longitudinal, team-based QI projects. The main outcome measures included self-assessment, objective assessment using the Quality Improvement Knowledge Assessment Tool (QIKAT) scores to assess QI knowledge, and performance-based assessment via presentation of longitudinal QI projects.ResultsOverall 175 residents participated, with a response rate of 160/175 (91%) post-curriculum and 114/175 (65%) after conducting their longitudinal QI project. Residents’ self-reported confidence in making changes to improve health increased and was sustained at twelve months post-curriculum. Self-assessment scores of QI skills improved significantly from pre-curriculum (53.4 to 69.2 percent post-curriculum [p-value 0.002]) and scores were sustained at twelve months after conducting their longitudinal QI projects (53.4 to 72.2 percent [p-value 0.005]). Objective scores using the QIKAT increased post-curriculum from 8.3 to 10.1 out of 15 (p-value for difference <0.001) and this change was sustained at twelve months post-project with average individual scores of 10.7 out of 15 (p-value for difference from pre-curriculum <0.001). Performance-based assessment occurred via presentation of all projects at the annual QI Project Podium Presentation Day.ConclusionThe competency based curriculum on QI improved residents’ QI knowledge and skills during residency training. Importantly, residents perceived that their QI knowledge improved after the curriculum and this also correlated to improved QIKAT scores. Experiential QI project work appeared to contribute to sustaining QI knowledge at twelve months.

Building capacity for quality: a pilot co-learning curriculum in quality improvement for faculty and resident learners.

Despite a mandate to teach quality improvement (QI) to residents, many training programs lack faculty capacity to deliver a QI curriculum. We piloted a co-learning curriculum in QI to train residents while simultaneously developing QI teachers. We evaluated the curriculum's acceptability and feasibility and its effect on faculty engagement in doing and teaching QI. The curriculum involved 2 half-day, interactive sessions, a team-based QI project, and end-of-year project presentations. Key curriculum design principles included (1) residents and faculty co-attend all interactive sessions, (2) residents and faculty work together on team-based QI projects, and (3) QI projects align with divisional QI priorities. Using the Kirkpatrick framework for learner outcomes, we focused our program evaluation on Level 1 (satisfaction) and Level 2 (knowledge and skills acquisition) outcomes using year-end curriculum evaluations. Our study included 14 residents (70%) and 6 faculty members (30%). With respect to satisfaction (Kirkpatrick Level 1 outcome), 93% (13 of 14) of residents and 100% (6 of 6) of faculty participants rated the overall curriculum as "above average" or "outstanding." Regarding faculty knowledge and skills acquisition (Kirkpatrick Level 2 outcomes), faculty self-rated their QI knowledge and interest in QI higher than their intent to incorporate QI into future practice and their comfort in teaching or supervising QI projects. All 5 faculty respondents (100%) rated the co-learning model for faculty development in QI as "above average" or "outstanding." Teaching QI to residents and faculty as co-learners is feasible and acceptable and offers a promising model for programs to teach QI to residents while concurrently building faculty capacity.

Improving Pediatric Health Care Delivery by Engaging Residents in Team-Based Quality Improvement Projects

The goal was to implement and evaluate an experimental and longitudinal team-based curriculum in quality improvement (QI) for pediatric residents that would increase their ability to apply QI methodology while improving clinical processes and outcomes. The curriculum evolved over 3 years based on resident feedback. Working in teams, residents and faculty apply QI principles to systematically design and implement QI projects. Residents increased their level of comfort with key QI concepts. They showed an increase in QI skills by meaningful integration of the following QI concepts into their projects: establishing the magnitude of the problem, developing focused aims for improvement, identifying areas to change, using QI tools, collecting data, and assessing if changes were successful. The 10 resident-led projects conducted over the past 3 years also resulted in improvements in measures of multiple clinical processes and outcomes. This curriculum was effective and feasible within the constraints of residency work hours.