How to Create a Scholarly Quality Improvement Project in Six Steps Jo Ann Mitchell, DO, MA, Director of Medical Education, McLaren Oakland, Gerri Navarre, LMSW, MA, Administrative Director of Medical Education, Metro Health, Brandy Church, MA, Faculty Development Director, Statewide Campus System, William Corser, PhD, RN, Research Specialist, Statewide Campus System

Background The Statewide Campus System (SCS) of Michigan State University College of Osteopathic Medicine identified a need for faculty development within the member institutions to further advance knowledge and skills in quality improvement and patient safety.

Background SCS hosted a statewide faculty development session: the “Teach for Quality” Program offered by the American Association of Medical Colleges (AAMC) This project was developed as part of the Teach for Quality Initiative

Rationale Programs transitioning from accreditation by the American Osteopathic Association (AOA) to the Accreditation Council for Graduate Medical Education (ACGME) and are in need of scholarly activity and faculty development The Clinical Learning Environment Review (CLER) established by the ACGME ACGME requires residents and faculty to be involved in quality improvement initiatives

Scholarly Activity Faculty in AOA programs are often lacking on scholarly activity QI projects can be accomplished in a shorter time frame Opportunities to present projects at regional or national conferences

Purpose of Project Develop and test an online course to provide participants with a basic understanding of quality improvement & patient safety (QIPS) concepts and processes Apply the content to the clinical learning environment in graduate medical education (GME) settings.

Course The course entitled “The 6-Step Program to Scholarly Activity” enrolled faculty and residents in two teaching hospitals which were affiliated with the MSU Statewide Campus System: McLaren Oakland Hospital and Metro Health Hospital.

Six Steps to Scholarly Activity On line course – 6 lessons Offered in Desire to Learn (D2L) – Michigan State University on line educational platform

Course Objectives By the end of the project, each learner shall: Complete the series of six online QIPS modules; Identify a specific QIPS problem in their office or hospital practice; Create an “AIM statement” for identified problem; Construct and evaluate one “Plan-Do-Study-Act” (PDSA) cycle for identified problem; Design and complete a QI project in identified problem; and Disseminate project results at a local, state or national conference.

Course Overview Learners assigned a series of QIPS project content/design readings and learning activities. Learners were able to post questions and comments through a course discussion forum with participants from both institutions. Participants were expected to complete assignments, identify a prospective QIPS topic area, design and conduct the project, and prepare a poster for state/regional/national dissemination. A series of course drop boxes were provided to enable course leaders to monitor learner’s progress.

Assessment Tool A Pre and Post Survey (QIKAT) was administered to measure knowledge of QIPS processes –12 point Quality Improvement and Application Tool (QIKAT)

Introduction Introduction to course Participants introduce themselves Navigate D2L Complete pre-course survey (QIKAT)

Lesson 1 Purpose: Overview of evolution of quality and patient safety education in health care Quality Improvement and Patient Safety (QIPS) concepts Institute for HealthCare Improvement (IHI) Open School Enrollment: Module to complete: –QI 101: Fundamentals of Improvement

Lesson 1 Articles to read –To Err is Human (IOM, 2000) –Quality Improvement in Medical Education: Current and Future Directions –Designing for the future: Quality and Safety Education in US teaching hospitals –Hospital Strategies to Engage Physicians in Quality Improvement

Lesson 2 Purpose Review a CLER PowerPoint providing an overview of CLER, the six pathways Review the CLER brochure IHI Module: –A Guide to the Clinical Learning Environment

Lesson 3 Purpose: Learners to become familiar with the quality and patient safety initiatives in their respective institutions View Presentation by Quality Director at the Institution Attend a Quality/Patient Safety Meeting Reflect on institutional quality initiative and respond to questions

Lesson 4 Purpose: Identify a quality and patient safety issue in your clinical practice Select a quality or patient safety issue to improve Select key individuals and residents to assist

Lesson 4 Modules- IHI –QI 102 – The Model for Improvement: Your Engine for Change –QI Guide to the IHI Open School Improvement Practicum Develop an AIM Statement utilizing worksheet Discussion Board

Lesson 5 Purpose: Build on Lesson 4 and further develop the Plan-Do-Study-Act (PDSA) cycle for your improvement plan IHI module: –QI 106 Mastering PDSA Cycles and Run Charts Complete PDSA worksheet and develop plan

Lesson 5 Complete CITI Modules Institutional Review Board (IRB) submission for approval Begin implementation of the project

Lesson 6 Purpose: Prepare completed project for poster presentation IHI Module: –QI 103 Measuring for Improvement Complete Post Survey

Enrollment A total of 17 learners enrolled in the course beginning 08/13/2015. The learner cohort was comprised of 15 program directors/associate program directors, with two residents also enrolled. Thirteen (76.5% of total) learners introduced themselves to the remainder of the class.

Results Initial Pre-Course Survey A total of nine (53.0% of total) completed the 12-item Quality Improvement Knowledge Application Tool (QIKAT) 2 pre-course survey concerning their perceived QIPS project confidence levels

QIKAT Survey Summary scores averaged on a possible scale from 0 to 36 and ranged from 5 to 31 per individual learner. The lowest average rating scores were obtained for two items concerning “writing a clear “AIM” project statement” and identifying how data are linked to processes”

The two equally highest responses were obtained or items concerning “making changes in a system” and “identifying if a changes leads to improvement”

Course Module Completion Lesson One: 13 learners (76.5%) entered module at least once, and five learners (29.4%) submitted Institute for Healthcare Improvement 3 IHI101 course completion certificate. Lesson Two: four learners (23.5%) turned in documentation re: viewing CLER module. Lesson Three: two learners (11.8%) completed module and described at least one QIPS project in their respective GME setting. Lesson Four: One learner (5.9%) entered module. Lessons Five and Six: No learner activity.

Outcomes Although overall participation in the course was low, we did learn that learners were confident “identifying change” and “making change” but were not confident writing “AIM” project statements and “identifying how data are linked to process.

Outcomes What is not identified in the statistics is that learners from McLaren Oakland began mentoring residents on their quality projects and one learner attended the Resident Quality Council meetings. Metro Health faculty, after the fact, are asking to enroll in the course

Barriers Timing Time Navigating D2L

Discussion Faculty Priorities Self-directed course Personal Interaction

Conclusion Future projects to test the best ways to educate faculty to mentor residents in this area of graduate medical education are certainly needed.

References Association of American Medical Colleges. Teaching for Quality: Program overview. Available at: Institute for Healthcare Improvement. IHI Open School (module series). Available at: Kohn, L.T., Corrigan, J.M. Donaldson, M. (eds). (2000). To Err Is Human: Building a Safer Health System Committee on Quality of Health Care in America, Institute of Medicine. ISBN: , 312. pages, 6 x 9, (2000) Liebhaber, A., Draper, D.A., Cohen, G.R. (2009). Hospital Strategies to Engage Physicians in Quality Improvement. Center for Studying Health System Change, Robert Wood Johnson Foundation 127

References Mate, K.S. & Johnson, M.B. (2015). Designing for the Future: Quality and Safety Education at US Teaching Hospitals. Journal of Graduate Medical Education: 7, ( 2) doi: Ogrinc, G., Mooney, S.E., Estrada, C., Foster, T., Goldman, D., Hall, L.W., …..Watts. B. (2008).The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration, BMJ Quality and Safety 17 (Suppl I):i13–i32. doi: /qshc Vinci LM, Oyler J, Johnson JK, & Arora VM. (2010). Effect of a quality improvement curriculum on resident knowledge and skills in improvement. Quality & Safety in Health Care. 19(4), Wong, B. M., Levinson, W., Shojania, K.G. (2012). Quality Improvement in Medical Education: Current State and Future Directions: Medical Education, 46: