An Interactive Web-based Approach to Teach Third Year Students Continuous Quality Improvement STFM Predoctoral Education Conference 2008 Peer Papers Session: Technology Pablo Joo MD, Silvia Amesty MD MPH MSEd, Sharon Krackov EdD, Rachel Bregman MD, Michelle Hall, and Edgar Figueroa MD MPH Columbia P&S Center for Family and Community Medicine New York, New York

Goals 1. Illustrate a framework to enable medical educators to develop a Continuous Quality Improvement (CQI) curriculum. 2. Demonstrate a dynamic and interactive web-based intervention for teaching CQI.

Background The Liaison Committee on Medical Education (LCME) expects medical students to achieve competency on Practice Based Learning and Improvement (PBLI) objectives1. Teaching third year students CQI principles enables this goal by providing a foundation for improved patient outcomes.

Challenges Medical students rotate through different clinical clerkships and may experience limited continuity of care. Standard methods to teach CQI include: patient chart reviews, didactics, or journal clubs. These static methods may be limited in conveying to students the overall long-term impact of patient care outcome improvements.

Primary Care Clerkship: Setting Students spend five weeks at one of 22 practices around the United States Practice Sites: Family Medicine, Medicine, or Medicine / Pediatrics Practice settings: Private practice Community health centers, Clinics: Indian Health Service, public and private hospital ambulatory clinics, VA system, and residency programs

Our Intervention We chose an interactive web-based module to reach all our students at distant and diversified sites. Bronx VA Shiprock, NM IHS New York Presbyterian Family Medicine

Framework for Practice Based Learning and Improvement (PBLI) Web-Based Module Based module on PBLI educational objectives recommended by an expert panel for each training level (student  resident)2 We selected objectives appropriate for our third year medical students Learning intervention focused on CQI in chronic diabetes care

Diabetes and CQI Web Module: PBLI Student Objectives2 Demonstrate usefulness of improvement principles to patients, health care providers, and medical students. Identify the variation inherent in health care systems. Map the process of care for a diabetic clinical encounter from a patient’s point of view.

Diabetes and CQI Web Module PBLI Student Objectives2 Identify outcome and process measures appropriate for diabetes care. Be able to recommend changes in a clinical process for a group of patients. Apply the introductory concepts of CQI to patient-focused outcomes.

Our DM CQI Web Module Focuses on national standards for diabetes prevention, diagnosis, and management American Diabetes Association American Academy of Family Physicians Reviews principles of continuous quality improvement and their role in improving diabetes patient care outcomes.

Our DM CQI Web Exercise Students become medical directors of a simulated Cybertown Family Health Center and: Audit patient records from the cyber-clinic Explore CQI initiatives from their “real-life” clinical sites Write an essay proposing CQI initiatives to improve diabetes care for their cyber-clinic The essays include faculty feedback are electronically shared with all students.

Implementation Debut November 2006 173 students have completed the module and assignment as of December 2007

Preliminary Results: Knowledge Assessment 113 of 121 students (93.4%) correctly identified core concepts of CQI on a post-module knowledge assessment question.

Preliminary Results: Student Satisfaction Approximately how long did it take to read the module and to complete all the assignments and questions? Less than 2 hours 35.3% 2 hours to 4 hours 30.3% 4 hours to 6 hours 12.6% 6 hours to 8 hours 16.0% Greater than 8 hours 5.9% N=119

Preliminary Results: Student Satisfaction The materials in this web module added to my understanding of diabetes.  N=119

Preliminary Results: Student Satisfaction The materials in this web module added to my understanding of CQI. N=60

Findings Learning intervention links students’ clinical knowledge about diabetes to new continuous quality improvement knowledge. The module is directed to their level of experience with the new material. Students are active in their own learning process and share what they know with their teachers and peers. Students share CQI essays from sites across the United States, enabling them to compare and contrast differences in clinical systems.

Findings Interactive web based approach integrates simulated and real clinical experiences to facilitate CQI teaching. Web-based approach provides the immediacy needed for learning this longitudinal topic. Web-based education may facilitate the learning of concepts that are: challenged by distance require unfeasible longitudinal experiences can’t be taught in patient care or classrooms settings May ease communication and subsequently, collaboration and team work.

Conclusions Students proposed CQI initiatives and described: diverse patient demographics diabetes care processes from multiple perspectives community-based culturally responsive interventions interdisciplinary chronic disease management

New Challenges Developing student assessments that are linked to the competency based objectives for the module. Balancing the interactive nature of this module with time demands of the students and faculty. Locating partners in education technology to successfully build and maintain the module. Identifying “cyberteacher” faculty to give students feedback on their work.

Acknowledgements Columbia University Medical Center / Center for Education Research and Evaluation Columbia University Center for New Media Teaching and Learning Columbia P&S Primary Care Education Fund

Bibliography Current LCME Accreditation Standards Functions and Structure of a Medical School [accessed June 2007] Ogrinc, G., Headrick, L. “A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review.” Acad Med. 2003 Jul;78(7):748-56. More available on handout