Practical strategies to enhance resident engagement in clinical quality improvement

Abstract

Background: Engaging residents in meaningful quality improvement (QI) is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. Various strategies to address these challenges for engagement have been described, but not as a unified approach. This paper describes a bundle of practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program.

Methods: 62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA (Plan-Do-Study-Act) cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents, and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1 = least desired and 5 = most desired result. Data were analyzed by paired t-test.

Results: All 62 residents participated in the program as members of ten QI teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p = 0.03), frequency of QI use (3.3 to 3.9, p = 0.001), and opinion about using QI in clinical work (3.9 to 4.0, p = 0.21). Resident assessment of QI priority in clinical work did not change.

Conclusions: We implemented a practical strategies bundle to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents' own practice, and real-time faculty coaching.

Keywords: Graduate medical education; Practice based learning and improvement; Quality improvement; Systems based practice.

Fig. 1

Resident QI Learning Documented in Posters. Number of resident team QI posters demonstrating achievement of key QI education program learning goals

Fig. 2

Resident QI Engagement. Responses to pre/post surveys, n = 40/62 (64.5%). Key to scales. Likelihood: 1 = Extremely Unlikely, 2 = Unlikely, 3 = Neutral, 4 = Likely, 5 = Extremely Likely. Frequency: 1 = Never, 2 = Rarely, 3 = Occasionally, 4 = Frequently, 5 = Always. Opinion: 1 = Skeptical, 2 = Not interested but acknowledge it has to be done, 3 = Indifferent, 4 = Interested, 5 = Enthusiastic. Priority: 1 = Not a priority, 2 = Low, 3 = Medium, 4 = High, 5 = Essential