A Longitudinal Curriculum for Quality Improvement, Leadership Experience, and Scholarship in a Family Medicine Residency Program

Residency programs must prepare physicians to meet the health care needs of our nation. The Accreditation Council for Graduate Medical Education (ACGME) requires that residents in all medical specialties be trained in quality improvement (QI), and that they complete scholarly projects.1 Physicians must be trained in leadership skills in order to achieve quality and safety goals of patient care.2,3 Residents, however, have described QI training as confusing, difficult to manage, and disconnected from clinical experience.4 Integrating QI training into clinical practice is challenging. Educational interventions that accomplish multiple educational goals simultaneously are desirable for their efficiency, as residency programs are challenged to meet all educational directives.5 A strategy for linking resident training in QI with scholarship has been published,6 but descriptions of existing curricula describe training that occurs in a single year,7 expect residents to work in isolation,8 and lack scholarship support.7-9

The aim of this study was to evaluate a Skills-based Experiential Embedded Quality Improvement (SEE-QI) curriculum that can be used for multiple missions: to train residents in QI, leadership, and scholarship. The goals of the curriculum are to achieve high resident competency in QI, provide resident leadership experience, and increase scholarship. This report describes the curriculum and its outcomes.

The University of Utah Family Medicine Residency Program (UUFMRP) developed the SEE-QI curriculum as a 3-year longitudinal skills-based QI curriculum. Key principles of the curriculum are: (1) longitudinal participation in QI teams throughout residency, with advancing responsibility each year; (2) leadership coaching for resident leaders on QI teams; and (3) scholarship training to help residents achieve QI scholarship (Figure 1).

The SEE-QI curriculum contains didactic sessions and application that is embedded in clinical operations at two residency clinics. Since 2012, residents learn by participating on and leading multidisciplinary teams through QI methodology for the advancement of clinical practice and disseminating their findings through scholarship.

Training includes 12 didactic sessions repeated each year. QI methods are based on the Model for Improvement (Figure 2).10,11

Example topics in the didactic sessions are process definition, team functionality, change management, and Squire guidelines (Table 1).12

Residents apply QI and leadership training by leading a QI team. All teams in this program are multidisciplinary, consisting of faculty, residents, nurses, clinical pharmacists, behavioral health providers, medical assistants, and reception staff. The teams meet monthly for 1 year and choose a topic related to chronic disease, screening, or immunization metrics.

All teams are led by third-year residents with direct supervision by faculty. First- and second-year residents participate as team members. Faculty leadership coaches debrief with residents after each team meeting and record qualitative feedback.

Resident leaders are required to disseminate the results of their team’s work in an oral presentation, and are encouraged to create an optional scholarship poster for external presentation. A faculty member serves as a scholarship coach on each team. To support scholarship, we created yearly scholarship time lines of submission deadlines, implemented an umbrella institutional review board approval, and offered staff assistance for poster preparation.

We based evaluation of the curriculum on a descriptive, explorative approach and focused on residency competency in QI and scholarship. We reviewed Practice-Based Learning and Improvement Milestone 3 (PBLI-3) “Improve systems in which the physician provides care,” developed by the ACGME for family medicine. Milestone competency levels range from Level 1 (novice) to Level 5 (expert).13 The Milestones were implemented in academic year 2015; competency levels were assessed by our Clinical Competency Committee, based on the ACGME rubric. For statistical analysis, we compared the mean scores achieved in PBLI-3 at the beginning and at the end of the residency program by using a Wilcoxon Matched-Pairs Sign-Rank Test. Because the Milestones were implemented in academic year 2015, data for the classes of 2017 and 2018 were available; only classes that completed all 3 years of measurement were included in statistical analysis.

In order to evaluate scholarship, we compared yearly resident-led scholarship products from 2008 to 2018. We constructed a stacked bar chart to show the number of products by type (required curricular QI scholarship, optional curricular QI scholarship, independent non-QI scholarship, and independent QI scholarship) by year.

The University of Utah IRB approved this study (#00124825).

Over the course of the curriculum, the mean scores for PBLI-3 increased significantly in the class of 2017 from 1.4 to 4.6 (P<.05) ,and in the class of 2018 from 1.4 to 4.4 (P<.05; Figure 3). Prior to implementing the curriculum, the baseline QI scholarship rate was eight required oral QI presentations per year with no optional or independent QI scholarship. Once the curriculum was implemented, optional curricular QI scholarship increased, independent QI scholarship increased and there was no decrease in other scholarship (Figure 4). In addition to the scholarship presentations, four residents published peer-reviewed articles of their required SEE-QI project after completing residency.14-17

The SEE-QI curriculum leveraged the ACGME requirements for QI for multiple educational purposes. Prior to the curriculum, resident QI work was an isolated endeavor, not embedded in clinical operations, with minimal scholarship. The curriculum resulted in a high level of resident competency, provided leadership experience in a clinical environment, and increased resident scholarship. By the end of the curriculum, every resident was able to lead a multidisciplinary team through the QI process. As measured by Milestone PBLI-3, residents demonstrated advancement in their QI skills over the course of the 3-year family medicine residency program.

Although residency scholarship requirements did not change, scholarship increased with implementation of the curriculum. The increase in scholarship was most notable in optional poster presentations, but new independent QI scholarship was also produced. We attribute this to creating an understanding of the QI framework as a scholarship opportunity and increased programmatic support.

This evaluation has several limitations. First, ACGME Milestones were implemented in academic year 2015. Prior to 2015, resident competency was assessed by direct faculty observation; we did not compile data on these observations. The QI competency scores described may be biased due to faculty involvement in the curriculum, but Milestone scores were determined by unanimous decision of the Clinical Competency Committee, following standard residency procedures. The Milestone evaluative process is likely to limit individual faculty bias. Second, no formal evaluation of resident leadership skills was conducted, as the curricular design followed a coaching model based on observation, reflection and discussion. Third, because this evaluation is based on a descriptive, explorative approach, the results are not generalizable.

The SEE-QI curriculum is an innovative approach that combines training in advanced QI skills, expectation for leadership, as well as a structure for supporting required and optional scholarship. The curriculum should be tested for its applicability in other programs and specialties.