Student-Led Adaptation of Improvement Science Learning During the COVID-19 Pandemic

The COVID-19 pandemic has created many changes in how medical students learn and contribute to patient care.¹ Improvement teaching is a vital component of medical education, and is ideally action-based, combining didactic and project work linked to local health system improvement efforts, with assessment of learner outcomes and modeling continuous improvement in educational processes.^2-4 We describe a new approach of teaching improvement whereby students apply didactic knowledge in a value-added manner during COVID-19. The Student Navigator Project (SNaP) is a longitudinal integrated preclinical program at a large urban academic medical center; SNaP includes improvement science learning where students complete mentored clinical improvement projects and collaborate interprofessionally with clinic staff.⁵ In this report, we describe how a student-led effort rapidly adapted this clinic-based improvement curriculum into a virtual experience where first-year students respond to patient needs while adhering to social distancing measures. This intervention serves as a model for others to implement virtually at their own institutions.

Upon transition to virtual-only learning in March 2020, two medical students convened with the SNaP director to adapt the improvement curriculum to be delivered virtually. All eight first-year medical students (age range 23-29 years; seven females, one male) in the SNaP cohort participated. Students had previously established a 1-3-month relationship with one to two patients as part of their patient navigation work and received an introduction to improvement science through the Institute for Healthcare Improvement (IHI) Open School Modules.⁶

Figure 1 shows curriculum objectives. The curriculum involved two phases: project-based learning followed by scholarly synthesis of work (Table 1). We utilized WebEx, a virtual meeting platform, and Box, an encrypted cloud drive with Microsoft Office applications. Didactics focused on purposefully linking improvement concepts to the impact of COVID-19 on the students’ patient navigation work. For the 3-question project brainstorming, students applied the Model for Improvement⁷ to the pandemic context by identifying a problem related to their patients’ needs, brainstorming change ideas, and generating measures. In teams of four, students spent approximately 2 months completing three plan-do-study-act (PDSA) cycles. Students utilized a shared Excel sheet on Box to record their project work, which included a project management template to record each phase of the PDSA cycle. WebEx meetings consisted of large-group learnings and separate project team discussions facilitated by a project coach. In the scholarly synthesis of work phase, students reviewed quality improvement tools and applied them to their projects. Students created posters to highlight key project learnings and to present at scholarly venues.

Students completed a voluntary, anonymous, online survey after each session that captured student satisfaction, session feedback, and reflections about the session content. A conventional content analysis approach was utilized to identify themes. Two lead medical students reviewed the survey results and developed preliminary themes. The students analyzed later surveys in a similar manner, adding new codes only if necessary. The Institutional Review Board determined this activity exempt from oversight. Curriculum materials are available on the Society of Teachers of Family Medicine Resource Library.⁸

The findings in this report reflect data collected from March 30, 2020 to June 1, 2020 during the project-based learning phase. Student projects focused on addressing patients’ health care and social resource needs through telephone and/or electronic interactions.

Table 2 outlines qualitative results of the postsession survey completed by students at an average response rate of 70% (n=8). Students reported enjoying a session 87% of the time, with the remainder as enjoying the session somewhat. We identified five themes: (1) learning by doing in the dynamic nature of improvement work; (2) enjoyment of virtual team-based learning; (3) project relevance to COVID-19; (4) utility of quality improvement tools; and (5) continuous curriculum improvement with student feedback.

In our student-led endeavor to implement a virtual improvement curriculum, first-year medical students learned and applied improvement science knowledge to patient needs during the COVID-19 pandemic. With the use of a virtual meeting platform and secure cloud drive for document, our program demonstrated the feasibility of teaching improvement in a virtual setting where learning is action-based with project work linked to health care priorities, evident by the two projects carried out by students as a product of this curriculum. Learners reported satisfaction with virtual group discussions and conducting projects relevant to their patients and current events (Table 2, themes 2 and 3). Learner reflections also highlighted the dynamic, trial-by-learning nature of improvement work (Table 2, theme 1). These methods allowed medical students to engage in issues related to COVID-19, further building competence and confidence in health systems improvement. While it is unclear whether the projects will generate a measurable impact on patients, our results nonetheless indicate the program’s salient effect on students by instilling the knowledge, skills (evident in theme 4, Table 2), and positive attitude to lead improvement work (shown by themes 1, 2, and 3, Table 2). Our role modeling of continuous improvement by utilizing student feedback to rapidly adapt the curricular content in real time also fulfills an important educational principle (proven by theme 5, Table 2).² Notably, students voiced concerns about session length, outside classwork volume, and insufficient practice with certain quality improvement tools, which helped to shape latter parts of the curriculum.

This study is limited by self-reported qualitative data and a small sample size of self-selected learners. The curriculum operates within a program where first-year medical students can gain longitudinal experience as patient navigators and therefore intimately understand patient needs during COVID-19. In the absence of such program and existing patient relationships, it may be challenging for early students to identify relevant and feasible project topics. Lastly, a conventional approach to content analysis may also fail to identify key categories.

In conclusion, this student-led implementation of a virtual curriculum engaged first-year medical students in improvement work that addressed patient needs during the COVID-19 pandemic. Engaged in virtual team-based discussions, students developed reflections about improvement work early in their clinical training. Future work should explore ways to incorporate more students and expand on project topics that align with both clinical and educational priorities.