The best of both worlds: strengthening medical education research and evaluation through quality improvement

In 2016, hospital pediatric medicine was recognized as a subspecialty by the American Board of Medical Specialties, with an emphasis on the roles of hospitalists as educators and experts in systems-based improvement.^1-3 Nationally, hospital paediatricians have a variety of non-clinical professional responsibilities, with medical education and quality improvement (QA) being the most common.^4.5 An underappreciated area of ​​research within pediatric hospital medicine can be described as Educational Quality Improvement (EQI): A Rigorous Approach to Implementing and Evaluating Educational Interventions in L help from QA frameworks and methodologies.⁶ Here we describe the opportunities and benefits of intentionally incorporating and integrating QA methodology into medical education research, highlighting the article by Bauer et al.⁷ in the June issue of Hospital pediatrics as well as relevant examples from the literature revealing EQI’s best practices to guide the development and rigorous evaluation of educational projects of potential interest to hospital pediatricians.

A literature search of Ovid Medline using the keywords “plan do study act (PDSA)” and “medical education” over the past decade yielded approximately 60 publications, most of which were published in 2018 or after. The clinical settings and problems for which the interventions took place varied (including medical, surgical, pediatric and adult specialties, with target groups of faculty, students, residents and fellows). The projects focused on a range of objectives, including improving procedural skills,⁸ transfers,⁹ patient flow,^ten preparation for the internship,¹¹ and reporting of patient safety incidents.¹² However, after careful examination of the methods of each project, we found that QA methods to achieve predetermined educational goals were applied in less than 20% of these publications.

High-quality medical education and QA interventions both emphasize adaptable, action-oriented collaborative learning to improve clinical practice and patient outcomes. Iterative improvement is needed in both areas to meet the changing needs of individuals and teams working in complex clinical environments with multiple stakeholders. Filling the gaps in medical education and clinical care often cannot wait for the publication of the results of large blinded randomized controlled trials (RCTs). In many cases, randomization and blinding is neither feasible nor ethical,¹³ and efficacy can be established without an RCT. Overlapping commonly used frameworks, such as the improvement model¹⁴ and Kern’s model for curriculum development,¹⁵ emphasizes a careful description of the problem (s) addressed before embarking on the intervention, structured approaches to understand the processes by which changes occur, and continuous reassessment while the intervention is underway to identify d ‘other areas for improvement.

A common methodological problem that contributes to the lack of rigor in medical education research and prevents successful publication is the design of the pretest-posttest study. Unfortunately, several meta-analyzes¹⁶ revealed that the majority of medical education studies use a pretest-posttest study design. A comparison between 2 cross sections over time often offers the advantages of ease and statistical power to detect a change; however, medical education interventions are rarely static, and this approach risks drawing premature conclusions about the impact of an intervention without the benefit of seeing trends over time.¹⁷ Monitoring results over time is fundamental for QA and is preferable to pre and post evaluations to allow more precise conclusions to be drawn about impact and sustainability. Rigorous evaluation of medical education interventions can also be limited by the lack of a guiding framework, small sample sizes, convenience sampling, and concurrent interventions. These limitations can introduce bias, obscure disparities in outcomes among learners, and therefore limit generalizability. Since medical education RCTs are relatively rare compared to clinical research RCTs, adapting QA methods allows for the strengthening of teaching studies without introducing additional constraints.

In the June issue of Hospital pediatrics, Bauer et al⁷ conducted a study titled “Let Residents Lead: Implementing the Resident Admission Triage Call Program and Practice.” The authors sought to increase resident participation in emergency department (ED) overnight admission calls to determine appropriate patient placement. Before this intervention, the attending hospital physicians were the ones involved in these admission triage decisions. What was particularly striking about this medical education research project is that the authors evaluated the impact of their curriculum, which they called their intake triage program, using the QA methodology. The primary outcome was the frequency of resident participation in joint and independent triage calls. Secondary outcomes included perceived self-confidence, satisfaction with night shifts, and emergency department efficiency. Their balancing measure was assessed by asking the outpatient who cared for the patient to determine the appropriateness of care, triage placement, and safety concerns with yes or no responses to monitor the patient. security. Impressively, the proportion of joint calls between a resident and a doctor in the emergency department increased from 7% to 88% from start to finish of the project and remained at over 60% over a period of 21 months. Additionally, residents reported a significant increase in the adequacy of triage training and self-confidence in 3 triage skills, and there were no complications or safety concerns for patients admitted by residents. .

What are the best practices in WQI to guide educators who wish to incorporate QA frameworks and methods into their teaching work? Four key actions in the design of the EQI study, based on our review of the literature, are highlighted in Table 1 with demonstrative examples. These 4 Key Actions are by no means exhaustive, intended as a substitute for collaboration and consultation with experts in medical education and IQ, or a review of published resources for scholarship, such as Standards for Improving Health. quality of educational excellence reports,¹⁸ which highlight important elements that authors should consider when applying QA methods to medical education studies. We recommend intentionally incorporating these key actions and standards for improving the quality of education excellence reporting into the planning stages of an EQI project so that interventions and measurable goals can be clearly defined in the planning stages. ahead and that more useful results can be captured over time, which is more likely to lead to successful research and publication.

This commentary highlights how existing frameworks within QA can be integrated with medical education research to bring greater validity and strength to data collection and analysis. Medical education and QA share an openness to iterative improvement and learning by doing. By more intentionally merging approaches from these 2 domains, the dynamic relationship between testing interventions and resulting learning can be more rigorously described and disseminated.

• Copyright © 2021 by the American Academy of Pediatrics