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Evidence scan: Quality improvement for healthcare professionals

August 2012

Identify Innovate Demonstrate Encourage Contents

Key messages 3

1. Scope 6

2. Examples of training 10

3. Most effective approaches 27

4. Important messages 33

References 39

Health Foundation evidence scans provide to help those involved in improving the quality of healthcare understand what is available on particular topics. Evidence scans provide a rapid collation of empirical research about a topic relevant to the Foundation's . Although all of the evidence is sourced and compiled systematically, they are not systematic reviews. They do not seek to summarise theoretical literature or to explore in any depth the concepts covered by the scan or those arising from it. This evidence scan was prepared by The Evidence Centre on behalf of the Health Foundation.

© 2012 Health Foundation Key messages

There is an increasing focus on improving healthcare in order to ensure higher quality, greater access and better for money. In recent years, training programmes have been developed to teach health professionals and formal quality improvement methods.

This evidence scan explores the following The training approaches most commonly questions: researched include: –– What types of training about formal quality –– courses about formal quality improvement techniques are available for improvement approaches health professionals? –– teaching quality improvement as one component –– What evidence is there about the most of other modules or interspersed throughout a effective methods for training clinicians in quality improvement? –– using practical projects to develop skills –– online modules, distance and printed For the purposes of this scan, quality improvement resources training was defined as any activity that explicitly aimed to teach professionals about methods that –– professional development workshops could be used to analyse and improve quality. –– and role play Courses about techniques, such as evidence-based –– collaboratives and on-the- training. , statistics and leadership, were included if the stated aim was to improve quality. Courses about improving a specific condition or pathway Training content were included if they incorporated material about In much of the Western world, quality improvement techniques that could also be widely improvement modules for medical and applied to other topics. students tend to focus on techniques such as and plan, do, study, act (PDSA) cycles. Most Ten electronic databases were searched for research courses run by academic tend to be published between 1980 and November 2011 and 367 unidisciplinary and based or undertaken studies were summarised. Sixty higher educational during clinical placements. However, there is institutions and other organisations in the UK and an increasing acknowledgement of the value of internationally were contacted for curricula. multidisciplinary training, especially in practical Unless otherwise specified, the trends reported are work-based projects. Many courses now contain a evident throughout the Western world. practical component. is also becoming popular as a training approach. Types of training Continuing professional development training Training in quality improvement is available for about quality improvement appears to be growing medical, nursing and paraprofessional students in at a faster rate than university . Ongoing many parts of the world. Continuing professional education includes workshops, online courses, development (CPD) courses are also available, collaboratives and ad hoc training up to support including short workshops, on-the-job training and specific improvement projects. There is a growing training related to specific projects. trend for training which supports participants to put what they have learned into practice or to learn key skills ‘on the job’.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 3 There are some geographic variations in the content Training effectiveness of formal courses and CPD programmes. In the US and to a lesser extent Canada, quality improvement Impact of training is conceived largely as a ‘total quality ’ A great deal has been written about training and training focuses on collating professionals to improve quality in healthcare. predominantly quantitative information. In the UK, In fact, more than 5,000 articles were identified a patient safety and change management approach is about this topic. However, the majority merely more common. To some extent the US approach is describe training approaches and content, rather more standardised and rigid and the UK approach is than examining the impacts of training or the most more open and less consistently applied. useful content and training methods. Courses in the US tend to focus on ‘named’ There is some evidence that training students and approaches such as PDSA cycles. Practical health professionals in quality improvement may projects are increasingly common. In Canada and improve , skills and attitudes. Care Australasia, training about quality improvement processes may also be improved in some instances. also emphasises putting theoretical concepts However, the impact on patient health outcomes, into practice using work-based projects. In the resource use and the overall quality of care remains Netherlands and Scandinavia there has been uncertain. more focus on and peer review, whereas in the UK training tends to concentrate Most of training focus on perceived on specific components of quality improvement, changes in knowledge rather than delving deeper such as leadership and safety. In recent years, UK into the longer-term outcomes for professionals courses have started to recognise the importance and patients. Programmes which incorporate of population health and risk assessment, but practical exercises and work-based activities are relatively few programmes emphasise the increasing in popularity, and evaluations of these and perspectives of users in any real depth. approaches are more likely to find positive changes in care processes and patient outcomes. In the US, training in quality improvement is mandatory for medical students. In contrast, in There is not a body of evidence assessing whether the UK, until recently there was less focus on training professionals is any more or less effective training students in quality improvement and for improving the quality of healthcare than other little integration of quality improvement concepts initiatives. into pre-qualification courses. This is beginning to change, with more time now spent on concepts Effectiveness of different methods such as evidence-based medicine, audit and Few studies have directly compared different improving safety. training methods. This means that there is insufficient evidence to conclude whether classroom In England, arms length bodies, workforce formats, practical projects, online modules or other deaneries and strategic health authorities methods are more or less effective. However, active run quality improvement courses for health learning strategies, where participants put quality professionals. Activity in this area has increased improvement into practice, are thought to be more in recent years. There is no consistent content or effective than didactic classroom styles alone. definition of quality improvement, but there tends to be a common approach which involves using It appears important to include quality practical, rather than simply didactic, methods. improvement methods in both pre-qualification training and CPD. It is also important to upskill trainers so that they can teach quality improvement methods robustly.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 4 In recent years, the concept of quality improvement has become more widely accepted in the UK and training is increasingly available, especially for qualified professionals. However, a great deal remains uncertain about training in quality improvement, including: the most appropriate content; how training can best be delivered to improve processes and patient outcomes; how to measure and ensure quality within training. This is an essential area for further exploration. Training professionals may be important not only to ensure that they have the skills needed to improve the quality of healthcare, but also to enhance their motivation to do so.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 5 1. Scope

For hundreds of years, clinicians have sought to make healthcare more effective and accessible. Recently, health professionals have begun to learn about formal methods to improve quality. This evidence scan summarises research about the types of training available and its impacts.

1.1 Purpose learn and apply new skills. The Health Foundation that training can be an effective lever for ‘Not all changes are improvements but all improving the quality of healthcare. Yet education improvement involves change. Changing and training initiatives are not always prioritised by the systems that deliver care has thus makers or practitioners.5,6 become the cornerstone of the movement that is now referred to as medical quality ‘While healthcare organisations are improvement.’1 initiating a number of strategies to improve care and respond to changing The focus on improving the quality of healthcare is not new. In 1517 the founding charter of the Royal regulatory and policy requirements, many of emphasised the for clinicians practicing in them have not members to set and maintain standards of practice received training on quality and safety as ‘for their own honour and the public benefit’.2 a part of their formal education.’7 However, over the past 20 years improving the Research suggests that a lack of knowledge and quality and safety of healthcare has taken on new skills among clinicians and managers is a significant importance in the UK. barrier to improving quality in healthcare.8–10 For Health services are now facing significant challenges. example, an of improvement projects There are constant medical and technological in England found that managers and practitioners advances to keep pace with, the population is often lacked basic skills and knowledge in how to assess evidence, plan improvements, manage growing in size, people are living longer but often in 11 poor health and the demand for healthcare outstrips projects and analyse data. 3,4 the staffing and financial resources available. Training health professionals in quality improvement has the potential to impact positively The focus on patient-centred care, holistic practice 12 and providing value for money means that there is on attitudes, knowledge and behaviours. In fact, a greater need to ensure that health professionals, some suggest that training professionals may be just as effective as financial incentives for improving the allied teams and managers have the knowledge and 13 skills to improve and develop healthcare services. quality of healthcare. A wide range of techniques have been used to Yet little is known about the most effective ways to improve healthcare including improvement train health professionals in quality improvement. cycles, clinical audit, guidelines, evidence-based This evidence scan explores the following questions: medicine, healthcare report cards, patient-held records, targets, national service frameworks, the –– What types of training about formal quality Quality and Outcomes Framework, performance improvement techniques are available for health management approaches, continuous quality professionals? improvement, financial incentives, leadership, –– What evidence is there about the most effective choice and competition. All of these initiatives methods for training clinicians in quality require health professionals and managers to improvement?

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 6 This section briefly describes the scope and Thus, the scan did not focus only on narrowly methods of the scan. Section 2 outlines some of defined quality improvement models such as ‘plan, the content and teaching methods used in quality do, study, act’ (PDSA) cycles, Six Sigma, LEAN and improvement training. Section 3 explores the so on – although it included courses that defined effectiveness of various types of training. quality improvement in this way too. Courses about techniques such as evidence-based 1.2 Defining quality medicine, statistics and leadership were only improvement included if the stated aim was to improve quality. Courses about improving a specific condition Quality improvement is not solely about ‘making or pathway were included if they incorporated things better’ by doing the same things and ‘trying material about improvement techniques that could harder’. Instead, quality improvement requires a also be widely applied to other topics. different approach to traditional ‘fact-based’ learning and needs a new set of knowledge and skills to put this approach into practice. For the purposes of this Terminology scan, training in quality improvement was defined The focus was on accredited education and as any activity that explicitly aimed to teach health ongoing training through courses and workshops professionals about methods or skills that could be rather than resources such as , mentoring, used to improve quality. fellowships or other learning methods. Table 1 lists the domains of quality improvement The term ‘education’ is often used to describe that the Health Foundation is interested in. formal courses run by higher educational The scan focused on training to support health institutions whereas the term ‘training’ is broader professionals to develop knowledge and skills in and encompasses CPD and short courses run by a these key areas. variety of providers. For simplicity, the scan uses the general term ‘training’ to apply to both formally Quality improvement was not defined solely as accredited education and other CPD. ‘continuous quality improvement’, ‘total quality management’ or other named models, but rather Unless otherwise specified, the trends reported are as a way of approaching change in healthcare that generalised to reflect what is happening throughout focuses on self-reflection, assessing needs and gaps, the Western world. and considering how to improve in a multifaceted manner. In this definition, training about quality improvement aims to create an ethos of continuous reflection and a commitment to ongoing improvement. It aims to provide practitioners and managers with the skills and knowledge needed to assess the performance of healthcare and individual and population needs, to understand the gaps between current activities and and to have the tools and confidence to develop activities to reduce these gaps.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 7 Table 1: Potential components of quality improvement14

Components Examples of topic areas

The wider context How the health system is structured and how it works Historical, social and political context within which health systems develop and operate Health policy Professionalism

Human behaviour of change Leadership Teamwork and collaboration Management Multidisciplinary working Reflection and learning from mistakes

Needs and preferences of people Seeing healthcare from the user’s perspective who use health services Identifying and targeting the needs and preferences of different subgroups of users Acquiring tools to assess and respond to users

Healthcare as a process Systems thinking Complexity and interdependencies Spread Sustainability Planning and predicting Understanding risk and

The nature of knowledge Different forms of evidence The of Variation Measurement Local versus generalisable knowledge Small versus large scale change Collecting, analysing and interpreting data Reporting and displaying information Process mapping

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 8 1.3 Identifying evidence More than 5,000 pieces of descriptive and empirical evidence were analysed to draw out key themes The review summarises the findings of 367 articles. about the types of training available and the To collate evidence for the scan, 10 bibliographic most effective training methods. Of these, 367 of databases were searched: Medline, Embase, ERIC, the most relevant and high-quality studies were Science Citation Index, Cochrane Database of summarised as examples alongside descriptive Systematic Reviews, NHS Evidence, PsychLit, and narrative articles to provide context. The Web of Science, Google and the Health chosen articles were selected based on relevance to Management Information Consortium. addressing the topics of interest, methodological quality, novelty of content and accessibility. The focus was on readily available literature published between 1980 and November 2011. The scan does not purport to summarise all Articles from any country and in any language available studies about training in quality were eligible for . Articles about training improvement, but rather seeks to provide a flavour in quality improvement outside healthcare were of the available research and an overview of key not included. trends and changes. The search terms included combinations of the Unless geographic trends are specifically noted, the following words and other similes: education, information reported reflects what is happening training, curriculum, course, competencies, throughout the Western world in generalised terms. teaching, learning, quality improvement, improving quality, improvement science, science of improvement, quality, continuous quality improvement and PDSA. In addition, the quality improvement domains listed in Table 1 were used. Articles about training in planning, systems thinking, the , needs assessment, health policy, learning styles, leadership, risk management and self-reflection were identified in order to assess whether these courses also included other components of quality improvement training. Furthermore, the scan identified examples of training by searching the and course outlines of organisations such as the General Medical Council and all royal , the Association of American Medical Colleges, the Institute for Healthcare Improvement (IHI), the NHS Institute for and Improvement, the Improvement Foundation and academic institutions. Sixty organisations were contacted for information about their quality improvement curricula.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 9 2. Examples of training

This section describes some of the content covered in courses about quality improvement and the variety of training methods used.

2.1 Content covered Medicine.23,24 This conceptualisation of quality improvement has also been implemented widely Quality improvement has been defined in a number throughout the world.25 of ways in training courses. This section outlines some of the broad content covered in training Adaptations of these continuous improvement courses. The aim is not to draw conclusions about models have been used in the UK in both formal how quality improvement should be defined, but accredited training and in CPD.26 rather to illustrate the scope of such courses in general terms. Core competencies Another approach is to see quality improvement as PDSA cycles and total one of a set of core competencies that are essential quality management for health professionals.27–33 One of the most common approaches, especially in formal accredited education, defines quality For instance, in the US, two out of the six improvement as a set of principles and methods Accreditation Council for Graduate Medical originally developed in the commercial sector and Education core competencies, that all residents known as total quality management, continuous (registrars) must achieve, relate to quality quality improvement or PDSA cycles.15 Other improvement. The competencies are ‘practice based learning and improvement’ and ‘systems descriptors include the IHI Improvement Model, 34–36 CANDO, Six Sigma and LEAN.16,17 based practice.’ Although these approaches have some differences, The Quality and Safety Education for Nurses they are similar in that they suggest that (QSEN) initiative also identifies six competencies unintended variation in processes can lead to essential for nursing practice: patient centred undesirable outcomes and that continuous small care, teamwork and collaboration, evidence scale tests of change can be used for improvement.18 based practice, quality improvement, safety and informatics.37–39 A systematic review of 41 quality improvement and patient safety curricula for medical students Another example of this competency-based and residents throughout the world found that the definition is the Institute for Healthcare most common content included continuous quality Improvement’s eight domains of quality improvement, root cause analysis and systems improvement knowledge (see Box 1). thinking.19 A number of educational institutions use similar types of competencies to guide teaching about In the US, quality improvement training is now 40–49 formally mandated for medical students and this quality improvement. is defined largely in terms of PDSA methods. These competency-based approaches are not This approach is supported by the Association mutually exclusive from definitions which focus on of American Medical Colleges,20 the Council on PDSA improvement cycles and the two are often Graduate ,21 the Pew Health used in tandem. Commission22 and the Institute of

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 10 Box 1: IHI’s eight domains of quality improvement knowledge50 Customer/beneficiary knowledge: Identifying people or groups using healthcare and assessing their needs and preferences. Healthcare as process/system: Acknowledging the interdependence of service users, procedures, activities and that come together to meet the needs of individuals and . Variation and measurement: Using measurement to understand variation in performance in order to improve the of healthcare. Leading and making change in healthcare: Methods and skills for making change in complex organisations, including the strategic management of people and their work. Collaboration: Knowledge and skills needed to work effectively in groups and understand the perspectives and responsibilities of others. Developing new, locally useful knowledge: Recognising and being able to develop new knowledge, including through empirical testing. Social context and accountability: Understanding the social context of healthcare, including financing. Professional subject matter: Having relevant professional knowledge and an ability to apply and connect the other seven domains. This includes core competencies published by professional boards and accrediting organisations.

Standards Safety It was only relatively recently that quality A great deal has been written about methods to improvement techniques began to be implemented improve patient safety and courses have been formally in healthcare and training has reflected developed explicitly with this in mind.56 This scan this growing interest.51 This has been accompanied did not focus explicitly upon safety initiatives, but a by the standardisation and institutionalisation of number of quality improvement curricula or efforts quality improvement via standards and guidelines. to improve quality in healthcare use safety as a primary focus.57 For instance, the International Standardisation Organisation (ISO) 9000 is a worldwide standard Some training postulates that most adverse events for the implementation of quality management in healthcare are the result of the cumulative effects systems. The ISO 9000 standards require of human errors and failures in organisational and organisations to develop, implement, improve and administrative processes so steps should be taken to sustain quality improvement processes. While less reduce variation.58 This is similar to the approach in common than continuous quality improvement formal quality improvement cycles. cycles or competency-based approaches, some educators have used ISO 9000 standards to Other approaches help develop educational strategies for quality Outside the US, slightly broader models of quality 52 improvement. This is more common in improvement are taught.59 However, there is no 53 than in North America. standard approach to, or definition of, quality Other standards have also been used as a basis for improvement. training. For instance, evidence-based guidelines have Whereas PDSA cycles often emphasise quality been considered an ‘’ for quality improvement, improvement at the level of service delivery, with training put in place to work towards certain broader models define quality improvement at a levels of care. Royal colleges have set standards that range of intervention levels (see Table 2). include quality improvement and audit.54,55

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 11 Table 2: Levels of quality intervention60 In the UK a number of courses focus on leadership and examining the social and historical context of Level Example health systems. Other approaches use complexity 62 Level 1: Micro- New education programme for theory and similar . Thus, in the UK a interventions to nurses or financing initiatives broader conceptualisation of quality improvement change individual is perhaps more common than in the US. behaviour

Level 2: Shared record system to improve 2.2 Training students Micro-system team communication interventions and registrars This section provides examples of accredited Level 3: Programme to train all education in quality improvement for health Organisational departments in quality professionals in training. interventions improvement methods Level 4: Information system linking all Classroom teaching Healthcare system health and social care groups A systematic review of 26 studies found that interventions relatively little emphasis is given to leadership, Level 5: Public Identifying population needs management and quality improvement in medical health systems or through multi-agency meetings curricula,63 but a number of studies have described wide the types of formal training available. interventions Accredited education most commonly uses classroom or style teaching alongside In this view, there are specific components of printed education materials.64,65 This is quality improvement initiatives that distinguish increasingly coupled with practical projects.66,67 them from audit and feedback or other similar methods. First, quality improvement implies a Formal courses are available for medical students review of practices at the organisational level and a and to a lesser extent nurses, pharmacists and effort to change, rather than focusing on others. These tend to focus on PDSA-style the individual. Second, once the problem has been approaches, be more common in US settings and identified, quality improvement initiatives a be uniprofessional.68,69 Some courses cover the solution to the problem and focus on addressing broad concept of quality improvement, whereas root causes. Third, quality improvement often others focus on particular components such as involves training as one of the solutions.61 population health or evidence-based practice.70–72 Numerous examples are available (see Box 2). A description of the underlying tenets of different quality improvement models and associated Most of the published articles about accredited training is outside the scope of this scan. However education are descriptive. For example, one it is important to note that most training university in the US developed a two-year approaches target individual practitioners or curriculum about systems thinking and human managers as the ‘change agent,’ seeking to improve factors analysis, root cause analysis, process knowledge, attitudes, skills and behaviours through mapping and other quality improvement educating individuals in change management or techniques. Learning was applied in practical tasks quality improvement methods. Some approaches and projects. The curriculum shifted residents’ target teams, but most do not take a wider systems thinking towards a systems-based approach, approach to quality improvement training. Though improved self-reported quality improvement the training itself may consider the importance skills and was associated with changes in practice of systems thinking and needs assessment, these following root cause analysis.73 strategies are rarely applied within training courses.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 12 Box 2: Examples of formal education about quality improvement

Newcastle University in England offers a Masters, Postgraduate and Postgraduate Certificate in health . Modules include health statistics, fundamentals of research, project management, , healthcare quality, applied epidemiology and others. The University of in England runs a Masters programme in healthcare management. Modules include health services management, healthcare policy, organisational development, public and user involvement, working, procurement and contracting, quality and service improvement, strategic commissioning and using quality and service improvement tools.74 The University of Sheffield in England offers postgraduate courses in . Modules include research methods, health needs assessment and economic evaluation, statistics, systematic reviews and critical appraisal techniques, evidence-based healthcare, economic analysis and health assessments. Some modules can be taken as standalone courses.75 The University of Dundee in Scotland offers a six-week course at undergraduate level focused on quality improvement and safety. Medical students reflect on improvement and safety skills as part of their annual portfolios.76 Betanien College of Nursing in Norway offers undergraduate courses in quality improvement. Nursing students follow a patient’s during their clinical placement and then take part in a two-day seminar about quality improvement methods. Students produce charts to identify areas of improvement and cause-and-effect diagrams.77 At Dartmouth Medical in the US, quality improvement concepts have been interspersed throughout medical training. Quality improvement skills form a background for students’ learning, rather than a separate course. In the first two years, students receive an orientation lecture about process analysis and variation in healthcare. Small group problem-based learning sessions cover topics such as clinical processes, medical error and systems improvement. During clinical placements in the third year, each picks a clinical problem to study and gathers evidence about the problem. In the fourth year, students take part in workshops and are given a real quality improvement problem to study in groups.78 Training in quality improvement occurs in many departments at the Medical School in the US, ranging from informal discussions to more formal or conferences. Quality improvement concepts are introduced to medical students formally during the second and third years. Students are also taught through role modelling by faculty and residents during clinical rotations.79 For medical students in the final two years of their residency,McGill University in Canada offers 20 hours of classroom instruction divided into four-hour blocks over a five-month period. Topics include leading and motivating change, risk management, quality improvement and balanced scorecards.80

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 13 Another US organisation used the metaphors Students learned how to make and interpret flow ‘the mirror’ and ‘the village’ to implement quality charts and cause-and-effect diagrams, develop improvement training which was divided into the causal statements and measure the impact of core competencies of practice-based learning and change.85 The second module focused on healthcare improvement and systems-based practice. Practice- for ethnic minorities. Small groups worked on based learning was likened to residents’ holding case scenarios and presented their findings and up a mirror to document, assess and improve recommendations to panels comprising heads of their practice. Tools such as morning reports, participating , cultural advisors and health self- and learning portfolios became the professionals.86 An unusual component of this mirrors. Systems-based practice was introduced approach was combining students from medicine, through multidisciplinary patient rounds, nursing nursing and pharmacy to encourage teamwork. evaluations and quality assessment exercises using The courses were also taught and assessed by a the metaphor ‘it takes a village to raise a ’. multiprofessional team. Evaluations found that the courses were well received but the impact on Elsewhere in the US, engineers and doctors behaviour and practice has not been assessed. partnered to provide a three-week elective course about quality improvement in healthcare. The Descriptive studies about tools and workbooks staff taught medical students about used within formal courses are available, such as stakeholder analysis, root cause analysis, process worksheets to support root cause analysis or team mapping, failure mode and effects analysis, assessment and competency tools.87–90 resource management, negotiation and leadership.81 Novel methods have been used to assess learning Examples for nurses and pharmacists are also too. For example, in the US, students used skits, available. For instance, a nursing course in the US filmed performances, plays and documentaries to used a ‘spiral’ approach to teach seven activities demonstrate competency in key skills.91 Simulated of increasing complexity that built on previously patients and actors have been used in courses to acquired skills. Working in teams, nursing students assess improvement skills.92,93 Portfolios have also learned how to develop an improvement question, been used to good effect.94,95 search for literature, synthesise current knowledge, identify the significance of the issue using models, In addition to published research about classroom examine existing data and compare those data to teaching, we reviewed 60 publicly available course national benchmarks, investigate a healthcare issue curricula from the UK and abroad to gain a more using quality improvement methods, and draft a in-depth understanding of the type of content proposal for a continuous quality improvement included. We identified courses in , Africa, initiative.82 , Canada, , France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, Also in the US, a five-module programme was the Americas and the UK and Ireland, among designed to educate pharmacists and pharmacy others. This analysis found that most information students about quality improvement.83 available about accredited courses relates to medical students at pre-registration or junior doctor level. An example of multidisciplinary learning There are fewer examples of nursing curricula comes from New Zealand where one university about quality improvement, although the literature provided quality improvement modules during suggests that quality improvement principles, such for medicine, nursing as and critical appraisal, may be and pharmacy students. The content included more likely to be interwoven throughout a nurse’s patient safety, equity, access, effectiveness, cultural 84 educational rather than taught in a specific sensitivity, efficacy and patient centredness. course.96 One two-day module focused on patient safety and was a requirement for all third year students. There were few examples of formal courses about The module examined weaknesses and root causes quality improvement methods for social workers or in healthcare systems that may lead to errors. allied health professionals in the UK.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 14 Selected multidisciplinary training and courses for Participants were satisfied with the course content managers are available at postgraduate level and as and thought that videoconferencing worked part of CPD. well as an interactive . In total, 71% of residents reported that they would have Most of the courses identified described continuous been unable to participate in the course without quality improvement cycles and data , videoconferencing.102 measurement and audit. Some courses included structured planning approaches and others focused on leadership. There was far less focus on needs Practical projects assessment and understanding the views and involves experiencing, context of service users. observing, conceptualising and retrying activities.103,104 This differs from theory-based Many of the courses were uniprofessional, although learning because it is case based rather than some offered opportunities for multiprofessional concept based and requires hands-on practice learning. and reflection.105 Most required some practical component, such as There is an increasing focus on experiential taking part in a work-based improvement project. learning in accredited quality improvement education.106 This often takes the form of practical Distance learning improvement projects or opportunities for Distance learning, such as online modules, dvds, students to apply their learning in day-to-day videos and other non-face-to-face education clinical practice.107–109 For instance, some training methods, have been tested to supplement or programmes place students into multiprofessional substitute for classroom methods.97–100 improvement teams110–112 or quality improvement committees,113 assign students to For instance, a US study examined the impact make improvements in community settings or of offering an online Masters in Public Health, rural areas,114–117 or ask students to undertake including content related to quality assessment improvement projects with or without formal and improvement. A survey of 49 students one training.118–121 year after completing the course found that most thought it was useful and said that they had applied Research suggests that the most promising form the techniques in their work.101 The limitation with of experiential learning for quality improvement follow-up surveys of this nature is that they provide combines classroom learning with practical little understanding of what value the online projects.122–124 Many educational programmes method added to the learner’s role or how they for medical students, junior doctors and nurses used what they learned to improve health services. in the US involve implementing quality improvement projects.125–127 In fact, from 2002, In Australia, a university used distance learning the Accreditation Council for Graduate Medical for postgraduate courses in quality improvement, Education introduced a new requirement that including graduate certificates, graduate residents must demonstrate competency in and Masters degrees. Students used online and ‘practice based learning and improvement,’ which postal methods to receive study materials. The requires hands-on improvement .128 courses were popular among quality coordinators and healthcare managers. For example, one study of 44 US registrars found that two sessions of instruction coupled with In Ireland, videoconferences were used to deliver implementation of a quality improvement project a course for radiology residents in practice-based over a month-long period helped to improve learning and evidence-based practice. The course registrars’ knowledge and skills. Pre and post included 16 weekly hour-long sessions for 21 tests were used to measure registrars’ knowledge second year residents at eight radiology centres. and confidence before and after implementing a At each site a staff radiologist who had completed project.129 However, the researchers found that an intensive one-day course acted as a coordinator.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 15 one month was not long enough for the students to quality indicators six months later. The programme fully develop and implement their projects. A much was associated with improved skills and knowledge longer period would be needed if educators wanted for students and enhanced clinical outcomes for to assess the impacts on systems or service users. people with diabetes.134 Similarly, a US study found that a six-week course, Others in the US developed an asthma project for whereby a university partnered with local health third and fourth year medical students in primary services to combine classroom teaching with care clerkships. Each student wrote a case report practical projects, improved pre-registration about a person with asthma who they were caring medical students’ knowledge and confidence, but for, with a particular focus on the cost of care, there was a need for more detailed teaching of A&E visits, hospitalisations and the quality of care quality improvement principles and role modelling compared with clinical guidelines. Students were of quality improvement behaviours by faculty.130 taught quality improvement methods to help them to analyse the care process and outcomes so that Elsewhere in the US, a curriculum was developed they could make improvement recommendations. for first and second year medical students that Service improvements were made in many cases included classroom teaching about systems theory and students felt that the course enhanced their and quality improvement. Students conducted skills and confidence.135 a project at clinical sites to develop a patient care improvement plan. The plan was presented Most US quality improvement training projects to a panel of for assessment but the with medical students and registrars have similar implementation of any recommended changes was characteristics. They tend to take place during left to the clinical providers.131 ambulatory care assignments or electives and combine didactic instruction with participation In another study, second year medical students in quality improvement activities.136 Most are undertaking a family medicine clerkship in the integrated into a short rotation, although some US learned about quality improvement principles hold weekly or biweekly meetings for a year.137–143 during six short sessions and then undertook chart For example, one organisation implemented review to make improvement recommendations. structured PDSA teaching modules and practical The students were positive about the experience projects for surgical residents over a year-long but wanted more time to discuss and implement 132 period. Residents’ self-reported knowledge and changes. skills improved and residents were eager to apply Practical training projects occur in primary care their learning to make service improvements.144 as well as in hospital. In the US, seven primary Most published information about education of this care practices incorporated quality improvement type focuses on doctors, but there have been similar into training for junior doctors as part of day- successes with nurses. For instance, a year-long US to-day practical work. An evaluation found that course encouraged nursing students in their senior practices that did this most successfully were likely year to work in small groups with community to be larger, have previous experience with quality nurse mentors to assess the healthcare needs of a improvement projects, have staff with extensive population, identify potential changes and develop experience in quality improvement and have an an intervention. Students then implemented and office manager or medical director who advocated 133 evaluated their interventions and presented their the process. outcomes and suggestions for improvement. The Another example involved 77 second year medical programme improved nurses’ confidence and skills students working in groups of two to four who in quality improvement and had tangible impacts conducted continuous quality improvement on the communities with which they worked. Good projects about diabetes at 24 primary care practices. relationships with community providers were a key Students collected baseline data, implemented an success factor.145 intervention based on the results, and reassessed

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 16 In Norway, second year nursing students followed a and the care of groups of patients, such as those patient during a day’s work, recording processes of with heart disease. The healthcare matrix was care from the patient’s perspective.146 They collected formatted to help identify what was learned and data about waiting times, patient characteristics, what needed to be improved. Residents were then people in contact with the patient and care offered. taught quality improvement approaches to help They then identified aspects of practice that could address the issues raised.153 be improved. Students attended a two-day course about quality improvement methods and produced A key learning point from these studies is that flow charts, cause-and-effect diagrams and quality ensuring that participants have practical experience in improving quality is becoming common in goals based on their observations. Nursing students 154,155 said that they had improved skills compared to formal education courses – but practice-based before the course and felt that this type of training learning alone is not enough. Training programmes should be included throughout the nursing appear more successful when classroom teaching curricula.147 and practical implementation are combined and when students have a long enough period of time Another nursing curriculum integrated didactic to learn both theory and application. instruction and quality improvement activities into an existing four-year programme.148 For example, first and second year medical students at one US university took part in a course that In the US a dedicated education unit was set up combined didactic learning and small group at one hospital to teach nurses about quality and work to improve an aspect of care at a community safety competencies through a 10-week experiential practice.156 The educators identified four factors learning programme. This practical approach that contribute to successful quality improvement improved competencies.149 training: An example of multidisciplinary learning also –– teaching about improvement concepts and tools comes from the US. The IHI partnered with a –– the availability of baseline data federal agency to develop a training programme to support quality improvement in community –– cohesive team characteristics and a sense of services. The training was available to pre- in the process registration and specialist medical students, nurses –– access to the information and resources needed and public health students. Teams of faculty to carry out an improvement, such as literature, and students met every fortnight. Students were databases and funds. taught continuous quality improvement through Other studies support these factors as being classroom learning, coaching by faculty members important for successful practical learning.157 in team meetings and hands-on project experience. This learning style was associated with self-reported improvements in competency and enhanced Ongoing training community services.150 A number of studies have examined CPD or training in quality improvement of already A number of resources such as workbooks and qualified health professionals. These are courses toolkits have been developed to help get the most that managers or health professionals might take 151 out of practical projects. One US medical school after their main accredited education is completed. combined the Institute of Medicine’s aims for Some courses span the bounds of both accredited improvement and the Accreditation Council for education and CPD. For instance, postgraduate Graduate Medical Education’s core competencies university modules may be taken alone as CPD, 152 into a tool called the ‘healthcare matrix’. The but may also be part of a Masters degree or core competencies helped junior doctors identify diploma programme. This section concentrates why care was not safe, timely, effective, efficient, on shorter, informal courses and training offered equitable or patient centred. Residents used the by organisations other than higher educational matrix to analyse the care of an individual patient institutions.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 17 Continuing professional development for quality improvement can be divided into three main areas: structured group training sessions, more informal group training and practical initiatives, and individualised training. Many studies combine some of these approaches. Box 3 provides some examples.

Box 3: Examples of continuing professional development In the UK the School of Health and Social Welfare offers a number of courses that focus on components of quality improvement. Key concepts from the courses include defining SMART goals, research methods and how to implement standards.163 The NHS Institute for Innovation and Improvement offers the Organising for Quality and Value: Delivering Improvement programme, spanning five days over a three-to-four month-period. Topics include leading improvement, project management, sustainability, engaging, involving and understanding others’ perspectives, process mapping, the role of in improvement, measurement for improvement and demand and capacity management. Participants are required to undertake a service improvement project.164 Brighton Healthcare in England developed a one-day course around the quality improvement cycle. Sessions include why quality matters, organising for quality, identifying and prioritising quality problems, defining and analysing quality problems, quality measurement and data presentation and solutions to quality problems. Practical tools are introduced in group exercises. In England the Institute of Healthcare Management offers modules through accredited NHS trusts and other centres. The training includes online resources, classroom teaching and practical assignments. Each programme typically lasts six weeks.165 In the US, the Institute for Healthcare Improvement offers a range of online modules and ‘webinars’ followed by assignments. Topics include the improvement model, reducing waiting times for appointments and improving office efficiency in primary care, improving systems for high hazard medications, applying reliability science to health, SBAR and other tools for improving communication between caregivers, skills in data collection, using run and control charts to understand variation and engaging hospital boards in quality and safety.166 The US Veterans Health Administration offers a one-day session covering quality improvement and development of a practical project. The Robert Wood Johnson Foundation in the US offers courses designed to increase learners’ competence in quality, safety and systems improvement. Four modules are taught which include the structure of healthcare and how it affects care delivered, who pays for care and why it matters, improving the care of individuals, populations and practices and improving the practice and health system. Participants put together a quality improvement plan and selected improvement initiatives are implemented in groups. The Columbus and Franklin County Health Departments in the US ran a two-year CPD course for improving performance at the local level. The programme consisted of four modules for its entire workforce. The modules included public health in transition, visionary leadership and employee empowerment, systems thinking and .

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 18 Seminars and workshops three-hour sessions focused on developing critical Health professionals suggest that CPD is essential appraisal skills. Each session included a seminar for ensuring that they maintain and learn new skills discussion and group work to allow staff an and competencies.158 opportunity ‘to have a go’ at critical appraisal using simple clinical scenarios. Participants included ‘Clinical professionals themselves report a nurses, doctors, occupational therapists, dieticians, lack of expertise and skills as crucial and physiotherapists, technicians and managers. emphasise continuing medical education The timing and length of sessions were carefully (CME), professional development, self considered to allow the maximum number of instructional learning, learning from people to attend. Short, regularly repeated sessions problems, and learning together with were used and the location of modules was varied colleagues as methods for improving across the trust to give staff more opportunity to 159 attend. The team found that these in-house sessions performance.’ were well received and attended, but suggested that A common method for training qualified it would be more appropriate to design seminars professionals in quality improvement involves that helped teams make a real change in their classroom or workshop style teaching, either at clinical environment. participants’ places of work or at other venues. Numerous examples have been studied.160,161 This hospital also found some barriers to participation. A number of organisations run such sessions. For example, the Practice-based Commissioning ‘Whilst staff express an interest in in England was targeted towards attending courses, if they are provided free general practitioners (GPs) and primary care trust of charge and not certificated, enthusiasm (PCT) managers interested in increasing their can wane and people fail to attend at the commissioning and analysis skills. The Academy last minute, particularly when there are was run jointly by the NHS Alliance and private competing pressures… There is no quick and offered 11 half-day modules that fix for this and those providing education professionals could combine or participate in as standalone training. Modules covered needs have to decide whether to use a carrot assessment, analysing data, leading and managing or stick approach; the carrot being, say change, business planning, improving patient education points, or a stick where some experience, financial modelling and ethics.162 imposition is placed for those booking a place but not attending.’169 Another example of offsite classroom type approaches is a course set up to train hospital Seminars to improve quality improvement skills nurses about quality improvement methods for and knowledge have been implemented across safety in Canada. A trial found that nurses who a wide range of disciplines including medicine, underwent seminar-based training had improved , nursing, and allied 170–173 self-reported skills.167 professions. As well as inviting health professionals to offsite Training has been set up for managers and policy training, there are examples of visiting practices or developers too. In total, 107 senior managers to provide onsite training and mentorship from 20 Serbian general hospitals took part in or developing in-house training. There are an improvement course. Organisational skills, sometimes difficulties providing ‘in service’ training motivating and guiding others, supervising the due to attendance problems, perceived relevance work of others, group discussion and situation and deciding on an appropriate level of education, analysis skills all improved. The least improved skills however in-house training is usually popular.168 were applying creative techniques, working well For instance, in England a partnership between a with peers, professional self-development, written 174 hospital trust and a university ran a series of seven communication and operational planning.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 19 In the US, all health department and public health skills,178–180 but most of these staff in one county were invited to attend four studies are not comparative so it is not possible half-day small group workshops over a two- to say whether one type of content or training year period. The sessions covered improvement approach is more effective than another. methods, leadership and systems thinking. In total, 600 people took part. Participants said that Simulation the training helped to reduce hierarchical barriers, Simulation techniques such as role play, using case support bottom-up decision making and involve studies, mock equipment, standardised patients more non-management staff in planning and policy and ‘high fidelity’ simulations which involve a 175 advisory committee roles. full practice of the situation or environment have Some suggest that it is important to train various been used to support healthcare improvements, 181,182 levels and types of staff simultaneously in quality particularly regarding safety and teamwork. In improvement approaches. One group of five US the US, simulation has been used extensively within hospitals and a multispecialty health practice formal nursing curricula and ongoing professional 183 trained leaders and frontline staff. One two- development about quality improvement. day course known as ‘leadership for healthcare Role play has been used to good effect in a number improvement’ was offered to senior managers of training initiatives. For instance, a hospital in and a four-month programme entitled ‘practical England used actors to help nurses develop critical methods for healthcare improvement’ was offered thinking and safety awareness skills. A study day to frontline staff and middle managers. More was developed to help change the in the than 600 staff completed the programme over hospital, to allow nurses to challenge one another a two-year period. There were improvements with a view to improving safety. The training in knowledge and confidence about quality was experiential and aimed to allow participants improvement principles. Participants also initiated to explore their thoughts and feelings about quality improvement projects, many of which were potential barriers as well as providing tools and a 176 sustained up to one year after the training. safe environment in which to practise new skills. Sometimes workshops or courses are run Actors performed scenarios to help nurses identify alongside other training approaches, especially and learn from issues, and nurses then role played when the aim is to improve a specific care process alongside actors. Nurses learned new skills and or pathway. For instance, in Australia, one hospital felt more confident in the need for, and methods tested a ward-based training programme for to achieve, basic hygiene and safety components 184 quality improvement in . of quality improvement. Other studies have also The programme consisted of two one-hour found that drama can be useful in developing new 185,186 workshops followed by one-to-one skills. coaching of nurses.177 One-to-one training There are many hundreds of articles describing One-to-one training can take the form of coaching, seminars or courses that aim to provide a quick academic detailing and informal teaching sessions. overview of quality improvement methods as part Due to costs, this approach is not common for of CPD or as a component of a specific quality training about quality improvement, but has been improvement initiative. What most of these articles found to be motivating in some instances. have in common is that they outline the potential merits of courses and participant satisfaction or In the US, outreach workers visited GPs and knowledge, but there is little focus on whether the primary care staff to teach them about quality training resulted in a real change in behaviours improvement. It was difficult to time among professionals. There are also studies of with primary care staff but outreach visits were particular , such as teaching crew associated with increased adoption of quality resource management approaches to upskill improvement tools.187 professionals in team work, communication and

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 20 One-to-one training may also be implemented as Researchers in China found that videos and a component of a broader learning strategy. For online learning were popular among nurses, example, in England a programme was developed especially those in rural areas. 96% percent of to improve patient care and develop leadership nurses surveyed said that they had changed their skills in 19 GPs in an area of social deprivation clinical practice as a result of this type of CPD.198 and underperformance on national quality But most studies suggest that online learning indicators. New and experienced GPs took part in or distance training should be coupled with biweekly action learning sets, individual coaching, interaction of some sort, such as coaching, and placements with national and local health or practical projects. organisations. One-to-one learning was integral for building confidence and motivation. Each GP In 2005, the NHS Clinical Governance Support completed a project to improve the quality of patient Team’s Primary Care Team launched a set care. The programme was associated with increases of e-modules targeting practice managers to in leadership competencies and confidence and support clinical governance. The modules were changes in services, care processes and culture.188 based on, and mapped to, the General Medical Services contract and initiatives. The programme targeted people who had little Distance learning formal training in practice management, but it was Online and distance learning and web conferences also applicable to pharmacy and dental practice 189–194 are becoming more popular for CPD. managers and PCT managers. There were nine For instance, PCTs in England partnered with a e-modules with core competencies and interactive university to implement a variety of accredited self-assessment, supported by a series of action work-based learning programmes for nurses. learning sets run by a network of local facilitators. Distance learning, mentorship, reflection and a Participants also undertook a service improvement portfolio were used. Nurses thought that the training project and vocational training schemes. helped them to improve the quality of care.195 Quality improvement was one component of the programme. This is a good example of blended In total, 195 public health workers and managers learning, whereby online modules were coupled from 38 local health departments in one US took with projects and facilitated support. part in a distance learning programme about quality improvement. Sixty-five of the participants completed Practical projects eight quality improvement projects, supported by As with accredited education, putting quality experts, over a 10-month period. Participants were improvement concepts into practice is becoming highly satisfied with the training sessions and projects increasingly common in CPD. An Australian study and had increased understanding of the relevance of training to build evidence-based practice into of quality improvement and enhanced knowledge mental health services found that without practice and confidence in applying these techniques. Six and follow-up shortly after classroom sessions, out of the eight practical projects were associated training lost its usefulness.199 with moderate to large improvements in quality or efficiency.196 One hospital adapted an industrial quality improvement process for use within the NHS by Elsewhere in the US, an online continuing providing training seminars alongside practical education programme for oncology nurses used implementation of the . The training a mentoring format. Twenty-five nurses was largely targeted at managerial staff. Staff said from specialist cancer centres partnered with that putting the methods into practice on a day- 50 oncology nurses over a seven-month period. to-day basis had improved their learning and most Learning methods included webcasts and printed thought there had been some improvements in resources. Several nurses implemented practice systems.200 changes as a result of the programme.197

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 21 Other examples of practical CPD are abundant. The Improving Prevention Through Organisation, In Sweden, 240 nurses participated in a four-day Vision and Empowerment (IMPROVE) and training course about quality improvement methods. Improving Diabetes Care Through Empowerment, One group received training alone and another took Active Collaboration and Leadership (IDEAL) part in a project to develop national guidelines as collaboratives taught quality improvement part of their training. Participating in the practical concepts to US primary care teams using didactic project enhanced nurses’ ability to implement instruction and interactive discussions during seven quality improvement methods but was no more half-day workshops run over a two-year period.218 likely to ensure that nurses maintained quality In between sessions, participants undertook quality improvement activities over a longer period.201 improvement initiatives supported by calls and site visits from faculty.219 Other common examples of practical training include collaboratives and courses set up as part of Eighteen hospitals in the US collected data about particular work-based improvement initiatives. breast cancer care and compared outcomes between institutions. Aggregate and blinded data were Collaboratives shared with project directors and institutions at Collaboratives combine structured education, collaborative meetings and trends were analysed practical projects and sharing information between over time. Site project directors disseminated the providers. For example, in the IHI Breakthrough data to their institutions and developed action collaboratives, organisations pay a fee to send plans for professional and patient education. This 220 teams to a series of seminars designed to aid in approach helped to improve care processes. making major, rapid changes in the quality of care. A systematic review of seven regional quality Teams from each organisation include a group improvement collaborations in surgical practice leader (usually a doctor) and a day-to-day manager found that collaboratives were often set up in (usually a nurse). Teams are taught how to study, response to external demands for performance , and implement systematic improvements in data. Collaboratives were associated with changes care processes. In between collaborative meetings, in care processes and improvements in clinical the teams recruit others from their sites to outcomes such as reduced mortality rates and fewer 202 participate in quality improvement interventions. surgical site infections. Success factors included Collaboratives have been applied to improve the establishing trust among health professionals quality of care and teach quality improvement and institutions, the availability of accurate and methods across a wide range of care areas and complete data, clinical leadership, institutional 221 disciplines, including cardiovascular disease, commitment and infrastructure support. neonatal care, asthma, primary care, end-of-life Adaptations of this type of collaborative approach care, rehabilitation, chronic obstructive pulmonary have been tested. Most adapted approaches support 203,204 disease (COPD), diabetes and many more. learners with audit and feedback at an initial Many studies have examined the potential benefits seminar followed by teleconferences or site visits to 205–215 of this model. facilitate collaboration during quality improvement 222–226 For instance, in the US, groups worked together for projects. 12 months, sharing information on their successes In the US, online learning collaboratives have and challenges by telephone and email between been tested. One initiative included an online meetings. An evaluation found that, compared educational toolkit, quality improvement coaching to a control group, the calls led by faculty, and individual feedback reports approach resulted in enhanced knowledge and to motivate doctors to change. The initiative implementation of quality improvement methods was associated with increased quality of care and better clinical outcomes and quality of care for processes.227 service users.216,217

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 22 Another related concept is managed clinical scope of the training or the learning outcomes networks, which involve collaboration across but such ‘on the job’ training could comprise short organisations. An evaluation of a diabetes managed hour or half-day sessions or span a few days. clinical network in Scotland over a seven-year period While this type of training may help managers found that the initiative involved progressively and practitioners learn transferable skills, its implementing multiple quality improvement purpose was not usually to teach about quality strategies directed at individuals and clinical teams, improvement methods. such as guideline development and dissemination, education, clinical audit, encouragement of An issue with the evaluation of all initiatives of multidisciplinary team working and task redesign. this type is that it is difficult to link work-based There were some changes in simple processes, but learning to specific outcomes. Researchers cannot more time was needed for improvement in more usually make causal attributions suggesting that any changes in quality of care are a direct result of complex processes and pathways. It was important 243 to gain widespread clinical engagement by learning initiatives. appealing to shared professional values and using clinical leaders and champions.228 Train the trainer approaches Train the trainer approaches have been used in Ad hoc training during projects some areas, especially to upskill professionals By far the most commonly researched example of about improvements in patient safety. Train the quality improvement training involves sessions run trainer approaches involve teaching managers and as part of a quality improvement initiative.229–232 professionals who then ‘roll out’ the material by offering training sessions to those in their own For example, a GP practice setting up a new 244–246 telephone helpline might run a training session for organisations or fields. For example, the staff covering principles of quality improvement Patient Safety Education Project used practice or nurses may be trained in research principles or improvement toolkits, online learning and safety ethics as part of a programme to achieve clinical trainers to support improvement in patient safety standards.233 in the US and Australia. The teaching style was based on a ‘stages of change’ model, matching There are many hundreds of articles describing people’s readiness and willingness to change with initiatives of this nature spanning the globe, attitudinal and behavioural interventions.247 These including Asia, Arab nations, Africa, Australasia methods have also been used to upskill medical and Oceania, the Americas and Europe.234–237 school faculty in how to teach quality improvement concepts.248 A smaller number of articles describe how quality improvement concepts have been taught at the Another example is public health training in beginning of improvement projects to support Nicaragua. The Centers for Disease Control and staff with implementation, particularly regarding Prevention partnered with local government and audit and feedback.238–242 In a number of cases the non-governmental agencies to develop a ‘train the trainers were faculty from medical schools. trainers’ programme for public health managers and government employees. This consisted of two The scan did not focus on these studies in any workshops, a practical project and a concluding detail because the training provided was not usually presentation. The first workshop was five days long about methods for general quality improvement, and covered team building, behavioural styles and but rather was specific to the particular project total quality management. Following the workshop, being implemented. This type of training was trainees disseminate their learning to peers by a component of the quality improvement leading a local team through a learning project intervention itself and did not necessarily aim to over a two-to-three-month period. This is followed teach participants skills that they may be able to by a seminar on presentation skills and a final apply outside of that particular initiative. There presentation. Trainers have been taught to roll out were usually very few details provided about the the programme widely.249

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 23 Sometimes train the trainer approaches In England, the Royal College of General are implemented to supplement to quality Practitioners developed a programme in improvement training. For example, one trust in partnership with other professional bodies such England partnered with the King’s Fund to develop as the Institute of Healthcare Management and in-house training to support quality improvement the Royal College of Nursing. The programme and audit. The training involved a one-day session aimed to support quality improvement through plus a follow-up session some months later.250 The practice team development, education and service project developed a facilitator’s guide (providing planning. Teams set their own development targets, instructions about running each session, group self-assessed, and took part in multidisciplinary work materials and overheads) to enable staff to peer review.254 train as facilitators after attending the course and then run the sessions themselves. The developers Formal audit and feedback has been used as a suggested that it was beneficial to have staff from training method for quality improvement. For different professional backgrounds involved in example, in Australia, a learning project was set up the training to bring their unique expertise and to improve discharge management of people with experiences to course participants. acute coronary syndromes. Forty-five hospitals across the country participated in a quality Other examples involve developing ‘learning improvement cycle of audit, feedback, intervention helpers’ or quality improvement facilitators and reaudit. In total, 3,034 staff took part in onsite.251,252 The theory is that having informal educational meetings and received reminders and learning support readily accessible will improve feedback about audit results. The training was practice of, and therefore skills in, quality associated with improved adherence to evidence- improvement. In Sweden, learning helpers in based guidelines about prescriptions, and hospital have helped increase reflective practice, referrals.255 facilitate experiential learning and support quality improvement projects.253 The theory behind using audit and feedback is that clinicians who learn that their performance or behaviour is below par compared to colleagues Feedback for improvement will be prompted to improve and will learn quality Feedback has been used as a training technique in improvement techniques more effectively. a variety of forms, including audit, videotaping and structured review sessions with teams. ‘Audit and feedback can be effective in improving professional practice. The effects For instance, 102 professionals in mental health teams took part in training to support team are generally small to moderate (median development and quality improvement. The teams 5% risk difference), greater when baseline spanned 12 US inpatient units and included the adherence to recommended practice is disciplines of psychiatry, psychology, nursing, low and when feedback is delivered more social work and occupational . The training intensively.’256 programme included structured feedback, A challenge with this approach is that often audit seminars, consultation and videotaping of sessions. and feedback is undertaken without providing The aim was to review treatment planning sessions any formal upskilling in quality improvement as a tool for examining team functioning and care techniques. Rating clinicians on a scale or processes. Feedback and videotaping worked well providing graphs showing how they compare with to help raise awareness of quality improvement others may raise awareness of the potential for and team function among multidisciplinary teams. quality improvement but does not train clinicians Here the focus was not so much on learning quality in how to address any gaps. improvement techniques, but rather on using these techniques to make a difference to day-to-day working practices.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 24 Another approach to using feedback involves peer outcomes.263 Every internal medicine specialist review ‘quality circles’. These have been researched must be recertified every 10 years. Other specialists most commonly in Europe.257 undergo a similar review cycle every six to 10 years. In the Netherlands, continuous quality One study found that the self-assessment and improvement is being prioritised by many quality improvement training required for professional organisations and educational recertification in the US can lead to meaningful institutions. In line with this priority, teams of behavioural change in doctors. A ‘practice midwives tried a quality circle approach which improvement module’ used as part of the focused on continuous, systematic and critical recertification programme for general internists reflection on their own and others’ performance. and endocrinologists consisted of a self-directed This method was found to improve knowledge audit, practice system survey and but it did not necessarily help midwives learn new patient survey. Coaching and self-assessment skills.258 helped doctors learn about, and implement, quality improvement techniques during recertification.264 In Austria, 445 GPs took part in quality circles to improve prescribing. These peer review In Belgium, GPs and specialists are legally required groups helped to improve prescribing of generic to comply with certain standards. For GPs, this medications, thus reducing costs. Quality circles includes continued development of skills to also helped GPs exchange ideas about the problems enhance performance and practical demonstration they encountered.259 of quality improvement.265 Similarly, in quality circles were used In New Zealand, doctors are expected to spend to help pharmacists review and provide feedback at least 50 hours per annum on recertification about GPs’ prescribing. Over a nine-year period, activities including external audit, peer reviewing there was a 42% decrease in drug costs in the group cases, analysis of outcomes and reflective practice. taking part in quality circles compared to a control Learning about and participating in quality group. This equated to cost savings of US$225,000 improvement initiatives is required to obtain an per GP per year.260 annual practicing certificate.266 In the UK, participation in CPD is a condition 2.3 Recertification of in the NHS and for continued Bridging the gap between CPD and accredited membership of the royal colleges. The Department education is recertification. Such revalidation of Health has outlined how doctors will be includes methods to ensure that clinicians remain required to renew a licence to practise every five competent and fit to practice. This can be used to years, but as yet quality improvement training is promote continuing improvement in the quality not a requirement.267 of care.261 In England, practice level or organisational The World Health (WHO) has accreditation has been tested, which includes outlined the mandatory and voluntary revalidation broadly defined quality improvement domains. strategies of many countries.262 Only a small The Primary Medical Care Provider Accreditation number such as the US, New Zealand and Australia (PMCPA) scheme included 112 separate criteria made learning about quality improvement methods across six domains: health inequalities and health an explicit focus for reaccreditation. promotion; provider management; premises, records, equipment and management; For example, the American Board of Internal provider teams; learning organisation; and patient Medicine now requires completion of a ‘practical involvement. An evaluation with 36 practices found improvement module’ for recertification. This that most could pass the core criteria, regardless of involves taking part in a quality improvement practice size or location.268 programme, collecting data and assessing

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 25 2.4 Summary Many descriptive and narrative articles outline training in quality improvement for qualified health professionals and health professionals in training. The training approaches most commonly researched include: –– university courses about formal quality improvement approaches –– teaching quality improvement as one component of other modules or interspersed throughout a curriculum –– using practical projects to develop skills –– online modules, distance learning and printed resources –– professional development workshops –– simulations and role play –– collaboratives and on-the-job training. The next section examines the impacts of these types of training and whether one approach is more effective than others.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 26 3. Most effective approaches

This section explores evidence about the impacts of training in quality improvement and the relative effectiveness of different training approaches.

3.1 Impacts of training tends to be small. This synthesis was about training for healthcare professionals generally, and was not The previous section described some of the impacts specific to training about quality improvement, but of individual training approaches. This section it emphasises that there are not necessarily ‘quick draws this information together to look at the wins’ from CPD.275 impacts of training more generally on outcomes for learners, patients and the wider healthcare system. Several other studies and reviews about the effectiveness of quality improvement training It is generally accepted that education and training suggest that the impacts may be mixed and can have an impact on the attitudes, knowledge, variable.276–279 For instance, a systematic review skills and potentially the behaviours of those of 26 studies found that education had variable who take part.269 Thus, it is often assumed that effects on students’ attitudes to clinical practice training professionals in quality improvement is guidelines, quality improvement techniques and beneficial. However, published evidence about the multidisciplinary teamwork.280 effectiveness of quality improvement training is not clear cut.270,271 In fact, some studies suggest that Another systematic review of postgraduate continuing medical education may have very little training programmes identified 39 studies with a impact on compliance with guidelines or improved comparative design. Of the 39 studies, 31 described care.272 team-based projects and 37 combined didactic instruction with experiential learning. The review For example, a randomised trial with 47 rural and found that most quality improvement curricula small community hospitals in the US compared were associated with improved knowledge and quality improvement education to a control group. confidence in the use of quality improvement The educational programme consisted of two techniques, but evaluation tools were not always of two-day didactic sessions about continuous quality high quality. There was much less certainty about improvement techniques, followed by the design, the impact of quality improvement training on implementation and reporting of a local quality clinical or patient outcomes. Randomised trials improvement project, with monthly coaching were more likely to have mixed or null effects.281 conference calls and annual follow-up meetings. The implication is that we cannot automatically There were no significant differences in processes assume that training has positive effects on quality. or clinical outcomes between hospitals that took part and those that did not.273 But not all research is negative, and more and more studies are emerging that suggest that Other trials comparing professionals who took part training in quality improvement can be beneficial. in quality improvement training and those who A systematic review of quality improvement curricula did not have also found no differences in skills and for medical students and residents found that outcomes.274 most formal education of this nature was associated A synthesis of 36 systematic reviews about training with improved knowledge. One-third of curricula methods found that most techniques have limited were associated with local changes in care delivery effects. Even where ongoing training does have and 17% improved specific processes of care. an effect on attitudes or behaviour, the magnitude

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 27 Factors that affected the success of curricula Table 3: Effectiveness of training295–297 included having sufficient numbers of familiar with quality improvement concepts, Technique Effects addressing competing educational demands and Printed educational Limited effects on 282 ensuring buy-in and enthusiasm from learners. materials, posted knowledge information and media298 Other individual studies from around the world reinforce these conclusions, suggesting that many CME courses, lectures and Limited effects on types of training improve professionals’ knowledge conferences299 knowledge and skills and may have some impact on care Reminders, prompts and Mixed effects on 283–290 processes. computers300–302 behaviours

A small number of studies suggest that training is Audit and feedback on Mixed effects on associated with improvements in clinical outcomes performance303,304 knowledge and and direct benefits for service users or care systems, behaviours though examination of these types of impacts is 305,306 291,292 Opinion leaders Mixed effects on rare. knowledge

An example comes from an evaluation of a Guidelines Mixed effects on programme sponsored by the US Agency for behaviours Healthcare Research and Quality to train ‘Patient Safety Improvement Corps’. Health professionals Education outreach visits/ Often effective for academic detailing307 and managers were taught methods for improving prescribing quality and safety, with the aim of helping to build a Interactive seminars and More effective for national infrastructure supporting effective patient small groups308 behaviours safety practices. One year after training, about half Including practical More effective for of state agency representatives reported that they components309–312 changing behaviours had initiated or modified legislation to strengthen and may influence care safe practices and modified adverse event oversight processes procedures. About three quarters of hospital staff said that training contributed to modifying adverse Courses plus other Usually effective for initiatives313–317 changing behaviours event oversight procedures and enhancing patient 293 and some effects on safety culture. patient outcomes The impact of training professionals on patient outcomes is uncertain. One randomised trial There may be a number of reasons for the varying in the US included 20 GP practices in 14 findings about the impact of quality improvement states. All practices received copies of practice training. Firstly, outcomes do not tend to be guidelines and quarterly performance reports. In measured systematically and widely varying addition, one group participated in meetings and measures may be used.318 The definition of quality received quarterly site visits to help them adopt improvement and what is encompassed in this term quality improvement approaches. The practices also varies widely. receiving onsite training did not have significant improvements in patient outcomes compared to Another issue with reviews of the effectiveness of the group receiving guidelines and performance quality improvement curricula is that they tend reports alone.294 to combine many disparate types of training. This means that it is not possible to assess whether one Table 3 illustrates the mix of findings about the type of training is more effective than others. effectiveness of training in quality improvement.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 28 Alternatively, the focus is on a narrowly defined 3.2 Effective training methods type of training, such as classroom-based methods, Most research published about quality but the reviewers generalise to all types of quality improvement training in healthcare comes improvement training. from North America. It is often descriptive or Most reviews tend to describe educational observational, with few rigorous evaluations of interventions that improve clinicians’ knowledge of, impact.326 A review of 27 articles about educational or adherence to, guidelines rather than providing strategies for quality improvement found that them with the skills needed to improve the quality 75% were descriptive and that only 7% included of care.319–321 This means that it may be unrealistic an experimental design.327 The quality of available to expect changes in clinical outcomes or system research impacts on the conclusions that can be issues. drawn about the benefits of different training methods. However, some broad statements can be Furthermore, in the US training in quality made about content, training methods and other improvement is a component of most professional key success factors. training curricula. As a result, most of the studies available about the effectiveness of quality improvement training are drawn from the US.322,323 Content The findings are not always generalisable to other Research suggests that to be most effective, training countries and this may influence some of the should examine the needs of learners, target variations observed. content appropriately and illustrate how the content applies to the participants’ work environment The extent to which training is more or less (see Box 4). However, the most beneficial content effective than other ways to improve quality is regarding quality improvement has not been uncertain. A systematic review found that the most researched in any depth. Studies have not compared effective strategies for improving quality and safety whether it is more effective to teach professionals in healthcare included audit and feedback, clinical about PDSA cycles or improvement science decision support systems, specialty outreach , for example. programmes, disease management programmes, continuing professional education with small group In the UK there is an increasing focus on case discussions and clinician reminders. Pay for combining overviews of the philosophies behind performance schemes and organisational process quality improvement with training about specific redesign were modestly effective. This suggests that tools. However, there is no research about whether training may be one way to improve quality, but it this is more useful than the more structured focus is not possible to say whether it is more effective on PDSA cycles often taken in the US. than other mechanisms. Furthermore, the training covered in this review was not solely about quality improvement.324 Others suggest that training professionals may be just as effective as financial incentives for improving the quality of healthcare.325 But there is a very limited evidence base comparing quality improvement training with financial or other initiatives to improve healthcare.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 29 Box 4: Features of effective training328 Needs assessment Include data showing a gap between current and best practice Include data showing how practices or teams have improved Identify evidence-based sources for programme content

Content Describe key learning from implementing known best practice Discuss data before and after successful implementation Include as an objective ‘by the end of course, participants will be able to summarise evidence on…’ Allow time for questions about the pros and cons of evidence

Application Describe how evidence relates to participants’ work environment Ask participants how they will apply the evidence to their work environment

Training approaches Reviews and studies have concluded that there Just as the most successful content remains is not one ‘magic blueprint’ for teaching quality uncertain, so too do the most effective training improvement, either in formal educational methods. A consensus from 53 countries in Europe environments or as part of CPD.330 But researchers suggested that: tend to agree that in order to be effective, quality improvement training should be part of the ‘Education strategies vary in format and curricula for students, as well as being available effectiveness. Passive strategies – didactic as part of ongoing professional development educational meetings, dissemination training.331 of printed or audiovisual educational A review of 26 systematic reviews and meta- material – often have no or modest analyses of general continuing medical education effects. Active strategies – interactive (not solely quality improvement), found that workshops, outreach visits, charismatic interactive techniques such as audit and feedback, opinion leaders – are more often effective. academic detailing and outreach and reminders The source of information, format of were the most effective at simultaneously presentation, frequency and timing of improving care and patient outcomes. Clinical delivery and content impact. There practice guidelines and opinion leaders were less is no magic bullet.’329 effective. Didactic presentations, such as lecture style teaching and distributing printed information, It is not possible to draw conclusions about which had little or no effect on professionals’ behaviour.332 training methods are most useful because there is A significant body of individual studies reinforce a lack of rigorous comparative research and little these conclusions. But the question is whether focus on sustainable outcomes for service users these observations also apply to training in quality and resource use. However, it is possible to suggest improvement methods. components of successful training which may be worth further exploration.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 30 A more specific review of 27 studies about quality feel that they are doing “real work”’ and improvement training concluded that there was facilitating important improvements in insufficient evidence to suggest which training quality, safety, and system performance, methods are most effective, but that courses that they are stimulated to learn more.’341 include a practical focus can be beneficial. However ongoing training opportunities may ‘Factors that may contribute to successful be needed to maintain effectiveness. It is also improvement experiences for students important to train new staff given the high turnover include using health data to set project of healthcare quality improvement personnel.342 priorities, having a clear definition of a target community, selecting projects Other training components that can be completed in short periods Some educational strategies suggest that practical of time that coincide with the structure implementation is so important that all learning of an academic year, and emphasising should be based around rather than divided by discipline.343–345 For example, interdisciplinary teamwork. However, a medical school in Canada changed from a there are no data to demonstrate the traditional disciplinary-based curriculum to a effectiveness of specific teaching methods problem-based learning curriculum. This included or learning outcomes.’333 training in quality improvement methods at each A number of other studies have concluded that in students’ learning. A before and after training with a strong practical component, study comparing students who learned through such as work-based learning, improvement traditional versus problem-based learning found projects or collaboratives, is often associated with that problem-based learning styles were associated changes in care processes and sometimes patient with improved quality improvement learning and 346 outcomes.334–336 In fact, most studies which have implementation. found benefits for patients or healthcare resource Others suggest that such significant changes to use relate to training as part of broader quality curricula are not required, but that experiential collaboratives or work-based improvement 337–339 learning, didactic activities that support initiatives. , structured reflective practice Including practical examples and projects as part that examines the role of teams, and faculty of the training process is important not only due development in, and role modelling of, quality to the benefits for learners, but also because the improvement are all essential components of 347–352 projects undertaken can have a real benefit for successful quality improvement training. 340 health systems, organisations and service users. The importance of ongoing support and coaching from mentors or faculty has also been ‘ learners are best educated by 353–355 involving them in real work that interests highlighted. them. In those circumstances, a teaching The importance of multidisciplinary learning organisation can leverage the power remains uncertain. There is growing consensus and enthusiasm of learners to create that multiprofessional collaboration is an essential change. Learners are a valuable untapped component for improving quality and safety, but resource for quality, safety and systems the importance of including a range of disciplines improvement in teaching hospitals. They in training about quality improvement methods is an area of debate. Some argue that in order for are not constrained by the usual ways teams to work collaboratively in practice, they of doing things, and can raise system must be taught teamwork skills as part of quality concerns in a way that others cannot, improvement education. or will not… In turn, when the learners

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 31 ‘Collaboration and teamwork do not just and collaboration. Studies suggest that many happen. Health professionals cannot be professionals and educators feel uncertain expected to work together collaboratively if about their knowledge of quality improvement they are not even exposed to one another competencies, let alone their ability to teach them to others.361–363 There is a gap in the training and during the formative educational training 356 development opportunities available for faculty years.’ themselves.364 Some have suggested that to be most effective, interdisciplinary training should begin early, In the US, a number of organisations have before learners become isolated in disciplinary set up ‘train the trainer’ initiatives to prepare educators to teach practice-based learning and domains and ensconced in traditional disciplinary 365,366 hierarchies and boundaries.357 improvement. In the US, higher educational institutions partnered 3.3 Summary with the Robert Wood Johnson Foundation to develop a self-directed, four module web-based and To summarise: action learning curriculum designed to increase –– It is important not to assume without question graduate level learners’ competence in quality, that training in quality improvement is the safety and systems improvement. Participants best or only method for helping professionals completed online modules and then set up quality improve the quality of healthcare. There is improvement programmes in their teaching mixed evidence about the effect of training on hospital. Students were drawn from internal outcomes. medicine, emergency medicine, anaesthesia, family medicine, gynaecology, nursing, physical –– Training in quality improvement may increase therapy, management and administration, surgery, the knowledge and confidence of health rehabilitation and psychiatry. Twelve hospitals professionals, but didactic sessions alone are took part in an initial evaluation, which found unlikely to improve care processes or patient that learners’ knowledge of, and self-assessed outcomes. competence in, quality improvement increased –– Learning methods that encourage active as did their attitude towards, and participation participation may be more effective than in, multidisciplinary work. This illustrates that classroom-based learning alone. relatively low intensity web-based programmes –– Online courses and other distance learning can have an impact on practitioners’ attitudes and approaches may be useful and popular, especially behaviour when coupled with a requirement to when ‘blended learning’ approaches are used apply learning in practical projects.358 which also incorporate face-to-face tuition. Some suggest that doctors and medical students –– Mentorship, supervision and audit and feedback may have a less positive attitude to multiprofessional cycles may be useful as components of training, education compared to nursing and pharmacy but used alone are unlikely to produce sustained 359 teams. To address this, the Robert Wood Johnson changes in quality improvement skills or Foundation programme was first piloted with behaviour. medical learners and was accredited using the US Accreditation Council for Graduate Medical –– There is no evidence about whether it is more Education requirements. Only then was the effective to train students versus qualified health programme rolled out as an interprofessional model. professionals in quality improvement. Training both students and professionals is likely to have Another key success factor in quality improvement a place. training may be the capacity of trainers to provide high-quality education.360 It has been suggested that strong clinical faculty role models are critical in learning about quality improvement

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 32 4. Important messages

4.1 Key trends Training students in quality More than 5,000 articles have been published improvement about training health professionals and students Some in the UK provide modules or in quality improvement approaches over the courses about quality improvement for students past 30 years. Most are descriptive overviews or before they qualify as health professionals, but small observational studies, predominantly from there appears to be less explicit focus on quality North America. There is relatively little empirical improvement in the UK compared to the US, research about the impact of training in quality Canada, Australia and Europe where medical improvement or the effectiveness of various and nursing students often have these concepts 368–371 training techniques. However, it is possible to draw interwoven throughout their studies. This is some conclusions from the current knowledge base. slowly beginning to change in the UK, and courses or modules are now available focusing on critical Conceptualising quality appraisal, measurement for improvement and quality assurance. improvement Within education for students and CPD for Compared to the US, where quality improvement qualified professionals, quality improvement training is mandatory for doctors and routinely is generally defined as PDSA cycles, total incorporated into the curriculum for nurses, quality management, or as a set of interrelated the UK has a more implicit focus on quality competencies. improvement within formal education. The outcomes of quality improvement may be talked However, there are some geographic variations. about, such as patient-centred care or safety, In the US, and Canada to a lesser extent, quality but formal techniques for thinking about and improvement is conceived largely as a PDSA cycle implementing improvement are less pervasive. paradigm and training focuses on collating and interpreting quantitative information. There may be For instance, a study in England found that a quantitative bias, whereby quality improvement although patient safety has been recognised as a is largely associated with audit and small tests of key priority nationally, this is implicit in the formal change. pre-registration nursing curriculum. It is included in teaching, but at a basic level and with limited In the UK, a leadership and change management- quality improvement content. Students reported orientated approach is more common. However, gaining most knowledge and experience about in CPD the focus is sometimes on making one-off safety improvement from clinical practice. The improvements rather than training professionals organisational culture of both education and practice and students how to think critically about was characterised as being defensive and closed and improvement, take a whole systems approach and as having an individual versus a systems approach.372 continuously improve healthcare processes and services.367 In the UK, formal education for students does not appear to draw on the full menu of techniques for quality improvement. Courses tend to be either narrowly focused on methods such as audit or

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 33 critical appraisal or to be very time and resource However, few studies have examined the impact intensive, such as postgraduate degrees or modules. of training on health outcomes, safety or resource There are few ‘middle ground’ courses providing use. It is important not to assume that training will participants with both theoretical and practical automatically improve outcomes. grounding but not taking excessive time or commitment in formal education. However, this Types of training gap may be increasingly being filled by CPD. The need to provide patient-centred care, and Most training of students in the UK and provide value for money, means that health internationally is unidisciplinary, although in some professionals require more than clinical skills cases multidisciplinary practical projects have been alone. They also need to know how to assess, 373,374 tested with success. enhance and disseminate good practice. Surveys of medical, nursing and pharmacy students Continuing professional have identified gaps in formal training about quality development improvement, leadership and safety.375,376 Students Over the past few years there have been significant often say that they do not feel well-prepared and developments in CPD about quality improvement that they would like additional training about in the UK. Arms length bodies such as the NHS quality improvement.377–381 For example, a survey Institute for Innovation and Improvement offer of 436 nurses in the US found that almost four out a number of quality improvement courses, as of 10 new nurses thought that they were ‘poorly’ do workforce deaneries, leadership , or ‘very poorly’ prepared for or had ‘never heard strategic health authorities and private of’ quality improvement. New nurses wanted organisations. These tend to cover the basic more information about evidence-based practice, philosophies underlying continuous quality assessing gaps in practice, and research skills such improvement as well as practical techniques such as data collection and analysis.382 as measurement and analysis. Research is available about a number of different In addition, training is commonly run as part of training techniques, including classroom format, specific improvement initiatives. For example, online modules, simulations and practical quality professionals taking part in a safety improvement improvement projects. Few studies have compared programme may participate in workshops related one type of training with another so it is not to quality improvement as one component of the possible to say that one type is most effective. There programme. There is also an increasing focus on is evidence that blended approaches that combine offering short courses with practical components classroom or online learning with opportunities and developing communities of practice or learning to apply that learning in practice may be effective. collaboratives to share learning in a less formal Active learning strategies are thought to be more manner. effective than didactic classroom styles alone but comparative research is rare. However, there does not appear to be one consistent conceptualisation of quality No studies have assessed whether formal improvement or a standard foundation of content. education for students before they become health Each course varies in approach and content. professionals is any more or less effective than CPD or on-the-job learning for enhancing skills Impact of training in in quality improvement. It may be important quality improvement to provide training for students as well as opportunities for CPD rather than relying on one Research suggests that training in quality or the other alone. Key to this is ensuring that improvement can improve health professionals’ trainers and faculty have a consistent concept of skills and knowledge and may be associated with quality improvement and are skilled at teaching short-term improvements in care processes. about this topic.383

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 34 Components of successful training Research suggests that there are a number of key Educating health professionals about how elements needed for successful and sustainable quality to improve quality and safety may be key to improvement education, including role models and the future of healthcare.384 However, training champions, strong partnerships between academia opportunities are currently somewhat limited and practice environments, a variety of educational and fragmented.385,386 This is more the case in the modalities and a supportive .393 UK than in the US but even in the latter, where training in quality improvement is mandated for 4.2 Geographic trends some professionals, there are opportunities for It is difficult and potentially inappropriate to development. A systematic review of 18 published generalise about the nature of training in different quality improvement curricula for medical students countries based solely on this rapid scan. However, and residents in the US found that curricula some broad trends are evident. varied widely in the quality of reporting, teaching strategies, evaluation instruments and funding There appears to be greater focus on quality obtained. Many curricula did not adequately improvement training in North America compared address the topic of quality improvement or to the UK. US training typically emphasises educational objectives.387 systematised methods and teaching managers and practitioners how to apply particular techniques, There may be scope to enhance the undergraduate including how to collect and analyse data. and specialist curriculum in order to: emphasise Quality improvement is generally taught as a very team working, communication skills, evidence- structured and quantitative method. In contrast, based practice and risk management strategies;388–390 the UK tends to emphasise leadership and theory develop a systematic approach to entrance much more. In the Netherlands and Scandinavia, requirements to medical school, the curriculum, there is more evidence of peer review and training environments and student assessment;391 structured feedback as a training method, whereas offer ongoing opportunities to develop quality Canada and Australasia are more likely to describe improvement skills; ensure that leaders are practical examples and work-based learning. committed to quality improvement.392 Studies have not investigated whether any one of these approaches is more beneficial than others. Figure 1: Models of quality improvement

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 35 It has been suggested that there is a ‘quality is now seen as mandatory for medical students – improvement lifecycle.’ Individuals, organisations and thus more has recently been published about or health systems move through the lifecycle as the topic. quality improvement conceptualisations become more advanced. In this view, basic quality assurance In the UK, the number of courses in quality approaches are contrasted with continuous quality improvement is growing, particularly in terms of improvement cycles and ‘quality improvement CPD. However, as yet there does not appear to be maturity’ (see Figure 1). a wide appreciation of the full menu of techniques for quality improvement. While it may be inappropriate to see the lifecycle as a hierarchy, this model may be useful for describing 4.3 Gaps in knowledge some of the variations in approaches to quality improvement training between countries. 394,395 Despite the quantity of published material available, there are gaps in information about quality While the US and Canada tend to focus on training improvement training. This scan identified the for ‘quality improvement’ or ‘continuous quality following questions as gaps in knowledge. improvement’, regions such as Australasia and Scandinavia may place more emphasis on ‘quality Does training make a difference? improvement maturity’. This is not to suggest There is an assumption that training in quality that any approach is more effective than others improvement makes a difference. While there is and it is acknowledged that such statements are evidence that training can influence participants’ generalisations. knowledge and confidence, most studies have It is difficult to categorise UK approaches within not explored whether training directly results in this typology because there is not necessarily a positive outcomes for service users, care quality or strong focus on quality improvement training. The resource use. training that does exist tends to be fragmented. The literature acknowledges that courses alone There are examples of training in the UK that are not enough to facilitate skills in quality fit within each of these four conceptualisations, improvement. Thus formal educational curricula but the majority may be within the ‘quality alone are not likely to generate improved quality of improvement’ category rather than ‘continuous care downstream. quality improvement’ or ‘quality improvement maturity’. ‘While most newly qualified physicians There may also be differences in the training are well prepared in the science base of prevalent in different disciplines. Based on medicine and in the skills that enable published studies, quality improvement training for them to look after individual patients, few nurses appears to be more reflexive and practical, have the skills necessary to improve care whereas training for doctors and managers is and patient safety continuously… medical sometimes more process orientated. school education can increase the number Based on the number of articles published, it of graduates prepared to reflect on and appears that there has been a substantial increase improve professional practice. Doing so in the awareness and ‘popularity’ of quality requires a systematic approach involving improvement training in recent years. It is difficult entrance requirements, the curriculum, to judge whether the developing interest in quality the organisational culture of training improvement is cyclical or marks a linear increase. environments, student assessment, and There seems to be a trend towards increasing programme evaluation.’396 interest over the past decade, but this is largely influenced by the US where improvement training

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 36 Who would benefit most How important is it to put quality from training? improvement concepts into practice Most published research focuses on doctors and, to as part of the learning style versus a lesser extent, nurses. However, taking a holistic classroom-based or online learning? approach to quality improvement may necessitate There is evidence that training that includes a considering the value of training allied health practical focus, such as implementing quality professionals, support workers such as healthcare improvement projects or work-based learning, assistants, faculty and healthcare managers. There may be more likely to result in tangible change appears to be a significant gap in the market for compared to classroom-based or online learning. training that supports management teams to put However, the balance of theoretical and practical quality improvement principles into practice. learning remains uncertain. The most effective Where managers are taught quality improvement methods for introducing practical experience techniques, these tend to focus on monitoring and into quality improvement training are also measurement rather than how to lead and manage unknown. change, incorporate the needs of service users and consider the impact on staff. How frequently should training be reinforced to ensure continued use? To be effective, it is likely that quality improvement In the US, doctors undergo training in quality training should begin at pre-registration level, have improvement as part of their formal preliminary options for specialist training and be available for education. But little follow-up work has been done regular updates during the of managers and to assess whether the skills and knowledge learned clinicians. pre-registration or as registrars lasts into longer- term practice. Are short courses, websites and one-to-one mentoring more or Studies with nurses, though rarer, suggest that less effective than building quality quality improvement teaching needs to be reinforced and practised regularly in order for improvement skills into to be sustained. pre-registration education? There has been little comparative research into the There may not be a shortage of quality most effective training methods and learning styles. improvement training, but rather a shortage Rather than considering the level of education of training that is simple and practical enough as an either/or question, it may be worthwhile to for managers and clinicians to apply in daily think about supporting a menu of education to practice. A study in Finland surveyed a large ensure that training is available to a wide range of sample of doctors about the availability of quality professionals at different times in their careers. improvement training in 1998 and again five years later in 2003. The authors found that in While much quality improvement education is both years, doctors thought that there was uniprofessional, in order to mirror the ethos of plenty of opportunity to obtain continuing quality improvement such training may be more medical education, in-house training, feedback effective if run on a multiprofessional basis, from colleagues and guidelines for quality emphasising reflective practice and providing improvement education.397 No similar study opportunities for action research or on-the- has been conducted in the UK so it is uncertain job learning. It seems unlikely that focusing on whether practitioners feel that there is adequate classroom-based learning alone will support training available and whether the training is managers and practitioners to improve and apply accessible and meets people’s needs. their skills.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 37 To conclude, researchers and practitioners are increasingly recognising gaps in training about quality improvement, both in terms of what is known about this topic and in terms of the quality and effectiveness of how the concepts and methods are taught.398,399 There is a move towards seeing quality improvement as a dynamic concept underpinning service planning and provision, but as yet this has not permeated most training courses.400 There is scope for major development in this area. ‘To the extent that quality and safety are addressed at all, they are taught using with a narrow focus on content transmission, didactic sessions that are spatially and temporally distant from clinical work, and quality and safety projects segregated from the provision of actual patient care… Transformation will require new pedagogies in which a) quality improvement is an integral part of all clinical encounters, b) health professions students and their clinical teachers become co-learners working together to improve patient outcomes and systems of care, c) improvement work is envisioned as the interdependent collaboration of a set of professionals with different backgrounds and perspectives skilfully optimising their work processes for the benefit of patients, and d) assessment in health professions education focuses on not just individual performance but also how the care team’s patients fared and how the systems of care were improved.’401

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 38 References

1 Batalden P, Davidoff 12 O’Brien MA, Freemantle 22 Healthy America. San 33 Gonnering RS. Complexity F. Teaching quality N, Oxman AD et al. Francisco, CA: Pew Health theory and the “puzzling” improvement: the devil Professions Commission, competencies: Systems- is in the details. JAMA meetings and workshops: Pew Charitable Trusts, based practice and practice- 2007;298(9):1059-1061. effects on professional 1991. based learning explored. J 2 Parsley K, Barnes J. Do or practice and 23 Briere R (ed). Crossing the Surg Educ 2010;67(2):122- die. Int J Health Care Qual outcomes. Cochrane Quality Chasm: A New 124. Assur 1995;8(7):9-13. Database of Systematic Health System for the 21st 34 Accreditation Council Reviews 2001, Issue 2. 3 World Health Organization. Century. Washington DC: for Graduate Medical Innovative Care for Chronic 13 Epstein AM. Performance National Academy Press, Education. Outcomes Conditions. Building Blocks measurement and 2001. Project: General for Action. Geneva: WHO, professional improvement: 24 Kohn L, Corrigan J, Competencies, 2004. www. 2002. approaches, opportunities Donaldson M (eds). To Err acgme.org/outcome/comp/ and challenges. Health compFull.asp 4 Department of Health. is Human: Building a Safer Systems, Health and Health System. Washington, 35 Djuricich AM, Ciccarelli M, Improving Chronic Disease . WHO Ministerial Management. London: DC: National Academy Swigons NI. A continuous Conference on Health Press, 2000. quality improvement Department of Health, Systems, June 2008. 2004. 25 Varkey P, Kollengode A. A curriculum for residents: 14 The Health Foundation addressing core 5 Parsley K, Barnes J. Do or framework for healthcare adapted this typology quality improvement in competency, improving die. Int J Health Care Qual from Batalden P, Davidoff systems. Acad Med Assur 1995;8(7):9-13. : the time is here F. Teaching quality and now! J Postgrad Med 2004;79(10): S65-67. 6 Wakefield A, Attree M, improvement: the devil 2011;57(3):237-241. 36 Wittich CM, Reed DA, Braidman I et al. Patient is in the details. JAMA 26 Parsley K, Barnes J. Do or McDonald FS et al. safety: Do nursing 2007;298:1059-1061. Perspective: Transformative and medical curricula die. Int J Health Care Qual 15 Melichar L. Transforming Assur 1995;8(7):9-13. learning: a framework using address this theme? care at the bedside for nurse critical reflection to link the Today faculty: can continuous 27 www.nationalacademies.org improvement competencies 2005;25:333-340. quality improvement 28 Van Hoof TJ, Meehan in graduate medical 7 Jones CB, Mayer transform nursing TP. Integrating essential education. Acad Med C, Mandelkehr LK. education? J Nurs Educ components of quality 2010;85(11):1790-1793. at the 2011 Nov;50(11):603-604. improvement into a new 37 Preheim GJ, Armstrong intersection of academia 16 Massey L, Williams S. paradigm for continuing GE, Barton AJ. The new and practice: facilitating CANDO: implementing education. J Contin Educ fundamentals in nursing: graduate nursing students’ change in an NHS Trust. Health Prof 2011;31(3):207- introducing beginning learning about quality Int J Pub Sector Manage 214. quality and safety education improvement and patient 2005;18:330-349. 29 Dysinger WS, King V, for nurses’ competencies. J safety. Qual Manag Health Foster TC, Geffken D. Nurs Educ 2009;48(12):694- Care 2009;18(3):158-164. 17 Kim CS, Lukela MP, Parekh VI et al. Teaching internal Incorporating population 697. 8 Neale G, Vincent C, medicine residents quality medicine into primary care 38 Armstrong GE, Spencer Darzi A. The problem of improvement and patient residency training. Fam TS, Lenburg CB. Using engaging hospital doctors safety: a lean thinking Med 2011;43(7):480-486. quality and safety education in promoting safety and approach. Am J Med Qual 30 Manning ML, Frisby for nurses to enhance quality in clinical care. J 2010;25(3):211-7. AJ. Multimethod competency outcome Royal Soc Med 2007;127:87- teaching strategies to performance assessment: a 94. 18 Henley E. A quality improvement curriculum integrate selected QSEN synergistic approach that 9 Audet A-MJ, Doty MM, for medical students. Jt competencies in a Doctor promotes patient safety and Shamasdin J, Schoenbaum Comm J Qual Improv 2002; of Nursing Practice distance quality outcomes. J Nurs S. Measure. Learn and 28(1):42-48. education program. Nurs Educ 2009;48(12):686-693. improve: ’s Outlook 2011;59(3):166- 39 Barton AJ, Armstrong G, involvement in quality 19 Wong BM, Etchells EE, 173. Kuper A et al. Teaching Preheim G et al. A national improvement. Health 31 Van Eaton EG, Pellegrini Delphi to determine Affairs 2005;24:843-853. quality improvement and patient safety to trainees: CA. Development and developmental progression 10 Devitt N, Murphy J. A a systematic review. Acad assessment of personal of quality and safety survey of the information Med 2010;85(9):1425-39. skills and aptitudes. Surgeon competencies in and 2011;9(Suppl 1):S40-42. education. Nurs Outlook 20 Batalden P. Contemporary 2009;57(6):313-322. technology training needs 32 Davó MA, Vives-Cases of doctors in an acute Issues in Medicine: Quality of Care. Washington DC: C, Benavides FG et al. 40 Fater KH, Ready R. NHS trust in the United Common competencies and An education-service Kingdom. Health Info Libr J Association of American Medical Colleges, 2001. contents in public health partnership to achieve 2004;21(3):164-172. in graduate programs. Gac safety and quality 11 Ham C, Parker H, Singh D, 21 Recommendations to Sanit 2011;25(6):525-534. improvement competencies Wade E. Getting the Basics Improve Access to Care in nursing. J Nurs Educ Right. Coventry: NHS through Physician Workforce (Published online Institute for Innovation and Reform. Rockville: Council September 2011). Improvement, 2007. on Graduate Medical Education, 1994.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 39 41 Weaver SJ, Salas E, 49 Fussell JJ, Farrar HC, 58 Reason JT. Human Error. 67 Welling R, Grannan K, King HB. Twelve best Blaszak RT, Sisterhen LL. : Cambridge Boberg J et al. Graduate practices for team training Incorporating the ACGME University Press, 1990. medical education as evaluation in health care. educational competencies 59 Kwast BE. Quality of care the driver for quality Jt Comm J Qual Patient Saf into morbidity and in reproductive health improvement and patient 2011;37(8):341-349. mortality review programmes: education safety: a national initiative 42 Neumann JA, Brady- conferences. Teach Learn for quality improvement. of independent academic Schluttner KA, Attlesey- Med 2009;21(3):233-239. Midwifery 1998;14(3):131- medical centers. J Surg Educ Pries JM, Twedell DM. 50 Batalden P, Berwick 136. 2009;66(6):336-339. Designing nursing D, Bisognano M et al. 60 Øvretveit J. Producing 68 Ogrinc G, Nierenberg DW, excellence through a Knowledge Domains for useful research about Batalden PB. Building National Quality Forum Health Professional Students quality improvement. Int experiential learning about nurse scholar program. Seeking Competency in the J Health Care Qual Assur quality improvement into a J Nurs Care Qual Continual Improvement Inc Leadersh Health Serv medical school curriculum: 2010;25(4):327-333. and Innovation of Health 2002;15(6-7): 294-302. the Dartmouth experience. Care. Boston: Institute for Health Aff 2011;30(4):716- 43 Preheim GJ, Armstrong 61 Gira EC, Kessler ML, GE, Barton AJ. The new Healthcare Improvement, 722. 1998. Poertner J. Influencing fundamentals in nursing: social workers to use 69 Paulman P. Integrating introducing beginning 51 Shortell SM, Bennett CL, research evidence in quality improvement into a quality and safety education Byck GR. Assessing the practice: lessons from family medicine clerkship. for nurses’ competencies. J impact of continuous medicine and the allied Fam Med 2010;42(3):164- Nurs Educ 2009;48(12):694- quality improvement on health professions. Res 165. 697. clinical practice: What Social Work Practice 70 Dysinger WS, King V, 44 Armstrong GE, Spencer it will take to accelerate 2004;14(2): 68-79. Foster TC, Geffken D. TS, Lenburg CB. Using . Milbank Quarterly Incorporating population 1998;76:593-624. 62 Price D. Continuing quality and safety education medical education, medicine into primary care for nurses to enhance 52 Carkhuff MH, Crago MG. quality improvement, and residency training. Fam competency outcome Advanced Organizers: a organisational change: Med 2011;43(7):480-486. performance assessment: a framework to implement implications of recent 71 Dysinger WS, King V, synergistic approach that learning readiness in for twenty-first- Foster TC, Geffken D. promotes patient safety and support of broad-scale century CME. Medical Incorporating population quality outcomes. J Nurs change. J Contin Educ Nurs 2005; 27(3): 259- medicine into primary care Educ 2009;48(12):686-693. 2004;35(5):216-221. 268. residency training. Fam 45 Barton AJ, Armstrong G, 53 Da Dalt L, Callegaro S, 63 Abbas MR, Quince Med 2011;43(7):480-486. Preheim G et al. A national Mazzi A et al. A model TA, Wood DF, Benson 72 Zhang Q, Zeng T, Delphi to determine of quality assurance and JA. Attitudes of Chen Y, Li X. Assisting developmental progression quality improvement for medical students to undergraduate nursing of quality and safety post-graduate medical medical leadership and students to learn evidence- competencies in nursing education in Europe. Med management: a systematic based practice through education. Nurs Outlook Teach 2010;32(2):e57-64. review to inform self-directed learning and 2009;57(6):313-322. 54 Booth BJ, Snowdon T. A curriculum development. workshop strategies during 46 Quinn DC, Bingham JW, quality framework for BMC Med Educ (Published clinical practicum. Nurse Garriss GW, Dozier EA. Australian general practice. online November 2011). Educ Today (Published Residents learn to improve Aust Fam Physician 64 Quinn DC, Bingham JW, online June 2011). care using the ACGME core 2007;36(1-2): 8-11. Shourbaji NA, Jarquin- 73 Voss JD, May NB, Schorling competencies and Institute 55 Morrell C, Harvey G, Valdivia, AA. Medical JB, Lyman JA et al. of Medicine aims for Kitson A. Practitioner students learn to assess care Changing : improvement: the Health based quality improvement: using the healthcare matrix. teaching safety and quality Care Matrix. J Grad Med a review of the Royal Medical Teacher 2007;29(7): in residency training. Acad Educ 2009;1(1):119-126. College of Nursing’s 660-665. Med 2008;83(11):1080- 47 Varkey P, Karlapudi S, dynamic standard setting 65 Kyrkjebø JM, Hanestad 1087. Rose S et al. A systems system. Qual Health Care BR. Personal improvement 74 www.hsmc.bham.ac.uk approach for implementing 1997; 6(1):29-34. project in nursing 75 www.sheffield.ac.uk practice-based learning and 56 Emanuel L, Walton M, education: learning improvement and systems- Hatlie M et al. The Patient methods and tools for 76 www.dundee.ac.uk based practice in graduate Safety Education Project: An continuous quality 77 www.betaniensyke medical education. Acad International Collaboration. improvement in nursing Med 2009;84(3):335-339. pleierhogskole.no/english. Unpublished, 2007. practice. J Adv Nurs html 48 Fater KH, Ready R. 2003;41(1): 88-98. 57 Thanh NX, Jacobs P, Wanke 78 www.dms.dartmouth.edu An education-service MI et al. Outcomes of 66 Marck P, Coleman- partnership to achieve the introduction of the Miller G, Hoffman C et 79 www.med.umich.edu/ safety and quality MOREOB continuing al. Thinking ecologically medschool improvement competencies education program in for safer healthcare: a 80 www.medicine.mcgill.ca in nursing. J Nurs Educ Alberta. J Obstet Gynaecol summer research student (Published online Can 2010;32(8):749-755. partnership. Nurs Leadersh September 2011). 2007;20(3):42-51.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 40 81 Varkey P, Karlapudi SP, 90 Walsh T, Jairath N, Paterson 100 Peters AS, Kimura J, 109 Nagy P, Vandermeer F, Bennet KE. Teaching MA, Grandjean C. Quality Ladden MD et al. A Olmsted WW. Tips for quality improvement: and safety education for self-instructional model incorporating quality a collaboration project nurses clinical evaluation to teach systems-based improvement projects between medicine and tool. J Nurs Educ practice and practice-based into a residency program engineering. Am J Med 2010;49(9):517-522. learning and improvement. curriculum. J Am Coll Qual 2008;23(4):296-301. 91 Terregino CA, Saks J Gen Intern Med Radiol 2011;8(2):84-85. 82 Ross AM, Noone J, NS. Creative group 2008;23(7):931-936. 110 Chessman A, Bellack J, Luce LL, Sideras SA. performances to assess core 101 Davis MV, Sollecito WA, Lahoz M, et al. Students Spiraling evidence-based competencies in a first-year Shay S, Williamson W. add value to learning practice and outcomes patient-centered medicine Examining the impact of a organisations: the Medical management concepts in an course. Med Educ Online MPH University of South undergraduate curriculum: 2010;15. program: a one-year follow- Carolina experience. a systematic approach. J 92 Varkey P, Gupta P, Bennet up survey of graduates. J Qual Manage Health Care Nurs Educ 2009;48(6):319- KE. An innovative method Public Health Manag Pract 1998;6(2):38-43. 326. to assess negotiation skills 2004;10(6): 556-563. 111 Ellrodt A. Introduction of 83 Warholak TL, Noureldin necessary for quality 102 O’Regan K, Marsden total quality management M, West D, Holdford D. improvement. Am J Med P, Sayers G et al. (TQM) into an internal Faculty perceptions of Qual 2008;23(5):350-355. Videoconferencing of medicine training program. the Educating Pharmacy 93 Okuda Y, Bryson EO, a national program for Acad Med 1993;68:817-823. Students to Improve DeMaria S Jr et al. The residents on evidence-based 112 Hall LW, Headrick LA, Cox Quality (EPIQ) program. utility of simulation in practice: early performance KR et al. Linking health Am J Pharm Educ medical education: what evaluation. J Am Coll Radiol professional learners and 2011;75(8):163. is the evidence? Mt Sinai J 2010;7(2):138-145. health care workers on 84 Horsburgh M, Merry Med 2009;76(4):330-343. 103 Kolb DA. Experiential action-based improvement A, Seddon M et al. 94 Buckley S, Coleman Learning Experience as teams. Qual Manag Health Educating for healthcare J, Davison I et al. The the Source of Learning and Care 2009;18(3):194-201. quality improvement educational effects Development. New Jersey: 113 Ashton C. ‘Invisible’ in an interprofessional of portfolios on Prentice-Hall, 1984. doctors: making a case learning environment: a undergraduate student 104 Batalden P, Davidoff for involving medical New Zealand initiative. J learning: a Best Evidence F. Teaching quality residents in hospital quality Interprof Care 2006;20(5): Medical Education (BEME) improvement: the devil improvement programs. 555-557. systematic review. BEME is in the details. JAMA Acad Med 1993; 68: 823- 85 Horsburgh M, Merry AF, Guide No. 11. Med Teach 2007;298(9): 1059-1061. 824. Seddon M. Patient safety 2009;31(4):282-298. 105 Schon DA. Educating the 114 Clay M, Cummings D, in an interprofessional 95 Tochel C, Haig A, Hesketh Reflective Practitioner. San Mansfield C, Hallock J. learning environment. Med A et al. The effectiveness of Francisco: Jossey-Bass, Retooling to Meet the Needs Educ 2005; 9(5):512-513. portfolios for post-graduate 1987. of a Changing Health Care 86 Horsburgh M, Lamdin assessment and education: 106 Stevenson TL, Hornsby System. Washington DC: R. Maori health BEME Guide No 12. Med LB, Phillippe HM et al. Association of Academic issues explored in an Teach 2009;31(4):299-318. A quality improvement Health Centers, 1999. interprofessional learning 96 Johnson L, Smith CM. course review of advanced 115 Gould BE, Grey MR, context. J Interprof Care A hybrid course for the pharmacy practice Huntington CG et al. 2004;18(3):279-287. RN-to-baccalaureate experiences. Am J Pharm Improving patient care 87 Gupta P, Varkey P. curriculum: patient- Educ 2011;75(6):116. outcomes by teaching Developing a tool for centered care and quality. 107 Horak B, O’Leary K, quality improvement assessing competency Nurse Educ 2011;36(4):155- Carlson L. Preparing to medical students in root cause analysis. Jt 160. health care professionals in community-based Comm J Qual Patient Saf 97 abim.org/online/pim/demo. for quality improvement: practices. Acad Med 2009;35(1):36-42. aspx The George Washington 2002;77(10):1011-1018. 88 Varkey P, Gupta P, 98 Stout PA, Villegas J, Kim University / George Mason 116 Knapp M, Bennett N, Arnold JJ, Torsher H. Enhancing learning University experience. Plumb J, Robinson J. LC. An innovative through use of interactive Qual Manage Health Care Community-based team collaboration tools on health-related 1998;6(2): 21-30. quality improvement for assessment tool for a websites. Health Educ Res 108 Bleakley A, Brennan the health professions: quality improvement 2001;16(6):721-733. N. Does undergraduate balancing benefits for curriculum. Am J Med Qual communities and students. 99 Manning ML, Frisby curriculum design make a 2009;24(1):6-11. difference to readiness to J Interprofessional Care AJ. Multimethod 2000;14:119-130. 89 Ogunyemi D, Eno M, teaching strategies to practice as a junior doctor? Rad S et al. Evaluating integrate selected QSEN Med Teach 2011;33(6):459- 117 Mak DB, Plant AJ. professionalism, practice- competencies in a Doctor 467. Reducing unmet needs: based learning and of Nursing Practice distance a prevocational medical improvement, and systems- education program. Nurs training program in based practice: utilization Outlook 2011;59(3):166- public health medicine of a compliance form and 173. and primary health care correlation with conflict in remote Australia. styles. J Grad Med Educ Aust J Rural Health 2010;2(3):423-429. 2005;13(3):183-190.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 41 118 Weingart S. A house 127 Sockalingam S, 135 Headrick L, Neuhauser 144 DF, Torbeck L, officer sponsored quality Stergiopoulos V, Maggi D, Melnikow J, Vanek E. Djuricich AM. Practice- improvement initiative: J, Zaretsky A. Quality Teaching medical students based learning and leadership lessons and education: a pilot quality about quality and cost improvement: a curriculum liabilities. Joint Commission improvement curriculum of care at Case Western in continuous quality J Qual Improvement for psychiatry residents. Reserve University. Acad improvement for surgery 1998;24:371-378. Med Teach 2010;32(5):e221- Med 1992;67:157-159. residents. Arch Surg 119 Jones CB, Mayer 6. 136 Kanna B, Deng C, Erickson 2007;142(5):479-482. C, Mandelkehr LK. 128 Tomolo AM, Lawrence SN, et al. The research 145 Thies KM, yersA L. Innovations at the RH, Aron DC. A case study rotation: competency- Academic microsystems: intersection of academia of translating ACGME based structured and adapting Clinical and practice: facilitating practice-based learning and novel approach to research Microsystems as an graduate nursing students’ improvement requirements training of internal evaluation framework for learning about quality into : systems quality medicine residents. BMC community-based nursing improvement and patient improvement projects Med Educ 2006;6:52-60. education. J Nurs Educ safety. Qual Manag Health as the key component 137 Ogrinc G, Headrick LA, 2007;46(7):325-329. Care 2009;18(3):158-164. to a comprehensive Morrison LJ, Foster T. 146 Kyrkjebø JM. Teaching 120 Lekan DA, Corazzini curriculum. Postgrad Med J Teaching and assessing quality improvement in KN, Gilliss CL, Bailey 2009;85(1008):530-537. resident competence in the classroom and clinic: DE Jr. Clinical leadership 129 Djuricich AM, Ciccarelli M, practice-based learning and getting it wrong and development in accelerated Swigons NI. A continuous improvement. J Gen Intern getting it right. J Nurs Educ baccalaureate nursing quality improvement Med 2004;19(5 pt 2):496- 2006;45(3):109-116. students: an education curriculum for residents: 500. 147 Kyrkjebø JM, Hanssen TA, innovation. J Prof Nurs addressing core 138 Varkey P, Reller MK, Smith Haugland BO. Introducing 2011;27(4):202-214. competency, improving A et al. An experiential quality improvement to 121 Villanueva AM, Hovinga systems. Academic Medicine interdisciplinary quality pre-qualification nursing ME, Cass JL. Master of 2004;79(10):S65-67. improvement education students. Qual Health Care public health community- 130 Henley E. A quality initiative. Am J Med Qual 2001;10(4):204-210. based practicum: students’ improvement curriculum 2006;21(5):317-322. 148 O’Connell MT, Rivo ML, and preceptors’ experiences. for medical students. Jt 139 Holmboe ES, Prince L, Mechaber AJ, Weiss BA. J Public Health Manag Pract Comm J Qual Improv 2002, Green M. Teaching and A curriculum in systems- 2011;17(4):337-343. 28(1):42-8. improving quality of care based care. Fam Med 122 Parenti C. Reduction of 131 Weeks W, Robinson in a primary care internal 2004;36(suppl):S99-104. unnecessary intravenous J, Brooks W, Batalden medicine residency clinic. 149 McKown T, McKown L, catheter use. Internal P. Using early clinical Acad Med 2005;80(6):571- Webb S. Using quality and medicine house staff experiences to integrate 577. safety education for nurses participate in a successful quality-improvement 140 Djuricich AM, Ciccarelli to guide clinical teaching quality improvement learning into medical M, Swigonski NL. A on a new dedicated project. Arch Intern Med education. Acad Med continuous quality education unit. J Nurs Educ 1994;154:1829-1832. 2000;75:81-84. improvement curriculum (Published online October 123 Headrick LA, Richardson 132 Henley E. A quality for residents. Acad Med 2011) A, Priebe GP. Continuous improvement curriculum 2004;79(10 suppl):S65-67. 150 Knapp M, Bennett N, improvement learning for medical students. Jt 141 Coleman MT, Nasraty Plumb J, Robinson J. for residents. Pediatrics Comm J Qual Improv 2002, S, Ostapchuk M et al. Community-based 1998;101:768-773. 28(1): 42-8. Introducing practice-based quality improvement for 124 Parenti CM, Lederle FA, 133 Chase SM, Miller WL, learning and improvement the health professions: Impola CL, Peterson LR. Shaw E et al. Meeting the ACGME core competencies balancing benefits for Reduction of unnecessary challenge of practice quality into a family medicine communities and students. intravenous catheter improvement: a study of residency curriculum. J Interprofessional Care use. Internal medicine seven family medicine Jt Comm J Qual Saf 2000;14:119-130. house staff participate residency training practices. 2003;29(5):238-247. 151 Huntington JT, Dycus P, in a successful quality Acad Med (Published 142 Nuovo J, Balsbaugh T, Hix C et al. A standardized improvement project. Arch online October 2011). Barton S et al. Development curriculum to introduce Intern Med1994;154:1829- 134 Gould BE, Grey MR, of a diabetes care novice health professional 1832. Huntington CG et al. management curriculum in students to practice-based 125 Diaz VA, Carek PJ, Improving patient care a family practice residency learning and improvement: Dickerson LM, Steyer outcomes by teaching program. Dis Manage a multi-institutional pilot TE. Teaching quality quality improvement 2004;7(4):314-324. study. Qual Manag Health improvement in a to medical students 143 Mohr JJ, Randolph GD, Care 2009;18(3):174-181. primary care residency. Jt in community-based Laughon MM, Schaff E. 152 Quinn DC, Reynolds Comm J Qual Patient Saf practices. Acad Med Integrating improvement PQ, Easdown J, Lorinc 2010;36(10):454-460. 2002;77(10):1011-1018. competencies into A. Using the healthcare 126 Murray ME, Douglas residency education. Ambul matrix with interns and S, Girdley D, Jarzemsky Pediatr 2003;3(3):131-136. medical students as a tool P. Teaching quality to effect change. South Med improvement. J Nurs Educ J 2009;102(8):816-822. 2010;49(8):466-469.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 42 153 Quinn DC, Bingham JW, 161 Ewers KM, Coker CT, 173 Cleary M, Freeman 182 Beaubien JM, Baker DP. Garriss GW, Dozier EA. Bajnok I, Denker AL. A A, Sharrock L. The use of simulation for Residents learn to improve collaborative curricular The development, training teamwork skills in care using the ACGME core model for implementing implementation, and Health care: how low can competencies and Institute evidence-based nursing in evaluation of a clinical you go? Qual Saf Health of Medicine aims for a critical care setting. Crit leadership program for Care 2004;13:51-56. improvement: the Health Care Nurs Clin North Am mental health nurses. 183 Jarzemsky P, McCarthy Care Matrix. J Grad Med 2008;20(4):423-434. Issues Ment Health Nurs J, Ellis N. Incorporating Educ 2009;1(1):119-126. 162 www.pbcacademy.co.uk 2005;26(8):827-842. quality and safety education 154 Headrick L, Moore S, 163 open.ac.uk/shsw 174 Supic ZT, Bjegovic V, for nurses competencies in Alemi F et al. Using PDSA Marinkovic J et al. Hospital simulation scenario design. to establish academic - 164 www.institute.nhs.uk/ management training and Nurse Educ 2010;35(2):90- community partnerships: quality_and_service_ improvement in managerial 92. the Cleveland experience. improvement_tools/ skills: Serbian experience. quality_and_service_ 184 Bailey R, Davies C. Acting Qual Manage Health Care Health Policy 2010;96(1):80- the part. Nurs Manag 1998;6(2):12-20. improvement_tools/ 89. quality_improvement_ 2006;13(1):16-19. 155 Headrick L, Knapp training_and_development. 175 Holtzhauer FJ, Nelson JC, 185 Oxtoby K. Using drama M, Neuhauser D et al. html Myers WC et al. improving for dignity. Nursing Times Working from upstream performance at the local 2005;29:24-25. to improve health care: 165 ihm.org.uk level: implementing a the IHI interdisciplinary 166 IHI.org public health learning 186 Walker C. Creating professional education workforce intervention. J reflections: reflective collaborative. Joint 167 Ginsburg L, Norton PG, Public Health Management practice and the expressive Commission J Qual Casebeer A, Lewis S. An Practice 2001;7(4):96-104. arts. Practising Midwife educational intervention 2002;5(7):30-33. Improvement 1996;22:149- 176 Rask KJ, Gitomer RS, 164. to enhance nurse leaders’ perceptions of patient safety Spell NO 3rd et al. A 187 Meehan TP, Van Hoof 156 Weeks W, Robinson culture. Health Serv Res two-pronged quality TJ, Giannotti TE et al. J, Brooks W, Batalden 2005;40(4):997-1020. improvement training A descriptive study of P. Using early clinical program for leaders educational outreach to experiences to integrate 168 Land LM, Ward S, Taylor and frontline staff. Jt promote use of quality quality-improvement S. Developing critical Comm J Qual Patient Saf improvement tools in learning into medical appraisal skills amongst 2011;37(4):147-153. primary care private staff in a hospital trust. practice. Am J Med Qual education. Acad Med 177 Jefferies D, Johnson M, 2000;75:81-84. Nurse Ed in Practice 2009;24(2):90-98. 2002;2:176-180. Nicholls D, Lad S. A 157 Fox C, Mahoney M. ward-based writing coach 188 Lynch M, McFetridge Improving diabetes care in 169 Land LM, Ward S, Taylor program to improve N. Practice leaders a family practice residency S. Developing critical the quality of nursing programme: entrusting program: a case study appraisal skills amongst documentation. Nurse Educ and enabling general in continuous quality staff in a hospital trust. Today (Published online practitioners to lead improvement. Fam Med Nurse Ed in Practice October 2011). change to improve patient 1998;30:441-445. 2002;2:176-180. experience. Perm J 178 Dunn EJ, Mills PD, Neily 2011;15(1):28-34. 158 Wun YT, Dickinson JA, 170 Cleary M, Jordan R, J et al. Medical team Chan CS. Primary care Happell B. Measuring training: applying crew 189 Loke Jennifer CF. Computer physicians in public and outcomes in the workplace: resource management mediated conferencing - a private sectors perceive The impact of an education in the Veterans Health hope or hype for healthcare different learning needs. program. Int J Mental Administration. Jt education in higher Med Teach 2002;24(1):62- Health Nurs 2002;11:269- Comm J Qual Patient Saf learning? A review of the 66. 275. 2007;33(6):317-325. literature. Nurse Educ Today 2007; 27(4):318-324. 159 Grol R. Changing 171 Hancox K, Lynch L, Happell 179 Mills P, Neily J, Dunn physicians’ competence B, Biondo S. An evaluation E. Teamwork and 190 Trevena LJ. Problem-based and performance: finding of an educational program communication in surgical learning in public health the balance between for clinical supervision. teams: implications for workforce training: a the individual and the Int J Ment Health Nurs patient safety. J Am Coll discussion of educational organisation. J Contin Educ 2004;13(3):198-203. Surg 2008;206(1):107-112. principles and evidence. Health Prof 2002;22(4):244- 172 Chur-Hansen A, Todd E, NSW Public Health Bull 180 Bagian JP, Gosbee J, Lee CZ 2007;18(1-2):4-8. 251. Koopowitz L. Description et al. The Veterans Affairs 160 Berlage S, Wenzlaff P, and evaluation of an root cause analysis system 191 Bond GE. Lessons learned Damm G, Sens B. In-house up-skilling workshop for in action. Jt Comm J Qual from the implementation team seminars: working rural and remote mental Improv 2002;28(10):531- of a Web-based nursing together as a team - from health practitioners in 545. intervention. Comput South Australia. Australas Inform Nurs 2006;24(2): data and statistics to quality 181 Kyrkjebø JM, Brattebø development. Z Evid Psychiatry 2004;12(3):273- 66-74. 277. G, Smith-Strøm H. Fortbild Qual Gesundhwes Improving patient safety 2010;104(1):45-50. by using interprofessional simulation training in health professional education. J Interprof Care 2006;20(5):507-516.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 43 192 Petersen DJ, Hovinga ME, 199 Deane FP, Crowe TP, King 208 Weeks WB, Mills PD, 216 Baker DW, Asch SM, Pass MA et al. Assuring R et al. Challenges in Waldron J et al. A model for Keesey JW et al. Differences public health professionals implementing evidence- improving the quality and in education, knowledge, are prepared for the based practice into mental timeliness of compensation self-management activities, future: the UAB public health services. Aust Health and pension examinations and health outcomes health integrated core Rev 2006;30(3):305-309. in VA facilities. J for patients with heart curriculum. Public Health 200 Massey L, Williams S. Health Care Manage failure cared for under the Rep 2005;120(5):496-503. CANDO: implementing 2003;48(4):252-262. chronic disease model: the 193 Shield M, Wiesner P, change in an NHS Trust. 209 Homer CJ, Forbes P, improving chronic illness Curran C et al. The Int J Pub Sector Manage Horvitz L et al. Impact of care evaluation. J Card Fail Northwest’s Hot Topics 2005;18:330-349. a quality improvement 2005;11(6):405-413. in Preparedness forum: a 201 Wallin L, Boström AM, program on care and 217 Asch SM, Baker DW, novel distance-learning Harvey G et al. Progress outcomes for children Keesey JW et al. Does collaborative. J Public of unit based quality with asthma. Arch the collaborative model Health Manag Pract 2005; improvement: an evaluation Pediatr Adolesc Med improve care for chronic Suppl:S25-32. of a support strategy. 2005;159(5):464-469. heart failure? Med Care 194 Examples of the types of Qual Saf Health Care 210 Landon BE, Wilson IB, 2005;43(7):667-675. online modules available 2002;11(4):308-314. McInnes K et al. Effects 218 O’Connor PJ, Desai include: 202 Stevens DP, Bowen of a quality improvement J, Solberg LI, et al. patientsafetyed.duhs.duke. JL, Johnson JK et al. A collaborative on the Randomized trial of quality edu multi-institutional quality outcome of care of patients improvement intervention with HIV infection: the to improve diabetes care aafp.org/x29503.xml improvement initiative to transform education EQHIV study. Ann Intern in primary care settings. eqipp.org for chronic illness care Med 2004;140(11):887-896. Diabetes Care 2005; 28(8):1890-1987. online.rit.edu/students/ in resident continuity 211 McInnes DK, Landon BE, online/view_course. practices. J Gen Intern Med Wilson IB et al. The impact 219 Solberg LI, Kottke TE, cfm?courseID=1173 2010;25 Suppl 4:S574-580. of a quality improvement Brekke ML et al. Failure 203 Daniel DM, Casey DE program on systems, of a continuous quality jobwerx.com/ processes, and structures in improvement intervention trainingcourses.html Jr, Levine JL et al. Taking a unified approach to medical clinics. Med Care to increase the delivery of qilearn.org teaching and implementing 2007;45(5):463-471. preventive services. Eff Clin Pract 2000;3(3): 105-115. ihi.org quality improvements 212 Peterson A, Carlhed R, across multiple residency Lindahl B et al. Improving 220 Breslin TM, Caughran J, training-classes.com/ programs: the Atlantic guideline adherence Pettinga J et al. Improving programs/00/17/ 1762_ Health experience. Acad through intensive quality breast cancer care management_leadership_ Med 2009;84(12):1788- improvement and the through a regional quality continuous_quality_ 1795. use of a National Quality collaborative. Surgery improvement_cqi_tra.php 204 Cronenwett L, Register in Sweden for 2011;150(4):635-642. abim.org/sep2/75A0601I/ Sherwood G, Gelmon acute . 221 Fung-Kee-Fung M, Watters html/Q1.htm SB. Improving quality Qual Manag Health Care J, Crossley C et al. Regional 195 Chapman L. Improving and safety education: 2007;16(1):25-37. collaborations as a tool for patient care through work- The QSEN Learning 213 Chin MH, Cook S, Drum quality improvements in based learning. Nursing Collaborative. Nurs Outlook ML, et al. Improving surgery: a systematic review Standard 2006; 20(41): 2009;57(6):304-312. diabetes care in midwest of the literature. Ann Surg 41-45. 205 Wagner EH, Glasgow community health centers 2009;249(4):565-572. 196 Riley W, Parsons H, McCoy RE, Davis C et al. Quality with the health disparities 222 Baier RR, Gifford DR, K et al. Introducing quality improvement in chronic collaborative. Diabetes Care Patry G et al. Ameliorating improvement methods illness care. Jt Comm J Qual 2004;27(1): 2-8. pain in nursing . into local public health Improv 2001;27(2):63-80. 214 Mangione-Smith R, J Am Geriatr Soc departments: structured 206 Landon BE, Hicks Schonlau M, Chan KS et al. 2004;52(12):1988-1995. evaluation of a statewide LS, O’Malley AJ et al. Measuring the effectiveness 223 Horbar JD, Carpenter JH, pilot project. Health Serv Improving the management of a collaborative for quality Buzas J et al. Collaborative Res 2009;44(5 Pt 2):1863- of chronic disease at improvement in pediatric quality improvement 1879. community health asthma care. Ambul Pediatr to promote evidence 197 Faiman B. Overview and centers. N Engl J Med 2005;5(2):75-82. based surfactant for experience of a nursing 2007;356(9):921-934. 215 Boushon B, Provost L, preterm infants. BMJ e-mentorship program. 207 Stoeckle-Roberts S, Gagnon J, Carver P. Using a 2004;329(7473):1004. Clin J Oncol Nurs Reeves MJ, Jacobs BS et virtual breakthrough series 224 O’Connor GT, Plume 2011;15(4):418-423. al. Closing gaps between collaborative to improve SK, Olmstead EM et al. 198 Edwards N, Hui ZD, Xin evidence-based stroke care access in primary care. Jt Northern New England SL. Continuing education guidelines and practices Comm J Qual Patient Saf Cardiovascular Disease for nurses in Tianjin with a collaborative quality 2006;32(10):573-584. Study Group. A regional Municipality, the People’s improvement project. Jt intervention to improve Republic of China. J Contin Comm J Qual Patient Saf the hospital mortality Educ Nurs 2001;32(1):31- 2006;32(9):517-527. associated with coronary 37. artery bypass graft surgery. JAMA 1996;275(11):841- 846.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 44 225 Young PC, Glade GB, 234 Nakajima K, Kurata Y, 242 McClellan WM, Hodgin 251 Fontana TA, Butcher S, Stoddard GJ, Norlin C. Takeda H. A web-based E, Pastan S et al. A O’Brien SA. Department Evaluation of a learning incident reporting system randomized evaluation deployment: integrating collaborative to improve and multidisciplinary of two health care quality quality improvement into the delivery of preventive collaborative projects for improvement program day-to-day management. services by pediatric patient safety in a Japanese (HCQIP) interventions to Qual Lett Healthc Lead practices. Pediatrics hospital. Qual Saf Health improve the adequacy of 1994;6(6):31-39. 2006;117(5):1469-1476. Care 2005;14(2):123-129. hemodialysis care of ESRD 252 Rhydderch M, Edwards 226 Colon-Emeric C, Schenck 235 Striem J, Øvretveit J, patients. J Am Soc Nephrol A, Marshall M et al. A, Gorospe J et al. Brommels M. Is health 2004;15(3):754-760. Developing a facilitation Translating evidence- care a special challenge 243 Dewar B, Walker E. model to promote based falls prevention into to quality management? Experiential learning: organisational development clinical practice in nursing Insights from the Danderyd issues for supervision. J Adv in primary care practices. facilities. J Am Geriatr Soc Hospital case. Qual Manag Nursing 1999;30(6):1459- BMC Fam Pract 2006;7:38. 2006;54(9):1414-1418. Health Care 2003;12(4):250- 1467. 253 Thor J, Wittlöv K, Herrlin 227 Gannon M, Qaseem 258. 244 Armstrong P, Chase L, B et al. Learning helpers: A, Snow V, Snooks Q. 236 Mohammadi SM, Cowan C et al. The quality how they facilitated Using online learning Mohammadi SF, Hedges coach – the facilitators’ improvement and improved collaboratives to facilitate JR, Zohrabi M, Ameli perspective. Langley, facilitation--lessons from practice improvement for O. Introduction of a Canada: Langley Memorial a hospital-wide quality COPD: an ACPNet pilot quality improvement Hospital, undated. improvement initiative. study. Am J Med Qual program in a children’s 245 Gjerde CL, Hla KM, Qual Manag Health Care 2011;26(3):212-219. hospital in Tehran: design, Kokotailo PK, Anderson 2004;13(1):60-74. 228 Greene A, Pagliari C, implementation, evaluation B. Long-term outcomes 254 Macfarlane F, Greenhalgh Cunningham S et al. Do and lessons learned. of a primary care faculty T, Schofield T, Desombre managed clinical networks Int J Qual Health Care development program T. RCGP Quality Team improve quality of diabetes 2007;19(4):237-243. at the University of Development programme: care? Evidence from 237 McDaniel GL. Applying Wisconsin. Fam Med an illuminative evaluation. a retrospective mixed a systems perspective 2008;40(8):579-584. Qual Saf Health Care 2004; methods evaluation. to quality improvement 246 Cronenwett L, 13(5):356-362. Qual Saf Health Care training. J Healthc Qual Sherwood G, Gelmon 255 Peterson GM, Thompson 2009;18(6):456-461. 1994;16(2):6-8. SB. Improving quality A, Pulver LK et al. 229 Solberg LI, Taylor N, 238 Margolis PA, Lannon CM, and safety education: Management of acute Conway WA, Hiatt RA. Stuart JM et al. Practice The QSEN Learning coronary syndromes at Large multispecialty group based education to Collaborative. Nurs Outlook hospital discharge: do practices and quality improve delivery systems 2009;57(6):304-312. targeted educational improvement: what is for prevention in primary 247 Emanuel L, Walton M, interventions improve needed to transform care? care: randomised trial. BMJ Hatlie M et al. The Patient practice quality? J Healthc J Ambul Care Manage 2004;328(7436):388. Safety Education Project: An Qual (Published online 2007;30(1): 9-17. 239 Hanson LC, Reynolds K, International Collaboration. March 2011). 230 Kottke TE, Solberg LI. Henderson M, Pickard C. Unpublished, 2007. 256 Jamtvedt G, Young JM, Optimizing practice A quality improvement 248 Ladden MD, Peters Kristoffersen DT, O’Brien through research: a intervention to increase AS, Kotch JB, Fletcher MA, Oxman AD. Does preventive services case palliative care in nursing RH. Preparing faculty telling people what they study. Am J Prev Med homes. J Palliat Med to teach managing care have been doing change 2007;33(6):505-506. 2005;8(3):576-584. competencies: lessons what they do? A systematic 231 Solberg LI, Kottke TE, 240 Horner JK, Hanson LC, learned from a national review of the effects of audit Brekke ML. Will primary Wood D, Silver AG, faculty development and feedback. Qual Saf care clinics organize Reynolds KS. Using program. Fam Med 2004;36 Health Care 2006;15(6):433- themselves to improve quality improvement to Suppl:S115-120. 436. the delivery of preventive address pain management 249 McEwan E, Conway MJ, 257 Andres E, Beyer M, services? A randomized practices in nursing homes. Bull DL, Malison MD. Schorsch B et al. Quality controlled trial. Prev Med J Pain Symptom Manage Developing public health circles in German 1998;27(4):623-631. 2005;30(3):271-277. management training ambulatory care: results of a 232 Arrighi JA. Educational 241 Rosenthal MS, Lannon capacity in Nicaragua. continuous documentation initiatives for quality CM, Stuart JM, et al. Am J Public Health in the regions of Bremen, improvement projects: A randomized trial of 2001;91(10):1586-1588. Saxony-Anhalt, Schleswig- can you teach an old dog practice-based education to Holstein and Westphalia- 250 Barnes J, Parsley K, Walshe Lippe 1995-2007. Z Evid new tricks? Circulation improve delivery systems K. Quality Matters: An 2011;123(5):471-473. for anticipatory guidance. Fortbild Qual Gesundhwes Introduction to Quality 2010;104(1):51-58. 233 Parkin C, Bullock I. Arch Pediatr Adolesc Med Improvement and Audit Evidence-based health care: 2005;159(5):456-463. in Healthcare. Brighton: development and audit Brighton Health Care, 1994. of a clinical standard for research and its impact on an NHS trust. J Clin Nurs 2005;14(4):418-425.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 45 258 Engels Y, Verheijen N, 267 Department of Health. 276 Institute of Medicine 284 Splaine ME, Ogrinc G, Fleuren M et al. The White Paper: Trust, Committee on Health Gilman SC et al. The effect of small peer assurance and safety – Professions Education Department of Veterans group continuous quality the regulation of health Summit. Health Professions Affairs National Quality improvement on the clinical professionals in the 21st Education: A to Fellowship practice of midwives in The century. London: Stationery Quality. Washington DC: Program: experience Netherlands. Midwifery Office, 2007. National Academy Press, from 10 years of training 2003;19(4):250-258. 268 Campbell SM, Chauhan 2003:45-96. quality scholars. Acad Med 259 Spiegel W, Mlczoch-Czerny U, Lester H. Primary 277 Ogrinc G, Headrick LA, 2009;84(12):1741-1748. MT, Jens R, Dowrick Medical Care Provider Mutha S, Coleman MT 285 Davis NL, Lawrence SL, C. Quality circles for Accreditation (PMCPA): et al. A framework for Morzinski JA, Radjenovich pharmacotherapy to modify pilot evaluation. Br J Gen teaching medical students ME. Improving the value general practitioners’ Pract 2010;60(576):295-304. and residents about of CME: impact of an prescribing behaviour for 269 Boonyasai RT, Windish practice-based learning and evidence-based CME generic drugs. J Eval Clin DM, Chakraborti C improvement, synthesized designation on faculty Pract (Published online et al. Effectiveness from a literature review. and learners. Fam Med May 2011). of teaching quality Acad Med 2003;78(7):748- 2009;41(10):735-740. 260 Niquille A, Ruggli M, improvement to clinicians: 756. 286 Varkey P, Karlapudi SP. Buchmann M et al. The a systematic review. JAMA 278 Chakraborti C, Boonyasai Lessons learned from a nine-year sustained 2007;298(9):1023-1037. RT, Wright SM, Kern 5-year experience with a cost-containment impact 270 Rotthoff T, Baehring T, DE. A systematic review 4-week experiential quality of Swiss pilot physicians- David DM, Scherbaum WA. of teamwork training improvement curriculum pharmacists quality The effectiveness of CME interventions in medical in a preventive medicine circles. Ann Pharmacother - quality improvement student and resident fellowship. J Grad Med Educ 2010;44(4):650-657. through differentiated education. J Gen Intern Med 2009;1(1):93-99. 261 Sutherland K, Leatherman advanced medical 2008;23(6):846-853. 287 Tomolo AM, Lawrence S. Does certification education research. Z Evid 279 Nie Y, Li L, Duan Y, RH, Aron DC. A case study improve medical standards? Fortbild Qual Gesundhwes Chen P et al. Patient of translating ACGME BMJ 2006;333(7565):439- 2009;103(3):165-168. safety education for practice-based learning and 441. 271 Patow CA, Karpovich undergraduate medical improvement requirements 262 Merkur S, Mladovsky K, Riesenberg LA et al. students: a systematic into reality: systems quality P, Mossialos E, McKee Residents’ engagement review. BMC Med Educ improvement projects as M. Do in quality improvement: 2011;11:33. the key component to a and revalidation ensure a systematic review of 280 Abbas MR, Quince comprehensive curriculum. that physicians are fit to the literature. Acad Med TA, Wood DF, Benson Qual Saf Health Care practice? WHO Ministerial 2009;84(12):1757-1764. JA. Attitudes of 2009;18(3):217-224. Conference on Health 272 Browner WS, Baron medical students to 288 Rana GK, Bradley DR, Systems policy brief, 2008. RB, Solkowitz S et al. medical leadership and Hamstra SJ et al. A 263 Epstein AM. Performance Physician management management: a systematic validated search assessment measurement and of hypercholesterolemia. review to inform tool: assessing practice- professional improvement: A randomized trial of curriculum development. based learning and approaches, opportunities continuing medical BMC Med Educ (Published improvement in a residency and challenges. . West J Med online November 2011). program. J Med Libr Assoc Systems, Health and 1994;161(6):572-578. 281 Boonyasai RT, Windish 2011;99(1):77-81. Wealth. WHO Ministerial 273 Filardo G, Nicewander D, DM, Chakraborti C 289 Applin H, Williams B, Day Conference on Health Herrin J et al. A hospital- et al. Effectiveness R, Buro K. A comparison Systems, June 2008. randomized controlled of teaching quality of competencies between 264 Holmboe ES, Meehan TP, trial of a formal quality improvement to clinicians: problem-based learning Lynn L, et al. Promoting improvement educational a systematic review JAMA and non-problem-based physicians’ self-assessment program in rural and small 2007;298(9):1023-1037. graduate nurses. Nurse Educ and quality improvement: community Texas hospitals: 282 Wong BM, Etchells EE, Today 2011;31(2):129-134. the ABIM diabetes practice one year results. Int J Qual Kuper A et al. Teaching 290 Hochberg MS, Kalet improvement module. J Health Care 2009;21(4):225- quality improvement and A, Zabar S et al. Can Contin Educ Health Prof 232. patient safety to trainees: professionalism be taught? 2006;26(2):109-119. 274 Morrison LJ, Headrick LA. a systematic review. Acad Encouraging evidence. Am 265 Peck C, McCall M, Teaching residents about Med 2010;85(9):1425-39. J Surg 2010;199(1):86-93. McLaren B, Rotem T. practice-based learning 283 O’Connor ES, Mahvi DM, 291 Coyle YM, Mercer SQ, Continuing medical and improvement. Jt Foley EF et al. Developing a Murphy-Cullen CL et education and continuing Comm J Qual Patient Saf practice-based learning and al. Effectiveness of a professional development: 2008;34(8):453-459. improvement curriculum graduate medical education international comparisons. 275 Grol R. Beliefs and evidence for an academic general programme for improving BMJ 2000;320(7232):432- in changing clinical care. surgery residency. J Am Coll medical event reporting 435. BMJ 1997;315:418-421. Surg 2010;210(4):411-7. attitude and behaviour. 266 Pringle M. Revalidation Quality and Safety in Health of doctors: the credibility Care 2005;14:383-388. challenge. London: Nuffield Trust, 2005.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 46 292 Buckley JD, Joyce B, Garcia 300 Balas EA, Austin 309 Mazmanian PE, Davis DA, 316 Compas C, Hopkins AJ et al. Linking residency SM, Mitchell JA et al. Galbraith R. Continuing KA, Townsley E. Best training effectiveness to The clinical value of medical education effect practices in implementing clinical outcomes: a quality computerized information on clinical outcomes: and sustaining quality improvement approach. Jt services: A review of effectiveness of continuing of care. A review of the Comm J Qual Patient Saf 98 randomized clinical medical education: quality improvement 2010;36(5):203-208. trials. Arch Family Med I American College of Chest literature. Res Gerontol Nurs 293 Teleki SS, Damberg CL, 1996;5:271-278. Physicians Evidence-Based 2008;1(3):209-216. Sorbero ME et al. Training 301 Hunt DL, Haynes RB, Educational Guidelines. 317 Buljac-Samardzic M, a patient safety work Hanna SE, Smith K. Effects Chest 2009;135(3 Dekker-van Doorn CM, force: the patient safety of computer-based clinical Suppl):49S-55S. van Wijngaarden JD, van improvement corps. Health decision support systems 310 Tess AV, Yang JJ, Smith Wijk KP. Interventions to Serv Res 2009;44(2 Pt on physician performance CC et al. Combining improve team effectiveness: 2):701-716. and patient outcomes: A clinical microsystems and a systematic review. Health 294 Ornstein S, Jenkins systematic review. JAMA an experiential quality Policy 2010;94(3):183-195. RG, Nietert PJ et al. A 1998,280:1339-1346. improvement curriculum 318 Varkey P, Natt N, Lesnick multimethod quality 302 Sullivan F, Mitchell E. to improve residency T et al. Validity evidence improvement intervention Has general practitioner education in internal for an OSCE to assess to improve preventive computing made a medicine. Acad Med competency in systems- cardiovascular care: difference to patient care? 2009;84(3):326-334. based practice and a cluster randomized A systematic review of 311 Oyler J, Vinci L, Arora V, practice-based learning and trial. Ann Intern Med published reports. BMJ Johnson J. Teaching internal improvement: a preliminary 2004;141:523-532. 1995;311:848-852. medicine residents quality investigation. Acad Med 295 Grol R. Changing 303 Thomson O’Brien MA, improvement techniques 2008;83(8):775-780. physicians’ competence Oxman AD, Davis D et al. using the ABIM’s practice 319 Evans D, Sheares BJ, and performance: finding Audit and feedback: Effects improvement modules. Vazquez TL. Educating the balance between on professional practice J Gen Intern Med health professionals to the individual and the and health care outcomes. 2008;23(7):927-930. improve quality of care for organisation. J Contin Educ Cochrane Database of 312 Tomolo AM, Lawrence asthma. Paediatr Respir Rev Health Prof 2002;22(4):244- Systematic Reviews, 2001. RH, Aron DC. A case study 2004;5(4):304-310. 251. 304 Balas EA, Boren SA, Brown of translating ACGME 320 Oxman AD, Thomson MA, 296 Bloom BS. Effects of GD et al. Effect of physician practice-based learning and Davis DA, Haynes RB. No continuing medical profiling on utilization. J improvement requirements magic bullets: a systematic education on improving Gen Int Med 1996, 11: 584- into reality: systems quality review of 102 trials of physician clinical care and 90. improvement projects interventions to improve patient health: a review of as the key component professional practice. CMAJ 305 Thomson O’Brien MA, to a comprehensive systematic reviews. Int J Oxman AD, Haynes R B et 1995;153(10):1423-1431. Technol Assess Health Care curriculum. Postgrad Med J al. Local opinion leaders: 2009;85(1008):530-537. 321 Gilbody S, Whitty P, 2005;21(3):380-385. Effects on professional Grimshaw J, Thomas 297 Gira EC, Kessler ML, practice and health care 313 Kappelman MD, Colletti R. Educational and Poertner J. Influencing outcomes. Cochrane RB et al. ImproveCareNow: organisational interventions social workers to use Database of Systematic The development of a to improve the management research evidence in Reviews, 2001. pediatric inflammatory of depression in primary bowel disease improvement practice: lessons from 306 Greer AL. The state of the care: a systematic review. medicine and the allied network. Inflamm Bowel JAMA 2003;289(23):3145- art versus the state of the Dis 2011;17(1):450-457. health professions. Res science: The diffusion of 3151. Social Work Practice new medical technologies 314 Hoffman KG, Brown 322 Halbach JL, Sullivan LL. 2004;14(2):68-79. into practice. Int J Tech RM, Gay JW, Headrick Teaching Medical Students 298 Freemantle N, Harvey Assess Health Care 1988;4:5- LA. How an educational About Medical Errors and EL, Wolf F et al. Printed 26. improvement project Patient Safety: Evaluation educational materials: improved the summative of a Required Curriculum. 307 Thomson O’Brien MA, evaluation of medical Effects on professional Oxman AD, Davis Dwt al. Academic Medicine practice and health care students. Qual Saf Health 2005;80:600-606. Educational outreach visits: Care 2009;18(4):283-287. outcomes. Cochrane Effects on professional 323 Madigosky WS, Headrick Database of Systematic practice and health care 315 Hoffman KG, Griggs LA, Nelson K et al. Reviews, 2001. outcomes. Cochrane MD, Kerber CA et al. An Changing and Sustaining 299 Thomson O’Brien MA, Database of Systematic educational improvement Medical Students’ Freemantle N, Oxman AD Reviews, 2001. project to patient Knowledge, Skills and et al. Continuing education encounters: toward a more Attitudes about Patient 308 Thomson O’Brien MA, complete understanding of meetings and workshops: Freemantle N, Oxman AD Safety and Medical Effects on professional third-year medical students’ Fallibility. Academic et al. Continuing education experiences. Qual Saf practice and health care meetings and workshops: Medicine 2006;81:94-101. outcomes. Cochrane Health Care 2009;18(4):278- Effects on professional 282. 324 Scott I. What are the most Database of Systematic practice and health care effective strategies for Reviews, 2002. outcomes. Cochrane improving quality and Database of Systematic safety of health care? Intern Reviews, 2002. Med J 2009;39(6):389-400.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 47 325 Epstein AM. Performance 333 Ogrinc G, Headrick LA, 341 Ladden MD, Bednash G, 350 Oyler J, Vinci L, Johnson measurement and Mutha S et al. A framework Stevens DP, Moore GT. JK, Arora VM. Teaching professional improvement: for teaching medical Educating interprofessional internal medicine approaches, opportunities students and residents learners for quality, safety residents to sustain their and challenges. Health about practice-based and systems improvement. improvement through the Systems, Health and learning and improvement, J Interprof Care quality assessment and Wealth. WHO Ministerial synthesized from a 2006;20(5):497-505. improvement curriculum. Conference on Health literature review. Acad Med 342 Filardo G, Nicewander D, J Gen Intern Med Systems, June 2008. 2003;78:748-753. Herrin J et al. Challenges 2011;26(2):221-225. 326 Mosser G, Frisch KK, 334 Kimmel S, Smith SL, in conducting a hospital- 351 Rotthoff T, Baehring T, Skarda PK, Gertner E. Sabino JN et al. Tobacco randomized trial of David DM, Scherbaum WA. Addressing the challenges screening multicomponent an educational quality The effectiveness of CME in teaching quality quality improvement improvement intervention - quality improvement improvement. Am J Med network program: beyond in rural and small through differentiated 2009;122(5):487-491. education. Acad Emerg Med community hospitals. Am J advanced medical 327 Ogrinc G, Headrick LA, 2009;16(11):1186-1192. Med Qual 2008;23(6):440- education research. Z Evid Mutha S et al. A framework 335 Varkey P, Karlapudi SP. 447. Fortbild Qual Gesundhwes for teaching medical Lessons learned from a 343 Neufeld VR, Barrows HS. 2009;103(3):165-168. students and residents 5-year experience with a The MacMaster philosophy. 352 Shunk R, Dulay M, Julian about practice-based 4-week experiential quality An approach to medical K et al. Using the American learning and improvement, improvement curriculum education. J Med Ed Board Of Internal Medicine synthesized from a in a preventive medicine 2003;84:2424. practice improvement literature review. Acad Med fellowship. J Grad Med Educ 344 Barrows HS, Tamblyn RM. modules to teach internal 2003;78:748–53. 2009;1(1):93-99. Problem-based Learning. medicine residents practice 328 Price D. Continuing 336 Quinn DC, Reynolds An Approach to Medical improvement. J Grad Med medical education, PQ, Easdown J, Lorinc Education. New York: Educ 2010;2(1):90-95. quality improvement, and A. Using the healthcare Springer, 1980. 353 Boonyasai RT, Windish organisational change: matrix with interns and 345 Kaufman A (ed). DM, Chakraborti C implications of recent medical students as a tool Implementing Problem- et al. Effectiveness theories for twenty-first- to effect change. South Med based Medical Education. of teaching quality century CME. Medical J 2009;102(8):816-822. Lessons from Successful improvement to clinicians: Teacher 2005;27(3):259-268. 337 Barceló A, Cafiero E, Innovations. New York: a systematic review. JAMA 329 Epstein AM. Performance de Boer M et al. Using Springer, 1985. 2007;298(9):1023-1037. measurement and collaborative learning to 346 Tamblyn R, Abrahamowicz 354 Hall LW, Headrick LA, Cox professional improvement: improve diabetes care M, Dauphinee D et al. KR et al. Linking health approaches, opportunities and outcomes: the VIDA Effect of a community professional learners and and challenges. Health project. Prim Care Diabetes oriented problem based health care workers on Systems, Health and 2010;4(3):145-153. learning curriculum on action-based improvement Wealth. WHO Ministerial 338 Riley W, Parsons H, McCoy quality of primary care teams. Qual Manag Health Conference on Health K et al. Introducing quality delivered by graduates: Care 2009;18(3):194-201. Systems, 2008. improvement methods historical cohort 355 Shojania KG, Levinson 330 Oxman A. No magic bullets. into local public health comparison study. BMJ W. Clinicians in quality A systematic review of 102 departments: structured 2005;331(7523):1002. improvement: a new trials of interventions to help evaluation of a statewide 347 Headrick L, Neuhauser career pathway in health care professionals pilot project. Health Serv D, Melnikow J, Vanek E. academic medicine. JAMA deliver services more Res 2009;44(5 Pt 2):1863- Teaching medical students 2009;301(7):766-768. effectively or efficiently. 1879. about quality and cost 356 Ladden MD, Bednash G, London: North East 339 Oyler J, Vinci L, Johnson of care at Case Western Stevens DP, Moore GT. Thames Regional Health JK, Arora VM. Teaching Reserve University. Acad Educating interprofessional Authority, 1994. internal medicine Med 1992;67:157-159. learners for quality, safety 331 Ogrinc G, Headrick LA, residents to sustain their 348 Shershneva MB, Mullikin and systems improvement. Mutha S et al. A framework improvement through the EA, Loose AS, Olson CA. J Interprof Care for teaching medical quality assessment and Learning to collaborate: a 2006;20(5):497-505. students and residents improvement curriculum. case study of performance 357 Barr H. Working together about practice-based J Gen Intern Med improvement CME. J to learn together: learning learning and improvement, 2011;26(2):221-225. Contin Educ Health Prof together to work together. synthesized from a 340 Tess AV, Yang JJ, Smith 2008;28(3):140-147. J Interprofessional Care literature review. Acad Med CC et al. Combining 2000;14:177-178. 2003;78:748-753. 349 Farquhar M, Kurtzman clinical microsystems and ET, Thomas KA. What do 358 Ladden MD, Bednash G, 332 Bloom BS. Effects of an experiential quality nurses need to know about Stevens DP, Moore GT. continuing medical improvement curriculum the quality enterprise? Educating interprofessional education on improving to improve residency J Contin Educ Nurs learners for quality, safety physician clinical care and education in internal (Published online April and systems improvement. patient health: a review of medicine. Acad Med 2010). J Interprof Care systematic reviews. Int J 2009;84(3):326-334. 2006;20(5):497-505. Technol Assess Health Care 2005;21(3):380-385.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 48 359 Gardner SF, Chamberlin 367 Pingleton SK, Davis DA, 375 Varkey P, Peloquin J, 384 Neale G, Vincent C, GD, Heestand DE, Stowe Dickler RM. Characteristics Reed D et al. Leadership Darzi A. The problem of CD. Interdisciplinary of quality and patient safety curriculum in engaging hospital doctors didactic instruction at curricula in major teaching undergraduate medical in promoting safety academic health centers in hospitals. Am J Med Qual education: a study of and quality in clinical J the : attitudes 2010;25(4):305-311. student and faculty Royal Soc Prom Health and barriers. Advances in 368 Alper E, Rosenberg EI, perspectives. Med Teach 2007;127:87-94. Health Sciences Education O’Brien KE et al. Patient 2009;31(3):244-250. 385 Jenson HB, Dorner D, 2002;7:179 -190. safety education at U.S. 376 Bleakley A, Brennan Hinchey K et al. Integrating 360 Parboosingh IJ, Reed and Canadian medical N. Does undergraduate quality improvement VA, Caldwell Palmer J, schools: results from the curriculum design make a and residency education: Bernstein HH. Enhancing 2006 Clerkship Directors difference to readiness to insights from the AIAMC practice improvement by in Internal Medicine practice as a junior doctor? National Initiative about facilitating practitioner survey. Acad Med Med Teach 2011;33(6):459- the roles of the designated interactivity: new roles for 2009;84(12):1672-1676. 467. institutional official and providers of continuing 369 Varkey P, Karlapudi S, 377 Warholak TL, Holdford DA, program director. Acad medical education. J Rose S, Swensen S. A West D et al. Perspectives Med 2009;84(12):1749- Contin Educ Health Prof patient safety curriculum on educating pharmacy 1756. 2011;31(2):122-127. for graduate medical students about the science 386 Watts B, Augustine S, 361 Ladden MJ, Peters AS, education: results from of safety. Am J Pharm Educ Lawrence RH. Teaching Kotch JB, Fletcher RH.. a needs assessment of 2011;75(7):142. quality improvement in Preparing faculty to educators and patient safety 378 Moses J, Shore P, the midst of performance teach the managing care experts. Am J Med Qual Mann KJ. Quality measurement pressures: competencies: Lessons 2009;24(3):214-221. improvement curricula mixed messages? Qual learned from a national 370 Armstrong GE, Spencer in pediatric residency Manag Health Care faculty development TS, Lenburg CB. Using education: obstacles and 2009;18(3):209-216. program. Fam Med quality and safety education opportunities. Acad Pediatr 387 Windish DM, Reed 2004;36(Suppl):S115-120. for nurses to enhance 2011;11(6):446-450. DA, Boonyasai RT et al. 362 Peters AS, Ladden MJ, competency outcome 379 Didwania A, McGaghie Methodological rigor Kotch JB, Fletcher RH. performance assessment: a WC, Cohen E, Wayne DB. of quality improvement Evaluation of a national synergistic approach that Internal medicine residency curricula for physician faculty development promotes patient safety and graduates’ perceptions trainees: a systematic review program in managing care. quality outcomes. J Nurs of the systems-based and recommendations Acad Med 2002;77:1121- Educ 2009;48(12):686-693. practice and practice-based for change. Acad Med 1127. 371 Kiersma ME, Plake KS, learning and improvement 2009;84(12):1677-1692. 363 Van Geest J B, Cummins Darbishire PL. Patient competencies. Teach Learn 388 Wakefield A, Attree M, DS An educational needs safety instruction in Med 2010;22(1):33-36. Braidman I et al. Patient assessment for improving US health professions 380 Schlett CL, Doll H, safety: do nursing and patient safety. National education. Am J Pharm Dahmen J et al. Job medical curricula address Patient Safety Foundation Educ 2011;75(8):162. requirements compared this theme? Nurse Ed Today White Paper Report 372 Attree M, Cooke H, to medical school 2005;25:333-340. 2003;3:1-28. Wakefield A. Patient education: differences 389 Lester H, Tritter JQ. 364 Cleghorn GD, Baker GR. safety in an English between graduates from Medical error: a discussion What faculty need to learn pre-registration nursing problem-based learning of the medical about improvement and curriculum. Nurse Educ and conventional curricula. of error and suggestions how to teach it to others. Pract 2008;8(4):239-248. BMC Med Educ 2010;10:1. for reforms of medical J Interprofessional Care 373 Van Hoof TJ, Meehan 381 Lyss-Lerman P, Teherani education to decrease error. 2000;14(2):147-159. TP. Integrating essential A, Aagaard E et al. What Med Educ 2001;35:855-861. 365 Ogrinc G, Headrick LA, components of quality training is needed in the 390 Wong JE. The future of Mutha S et al. A framework improvement into a new fourth year of medical medical education: the for teaching medical paradigm for continuing school? Views of residency second 100 years. Ann Acad students and residents education. J Contin Educ program directors. Acad Med 2005;34:166C-171C. about practice-based Health Prof 2011;31(3):207- Med 2009;84(7):823-829. 391 Aron DC, Headrick LA. learning and improvement, 214. 382 Kovner CT, Brewer CS, Educating physicians synthesized from a 374 Abbott MB, First LR. Yingrengreung S, Fairchild prepared to improve care literature review. Acad Med Report of colloquium III: S. New nurses’ views of and safety is no accident: 2003;78:748-753. challenges for pediatric quality improvement it requires a systematic 366 Ladden MD, Peters graduate medical education education. Jt Comm J Qual approach. Qual Saf Health AS, Kotch JB, Fletcher and how to meet them Patient Saf 2010;36(1):29- Care 2002;11:168-173. RH. Preparing faculty - a quality improvement 35. 392 Stevens DP. Finding safety to teach managing care approach to innovation in 383 Varkey P, Karlapudi SP. in medical education. competencies: lessons pediatric graduate medical A systems approach Qual Saf Health Care learned from a national education. Pediatrics to teach core topics 2002;11:109-110. faculty development 2009;123 Suppl 1:S22-25. across graduate medical program. Fam Med 2004;36 education programmes. Suppl:S115-120. Ann Acad Med Singapore 2008;37(12):1044-1045.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 49 393 Dolansky MA, Singh 396 Aron DC, Headrick LA. 399 Huang GC, Newman LR, MK, Neuhauser DB. Educating physicians Tess AV, Schwartzstein RM. Quality and safety prepared to improve care Teaching patient safety: education: foreground and and safety is no accident: conference proceedings and background. Qual Manag it requires a systematic consensus statements of the Health Care 2009;18(3):151- approach. Qual Saf Health Millennium Conference 157. Care 2002;11(2):168-173. 2009. Teach Learn Med 394 Beaudin CL, Beaty J. 397 Sumanen M, Virjo I, 2011;23(2):172-178. Strategies and innovations Hyppölä H et al. Use of 400 Moses J, Shore P, for successful quality quality improvement Mann KJ. Quality improvement in methods in Finnish health improvement curricula behavioural health. J Nurs centres in 1998 and 2003. in pediatric residency Care Qual 2004;19(3):197- Scand J Prim Health Care education: obstacles and 206. 2008;26(1):12-16. opportunities. Acad Pediatr 395 Simon JS. 5 Life Stages of 398 Sklar DP, Lee R. 2011;11(6):446-450. Nonprofit Organisations. St Commentary: what if high- 401 Cooke M, Ironside PM, Paul: Amherst H. Wilder quality care drove medical Ogrinc GS. Mainstreaming Foundation, 2001. education? A multiattribute quality and safety: a approach. Acad Med reformulation of quality 2010;85(9):1401-1404. and safety education for health professions students. BMJ Qual Saf 2011;20 Suppl 1:i79-82.

THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 50 THE HEALTH FOUNDATION Evidence scan: Quality improvement training for healthcare professionals 51 The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK.

We want the UK to have a healthcare system of the highest possible quality – safe, effective, person-centred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work.

We are here to inspire and create the space for people, teams, organisations and systems to make lasting improvements to health services.

Working at every level of the healthcare system, we aim to develop the technical skills, leadership, capacity, knowledge, and the will for change, that are essential for real and lasting improvement.

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