Students are underused and undervalued in quality improvement
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2602 (Published 19 June 2018) Cite this as: BMJ 2018;361:k2602
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Dear Editor,
We read with interest Gurung’s response to the importance of quality improvement citing the need to mobilise medical students as ‘agents of change’ to drive improvement (1). A 21st century medical graduate is most likely to succeed in their chosen career, and the profession is most likely to be able to flexibly adapt if the education system is itself responsive and adaptable to the relevant changes around us. At Guy’s, King’s and St Thomas’ (GKT) School of Medicine, King’s College London, we are currently implementing a new undergraduate medical curriculum which embeds situated learning of “real world” Quality Improvement (QI) methodology and skills. Quality improvement teaching and learning are embedded in the programme through an integrated spiral approach. All Year 4 medical students participate in a 6-month module to undertake a QI project in a healthcare setting. The University’s Virtual Learning Environment is used to deliver the theoretical background and resources, with four “face to face” tutorials. The GKT Module on QI is based on the Institute for Healthcare Improvement (IHI) Methodology adapted for application in the UK.
This module was delivered for the first time between September 2016 and March 2017: 420 medical students undertook a QI project, working in groups of 2-5. Projects were set in primary (9 projects) and secondary care (123 projects) in London and the South East of England. All groups were able to identify a clinical problem, collect baseline data and design at least one PDSA (Plan, Do, Study, Act) cycle. Of a random selection of 20 projects 8 (36%) were able to implement improvement with 2 (9%) reaching their improvement aim. The second cohort of students has just completed their quality improvement module.
Examples of projects include;
1. Introducing an asthma monitoring app into the Paediatric service at King’s College Hospital which improved inhaler technique accuracy to 100% and subsequently asthma control by more than 3 points.
2. Successfully reducing the time to treatment for Biological therapies in patients with Inflammatory Arthritis.
3. Improving the documentation on the Acute Medical Unit in Lewisham Hospital by introducing Consultant checklist cards and personal electronic device access to laboratory results on the ward.
A longitudinal educational study to determine the effectiveness of the module and to inform the future development of it is in place with early findings being published in due course. It includes understanding the conditions under which the student engagement in QI was successful, providing meaningful change for patients and the factors that frustrated success.
References:
(1) Binay Gurung BMJ 2018;361:k2602
Competing interests: No competing interests
I fully agree with the statement "Students are excellent vehicles of change. With fresh eyes, they can often recognize areas needing improvement that clinicians working in that environment may have become immune to."
Similar has been our experience during field effectiveness testing of "Health Account Scheme" where monthly health diary of individuals was supposed to be updated for health status, treatment, test experience, and needs. This also gives the opportunity to counsel and screen for illness and provide the solution on spot.
However, students of medical college posted at the study site were found completely not utilized for this work. It was observed that students are supposed to just do formality of field experience during their posting in preventive and social medicine department. It was also observed whatever little students were doing to show records of communicating with the community- was irritating the residents rather providing them with any solution. Students were not trained to provide solutions also.
Therefore health account scheme staff had to face resistance from community initially due to non-compliance majorly created by irritating questions by students posted at the field sites. People were not ready to fill the health diary since they thought that it will be the same students experience the type of work to full fill posting requirements and not be going to be of any help to them. Gradually they came to know that this is not student posting type of work and surely helping them than they started cooperating.
Therefore grooming of students is required to actually bring some change, rather than just completing formality of posting to get the certificate of field experience.
Competing interests: No competing interests
Creating space(s) for quality improvement across the health and care curriculum
The contributions of Gurung (1) and Gulshan (2) highlight both the challenges and opportunities associated with creating space for quality improvement (QI). Both quite rightly draw attention to the importance of medical education in this regard, and that while QI does feature (3) there are clear areas for improvement needed in order to achieve the vision of clinically led systematic quality improvement (4).
In 2016, the Health Services Management Centre at the University of Birmingham launched an intercalated degree in Health Management and Leadership (HML) for medical students (5). Central to this degree is a module covering various aspects of ‘Improving Quality and Safety’. The module includes critically engaging with key concepts, tools and techniques related to QI; participating in a site visit to University Hospitals Birmingham Foundation Trust to engage with QI examples and experiences; and requiring students to carry out desk based research to analyse the Quality and Safety ‘intelligence’ associated with NHS Trusts.
HML has been well received (6) with plans afoot to further expand this programme in the future. Like the course at Guy’s, King’s and St Thomas’ School of Medicine, the programme represents an exciting opportunity to introduce and embed QI methodology and skills into a future medical career.
However, to ensure that any future plans to grow QI within the medical curriculum are successful will also require similar developments in other degree programmes. QI is notorious for being ‘lost in translation’ therefore it is crucial that all health related undergraduate programmes are exposed to QI theory and practice in order to generate the shared understandings that are necessary to realise any improvement efforts.
In response to such debates and dilemmas, QI is forming a central component of a cross University partnership between the Universities of Birmingham and Nottingham to co-design and pilot a series of learning resources for health related undergraduate students (7). Launching in 2018-2019, our goal is to initially provide these resources to medical, nursing, and pharmacy students with the view to these being expanded across other health related areas such as physiotherapy, biosciences, social care and social work. This exciting new development provides a real opportunity to create a range of spaces for learning and understanding about QI that are needed to generate systematic quality improvement across health and care systems.
References:
1. Binay G. Students are underused and undervalued in quality improvement BMJ 2018; 361 :k2602
2. Sethi GC. Educational Leadership for Quality Improvement BMJ 2018;361:k2602
3. Huntington GR. Motivated junior doctors pursue quality improvement projects BMJ 2018;361:k2601.
4. Allwood D. Fisher R. Warburton W. Dixon J. Creating space for quality improvement. BMJ
2018;361:k1924.
5. University of Birmingham Health Management and Leadership - Intercalated Degree https://www.birmingham.ac.uk/undergraduate/courses/med/health-management...
6. Cuckow L. Ghezelayagh S. Intercalating in healthcare management and leadership Student BMJ 2017; DOI: 10.1136/sbmj.j3384
7. In Partnership: The Universities of Birmingham and Nottingham. 21st century healthcare: Assessing the challenges and futures for health organisation and management http://www.birmingham-nottingham.ac.uk/projects/education-case-studies/2...
Competing interests: No competing interests