Quality Improvement Training For Healthcare Professionals: Evidence Scan

Evidence scan:
Quality
improvement
training 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 information to help those involved in improving the quality
of healthcare understand what research is available on particular topics.
Evidence scans provide a rapid collation of empirical research about a topic relevant to the Health
Foundation's work. 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 value for money.
In recent years, training programmes have been developed to teach
health professionals and students 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 –– university 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 curriculum
quality improvement? –– using practical projects to develop skills
–– online modules, distance learning 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. –– simulations and role play
Courses about techniques, such as evidence-based –– collaboratives and on-the-job training.
medicine, 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 nursing
applied to other topics. students tend to focus on techniques such as
audit and plan, do, study, act (PDSA) cycles. Most
Ten electronic databases were searched for research courses run by academic institutions tend to be
published between 1980 and November 2011 and 367 unidisciplinary and classroom 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 course 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. Simulation 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 education. Ongoing
many parts of the world. Continuing professional education includes workshops, online courses,
development (CPD) courses are also available, collaboratives and ad hoc training set 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 management’ A great deal has been written about training
paradigm 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 knowledge, 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 mentorship and peer review,
whereas in the UK training tends to concentrate Most evaluations 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 needs increasing in popularity, and evaluations of these
and perspectives of service 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.
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.
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
believes 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 policy 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
College of Physicians emphasised the need 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 evaluation 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
growing in size, people are living longer but often in to assess evidence, plan improvements, manage
poor health and the demand for healthcare outstrips projects and analyse data.11
the staffing and financial resources available.3,4 Training health professionals in quality
The focus on patient-centred care, holistic practice improvement has the potential to impact positively
and providing value for money means that there is on attitudes, knowledge and behaviours.12 In fact,
a greater need to ensure that health professionals, some suggest that training professionals may be just
allied teams and managers have the knowledge and as effective as financial incentives for improving the
skills to improve and develop healthcare services. quality of healthcare.13
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?
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 books, 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 best practice and to
have the tools and confidence to develop activities
to reduce these gaps.
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
Accountability
Professionalism
Human behaviour Psychology of change

Learning styles
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 theory and interdependencies
Spread
Sustainability
Planning and predicting
Understanding risk and risk management
The nature of knowledge Different forms of evidence

The philosophy of science
Variation
Measurement
Local versus generalisable knowledge
Small versus large scale change
Collecting, analysing and interpreting data
Reporting and displaying information
Process mapping
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 Scholar 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 inclusion. 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 philosophy of science,
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 websites and course
outlines of organisations such as the General
Medical Council and all royal colleges, the
Association of American Medical Colleges, the
Institute for Healthcare Improvement (IHI), the
NHS Institute for Innovation and Improvement,
the Improvement Foundation and academic
institutions. Sixty organisations were contacted
for information about their quality improvement
curricula.
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
descriptors include the IHI Improvement Model, based learning and improvement’ and ‘systems
CANDO, Six Sigma and LEAN.16,17 based practice.’34–36
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
In the US, quality improvement training is now types of competencies to guide teaching about
formally mandated for medical students and this quality improvement.40–49
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 Medical Education,21 the Pew Health used in tandem.
Professions Commission22 and the Institute of
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 technologies that come together to meet the needs of individuals and communities.
Variation and measurement: Using measurement to understand variation in performance in order to
improve the design 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
improvement.52 This is more common in Europe improvement are taught.59 However, there is no
than in North America.53 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 ‘ideal’ 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
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
Level 1: Micro- New education programme for theory and similar paradigms.62 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
interventions
team communication
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
community wide the types of formal training available.
interventions
Accredited education most commonly uses
classroom or lecture 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
collective 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 tailor 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.
Box 2: Examples of formal education about quality improvement
Newcastle University in England offers a Masters, Postgraduate Diploma and Postgraduate Certificate
in health sciences. Modules include health statistics, fundamentals of research, project management,
health economics, healthcare quality, applied epidemiology and others.
The University of Birmingham in England runs a Masters programme in healthcare management.
Modules include health services management, healthcare policy, organisational development, public
and user involvement, partnership 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 public health. Modules include
research methods, health needs assessment and economic evaluation, statistics, systematic reviews
and critical appraisal techniques, evidence-based healthcare, economic analysis and health technology
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 experiences during their clinical placement and then take part in a
two-day seminar about quality improvement methods. Students produce flow charts to identify areas
of improvement and cause-and-effect diagrams.77
At Dartmouth Medical School 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 student 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 University of Michigan Medical
School in the US, ranging from informal discussions to more formal lectures 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
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 schools, cultural advisors and health
self-audits 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 child’. 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
engineering 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 Australia, Africa,
initiative.82 Belgium, Canada, China, 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
undergraduate education for medicine, nursing as reflective practice 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 educational career rather than taught in a specific
sensitivity, efficacy and patient centredness.84 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.
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 teaching method. 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 collection, 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 Experiential learning 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 hospital 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 diplomas 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 experience.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.
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 experts 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 period. Residents’ self-reported knowledge and
changes.132 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 evaluated their interventions and presented their
the process.133 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
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
goals based on their observations. Nursing students in improving quality is becoming common in
said that they had improved skills compared to formal education courses154,155 – 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- ownership 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
out of practical projects.151 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,
into a tool called the ‘healthcare matrix’.152 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.
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 Open University 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 creativity 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, building 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 partnerships.
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
across the trust to give staff more opportunity to
colleagues as methods for improving
attend. The team found that these in-house sessions
performance.’159 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
Academy 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
industry 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 mental health, nursing, social work and allied
self-reported skills.167 professions.170–173
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
hospitals 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
hospital trust and a university ran a series of seven communication and operational planning.174
In the US, all health department and public health critical thinking 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
advisory committee roles.175 full practice of the situation or environment have
Some suggest that it is important to train various been used to support healthcare improvements,
levels and types of staff simultaneously in quality particularly regarding safety and teamwork.181,182 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
trained leaders and frontline staff. One two- development about quality improvement.183
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 culture 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
sustained up to one year after the training.176 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
quality improvement in nursing documentation. of quality improvement.184 Other studies have also
The programme consisted of two one-hour found that drama can be useful in developing new
writing workshops followed by one-to-one skills.185,186
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 schedule time
among professionals. There are also studies of with primary care staff but outreach visits were
particular methodologies, such as teaching crew associated with increased adoption of quality
resource management approaches to upskill improvement tools.187
professionals in team work, communication and
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 blended learning 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 public policy 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
are becoming more popular for CPD.189–194 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 state 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 methodology. The training
a mentoring format. Twenty-five expert 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
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 telephone
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
teams to a series of seminars designed to aid in approach helped to improve care processes.220
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
test, 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
participate in quality improvement interventions.202 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
disciplines, including cardiovascular disease, commitment and infrastructure support.221
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
disease (COPD), diabetes and many more.203,204 learners with audit and feedback at an initial
Many studies have examined the potential benefits seminar followed by teleconferences or site visits to
of this model.205–215 facilitate collaboration during quality improvement
For instance, in the US, groups worked together for projects.222–226
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 collaborative learning 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
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
complex processes and pathways. It was important any changes in quality of care are a direct result of
to gain widespread clinical engagement by learning initiatives.243
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
For example, a GP practice setting up a new offering training sessions to those in their own
telephone helpline might run a training session for organisations or fields.244–246 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
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, advice 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
For instance, 102 professionals in mental health
improving professional practice. The effects
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 therapy. 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.
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 medical record 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 Switzerland 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 employment 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 Organization (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 medicines 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
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.
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
Factors that affected the success of curricula Table 3: Effectiveness of training295–297
included having sufficient numbers of teachers
familiar with quality improvement concepts, Technique Effects
addressing competing educational demands and Printed educational Limited effects on
ensuring buy-in and enthusiasm from learners.282 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
processes.283–290 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
Opinion leaders305,306 Mixed effects on
rare.291,292 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 prescribing
and managers were taught methods for improving
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
Courses plus other Usually effective for
said that training contributed to modifying adverse
initiatives313–317 changing behaviours
event oversight procedures and enhancing patient
and some effects on
safety culture.293 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.
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 philosophies, 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.
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 affect impact. There practice guidelines and opinion leaders were less
effective. Didactic presentations, such as lecture
is no magic bullet.’329
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.
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
should be based around problem solving rather
of an academic year, and emphasising
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 stage 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
outcomes.334–336 In fact, most studies which have implementation.346
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 learning, didactic activities that support
initiatives.337–339 active learning, 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
projects undertaken can have a real benefit for successful quality improvement training.347–352
health systems, organisations and service users.340 The importance of ongoing support and
‘Adult learners are best educated by coaching from mentors or faculty has also been
highlighted.353–355
involving them in real work that interests
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
in training about quality improvement methods
improvement in teaching hospitals. They
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
‘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
competencies, let alone their ability to teach them
they are not even exposed to one another
to others.361–363 There is a gap in the training and
during the formative educational training development opportunities available for faculty
years.’356 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
domains and ensconced in traditional disciplinary educators to teach practice-based learning and
hierarchies and boundaries.357 improvement.365,366
In the US, higher educational institutions partnered

with the Robert Wood Johnson Foundation to
3.3 Summary
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
teams.359 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
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 universities 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
training techniques. However, it is possible to draw interwoven throughout their studies.368–371 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
appraisal, measurement for improvement and
Conceptualising quality 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
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,
tested with success. enhance and disseminate good practice.373,374
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 academies, 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
to provide training for students as well as
quality improvement 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
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 learning environment.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
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
some of the variations in approaches to quality
4.3 Gaps in knowledge
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
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 careers 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
quality improvement teaching needs to be
less effective than building quality
reinforced and practised regularly in order for
improvement skills into formal learning 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.
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
pedagogies 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
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 Continuing education 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 health care 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. Century. Washington DC: for Graduate Medical
3 World Health Organization.
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 is Human: Building a Safer compFull.asp
4 Department of Health. Systems, Health and
Improving Chronic Disease Health System. Washington, 35 Djuricich AM, Ciccarelli M,
Wealth. WHO Ministerial DC: National Academy Swigons NI. A continuous
Management. London: Conference on Health
Department of Health, Press, 2000. quality improvement
Systems, June 2008. curriculum for residents:
2004. 25 Varkey P, Kollengode A. A
14 The Health Foundation framework for healthcare addressing core
5 Parsley K, Barnes J. Do or adapted this typology competency, improving
die. Int J Health Care Qual quality improvement in
from Batalden P, Davidoff India: the time is here systems. Acad Med
Assur 1995;8(7):9-13. F. Teaching quality 2004;79(10): S65-67.
and now! J Postgrad Med
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 McDonald FS et al.
safety: Do nursing 2007;298:1059-1061. 26 Parsley K, Barnes J. Do or
die. Int J Health Care Qual Perspective: Transformative
and medical curricula 15 Melichar L. Transforming learning: a framework using
address this theme? Assur 1995;8(7):9-13.
care at the bedside for nurse critical reflection to link the
Nurse Education 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.
Innovations 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: physician’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 nursing
management and 2011;9(Suppl 1):S40-42. education. Nurs Outlook
technology training needs 20 Batalden P. Contemporary 2009;57(6):313-322.
Issues in Medicine: Quality 32 Davó MA, Vives-Cases
of doctors in an acute C, Benavides FG et al. 40 Fater KH, Ready R.
NHS trust in the United of Care. Washington DC:
Association of American Common competencies and An education-service
Kingdom. Health Info Libr J contents in public health partnership to achieve
2004;21(3):164-172. Medical Colleges, 2001.
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.
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: 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.
43 Preheim GJ, Armstrong Care. Boston: Institute for Health Aff 2011;30(4):716-
Healthcare Improvement, 61 Gira EC, Kessler ML, 722.
GE, Barton AJ. The new Poertner J. Influencing
fundamentals in nursing: 1998. 69 Paulman P. Integrating
social workers to use
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 progress. 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 theories 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 Teacher 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 conversations:
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
practice-based learning and 75 www.sheffield.ac.uk
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
medical education. Acad 77 www.betaniensyke
International Collaboration. improvement in nursing pleierhogskole.no/english.
Med 2009;84(3):335-339. Unpublished, 2007. practice. J Adv Nurs html
48 Fater KH, Ready R. 57 Thanh NX, Jacobs P, Wanke 2003;41(1): 88-98.
An education-service 78 www.dms.dartmouth.edu
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
in nursing. J Nurs Educ 80 www.medicine.mcgill.ca
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.
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 distance education 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 curriculum design make a communities and students.
2009;24(1):6-11. 99 Manning ML, Frisby J Interprofessional Care
AJ. Multimethod difference to readiness to
89 Ogunyemi D, Eno M, practice as a junior doctor? 2000;14:119-130.
teaching strategies to
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.
118 Weingart S. A house 127 Sockalingam S, 135 Headrick L, Neuhauser 144 Canal 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, Ayers 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 reality: 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.
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
Improvement 1996;22:149- educational intervention 2002;5(7):30-33.
to enhance nurse leaders’ 176 Rask KJ, Gitomer RS,
164. Spell NO 3rd et al. A 187 Meehan TP, Van Hoof
perceptions of patient safety
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
education. Acad Med staff in a hospital trust. practice. Am J Med Qual
Nurse Ed in Practice 177 Jefferies D, Johnson M, 2009;24(2):90-98.
2000;75:81-84. Nicholls D, Lad S. A
2002;2:176-180.
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
171 Hancox K, Lynch L, Happell 2007; 27(4):318-324.
159 Grol R. Changing 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
data and statistics to quality South Australia. Australas Inform Nurs 2006;24(2):
Psychiatry 2004;12(3):273- 181 Kyrkjebø JM, Brattebø 66-74.
development. Z Evid G, Smith-Strøm H.
Fortbild Qual Gesundhwes 277.
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.
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
improvement initiative with HIV infection: the to improve diabetes care
aafp.org/x29503.xml EQHIV study. Ann Intern in primary care settings.
to transform education
eqipp.org for chronic illness care Med 2004;140(11):887-896. Diabetes Care 2005;
in resident continuity 211 McInnes DK, Landon BE, 28(8):1890-1987.
online.rit.edu/students/
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
quality improvements 212 Peterson A, Carlhed R, Pract 2000;3(3): 105-115.
ihi.org
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 Register in Sweden for 2011;150(4):635-642.
204 Cronenwett L,
abim.org/sep2/75A0601I/ Sherwood G, Gelmon acute myocardial infarction. 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 homes.
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.
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.
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 Bridge to Scholars 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 credit
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 lifelong learning 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. Health education. 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.
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
practice: lessons from bowel disease improvement care: a systematic review.
306 Greer AL. The state of the network. Inflamm Bowel
medicine and the allied art versus the state of the JAMA 2003;289(23):3145-
health professions. Res Dis 2011;17(1):450-457. 3151.
science: The diffusion of
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 track 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.
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.
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 United States: 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 construction
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.
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 is an independent charity working
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organisations and systems to make lasting improvements to
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Quality Improvement Training For Healthcare Professionals: Evidence Scan

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Quality Improvement Training For Healthcare Professionals: Evidence Scan

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Evidence scan:

Identify Innovate Demonstrate Encourage

3. Most effective approaches 27

© 2012 Health Foundation

Components Examples of topic areas

Human behaviour Psychology of change

Healthcare as a process Systems thinking

The nature of knowledge Different forms of evidence

2.1 Content covered Medicine.23,24 This conceptualisation of quality

Level 2: Shared record system to improve 2.2 Training students

Level 4: Information system linking all Classroom teaching

Box 3: Examples of continuing professional development

Training approaches Reviews and studies have concluded that there

In the US, higher educational institutions partnered

4.1 Key trends Training students in quality

‘To the extent that quality and safety are

We want the UK to have a healthcare system of the highest

Working at every level of the healthcare system, we aim to

The Health Foundation

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