CULTIVATING A CULTURE OF CURIOSITY AND CONTINUOUS QUALITY IMPROVEMENT

By Alicia Fung

Providing the highest quality care for everyone should be the goal that all those involved in delivering health care strive for. As our understanding of high-quality care evolves, we must adapt and improve our systems and processes to meet ever-changing standards of quality. Change-making can be a slow process, but the healthcare system will not fully realize its potential unless continuous efforts to improve are made by those who have the ability to change the system from the inside. A good starting point for this is cultivating a culture of curiosity where errors made, questions asked, and areas of improvement are seen as opportunities rather than failures. What better place to start fostering such a culture than during postgraduate medical education?

The University of Toronto Department of Family and Community Medicine (DFCM) Postgraduate Program, under the leadership of Dr. Risa Freeman, Vice-Chair of Education and Scholarship, formalized the development of a continuous quality improvement (CQI) program with the goal to improve educational outcomes for residents. The program was created in response to a new national standard maintained by the College of Family Physicians of Canada for the evaluation and accreditation of family medicine residency programs; the Postgraduate Program at DFCM saw the value of creating a process that ensures that CQI is embedded in medical education.

“While we had already been collecting multiple forms of education data to evaluate our educational offerings, we needed a formal process to really assess areas of improvement and develop measurable action plans. DFCM has been leading QI in patient care for the last 10 years, and it is time to bring that culture and lens to our educational programs,” says Dr. Stuart Murdoch, who is an Associate Professor and Postgraduate Program Director at DFCM.

While many are familiar with quality improvement in clinical practice, bringing this perspective to medical education is relatively new, says Dr. Gurpreet Mand, an Assistant Professor and the CQI Lead at DFCM. “There was no guidebook or other postgraduate programs that we could look to as a reference, but that doesn’t mean that QI wasn’t happening in medical education before. We were always trying to improve and always trying to get better, but I think part of this new CQI program at DFCM has really been about capturing those endeavors,” she says.

The first step was to gain insight into the residency program at DFCM. To do this, the CQI team developed the CQI Promotion survey to get direct feedback from the residents at each academic teaching site about their experience, the learner environment and learner treatment. The feedback received would then be analyzed and used to inform improvement goals and guide action planning at each of the teaching sites. While work in this area has just started, Dr. Mand is already starting to see CQI being integrated into the culture of medical education at DFCM.

“We’ve had a lot of engagement from the sites. People have really opened their calendars to meet with the CQI team and review the data to identify what the opportunities are for improvement, but also to celebrate what’s working well—because that’s important, too. CQI is becoming a standing agenda item at our sites’ committee meetings, and program directors have plans to share the data with faculty and residents at their sites,” says Dr. Mand. “We want to show residents that we care about their learning environment and that we’re responding to their feedback. We don’t do surveys to put them on a shelf…This work is real and in time, the residents will start to see action plans based on their feedback.”

Plans for improvement are already underway at many of the teaching sites. For example, survey results at Scarborough Health Network (SHN) noted that residents did not find field notes very helpful. Field notes are short reflections by both residents and preceptors to record, assess and provide feedback on resident performance. Not only are they useful for tracking progress throughout their residency, but they are also required by the College of Family Physicians of Canada to ensure that competencies are being met. Getting documented feedback for improvement should be useful; Dr. Jennifer McDonald, the site director at SHN, says she finds it curious that residents at her site do not find the field notes helpful. She plans to review the importance of field notes with preceptors and residents at SHN, so they understand their value and get the most out of it.

“We know people are getting lots of good feedback all the time, but the question is whether we’re writing it down as a field note. So, we want to make sure preceptors are capturing verbal feedback as field notes, but also that residents understand that as a professional family doctor, learning also comes through self-reflection. So, we’re hoping to bring this message better to residents, so they really understand the importance and value of field notes,” says Dr. McDonald.

The CQI process is on-going. Although it has been less than a year since the CQI team launched their inaugural survey, they are gearing up to launch the next survey, with plans to improve it to capture actionable feedback more effectively and to ensure that the resident voice is represented when developing change initiatives within the residency program.

“No matter how good something is, there’s always room for improvement, and I think that allows for a dynamic environment where we’re always looking to be better. I genuinely believe that if residents and learners feel that we are being responsive to the feedback they’re giving, then they will be more engaged in their learning. And if people feel engaged, they do better work,” says Dr. Mand.

“Our overall aim is to set a positive tone and create a culture of CQI,” adds Trish O’Brien, the Education Development Projects Manager at DFCM who works closely with Dr. Mand on the CQI team. “Sometimes the feedback is unexpected and hard to understand, but we’re willing to explore the messiness of improvement. We try to model the mantra ‘start where you are, use what you’ve got, do what you can’ and acknowledge that better is always possible.”