Quality improvement (QI) education for medical students represents an important area of evaluation in medical education. QI is an essential part of modern clinical practice, and front-line professions can offer valuable perspectives on the areas of improvement in which they are motivated for delivering change (Lopes Sauers et al., 2017). Thus, medical students and junior doctors are expected to take part in QI programs in order to get the needed boost for advancing in the following stages of training (Ewins et al., 2018). However, there is a challenge associated with the fact that medical undergraduates rarely receive standardized training in QI, which is perpetuated by the lack of teaching capacity at medical education institutions and competing priorities.
QI program that can be evaluated entails near-peer teaching that was carried out as a pilot study at Imperial College Healthcare NHS Trust. The teaching was delivered by tutors that were close to medical students in terms of experience and training and thus can offer advantages over traditional senior-led teaching. Because of the smaller gap in knowledge and experience between medical students and junior tutors, the program intended to foster a positive environment to facilitate QI training. The materials that are being taught usually seem more applicable and relevant to students, enabling their development into tutors that will later participate in sustainable teaching programs. The program is beneficial all-around because it can help tutors develop essential skills and consolidate their own knowledge. Within such a program, quality assurance represents an important step, and it is recommended to facilitate the development of appropriate materials and oversight by senior clinicians and educators.
The QI program entailed teaching delivered by eight junior doctors, each having at least one year of postgraduate experience. The tutors involved in training all had direct experience associated with audit and QI projects in the form of either attending QI sessions or receiving training within the context of other initiatives. The tutors were recruited from the personal or professional circles of the doctors designing the sessions to deliver workshops within an unpaid voluntary capacity. The program developers encouraged tutors to draw from their personal experience working in the medical field to provide both practical and theoretical insights into QI within healthcare. It was expected that students and their tutors would give transparent and structured feedback on the program and its usefulness in facilitating the understanding of QI initiatives and their implementation in practice. Students were asked questions related to their confidence by using Likert scales, while they were also invited to recommend improvements for the future to provide a more comprehensive assessment of their experiences.
An important takeaway from the program was that students had positive attitudes when it comes to being taught by junior doctors, with 86% of participants expressing a preference for being taught by junior doctors instead of senior experts in QI (McGeorge et al., 2020). The rationale for the positive feedback regarding near-peer QI training was related to the proximity of junior doctors to the undergraduate level, as well as their appreciation for the relevance of QI to students. Also, students said that near-peer tutors were more relatable and less daunting in their overall approaches to teaching. Importantly, tutors unanimously agreed that the participation in the QI program had boosted their confidence in teaching alongside their knowledge of effective QI techniques. Following the sessions, the tutors said that they would be more likely to engage in QI at their workplaces.
Therefore, there are significant indications to suggest that the near-peer QI initiative involving tutors teaching students would be beneficial for addressing the challenges of quality improvement education at universities. Considerable value was found in terms of students’ self-reported understanding of QI tools and methods to have confidence in applying them in their own work. Junior doctors have also benefited from the teaching process because they were expected to have both teaching and leadership skills alongside additional clinical competencies. The initiative helped develop teaching and QI skills among trainees, and the need for the steady supply of highly motivated junior doctors is closely related to such an advantage. Such a model has the capacity of providing valuable teaching opportunities for junior healthcare providers and easing the tensions that overburdened faculty members endure.
The overall purpose of the program was to address the limitations of QI teaching at medical educational facilities by introducing a new approach that is applicable and relevant to students. The objective was to make quality improvement learning more accessible to students while also allowing tutors to develop good leadership skills that they can use in other teaching programs. It was expected that tutors would benefit from the experience and become more proficient in understanding the application of quality initiatives in their workplace settings. The program developers also wanted to determine whether education through the near-peer approach could boost the self-reported understanding of QI by students for them to apply relevant techniques in their future careers (WHO, 2018). The secondary objective was to provide junior doctors with valuable experience in near-peer education and teaching techniques of quality improvement. There is great potential for similar programs being carried out at different medical education institutions, mainly since students have found the QI training implemented by senior tutors to be less effective.
Due to the great importance of quality improvement teaching in medical education, researchers have looked at the advantages and disadvantages of current practices of QI application within the curriculum. Malak (2017) stated that QI had to be indeed introduced as a part of the main content, but it should not be taught in isolation from the rest of the medical curriculum. The information taught to students should be taught together with consistent reinforcement from medical opportunities and different courses. For instance, a medical institution can start by introducing the basic principles of QI, allowing students to think about the specific areas of quality improvement in which they would like to participate. For instance, some students may choose to place emphasis on the prevention and management of at-hospital infections, while others find the topic of cardiac diseases more appealing.
Researchers mention that current QI efforts implemented in the context of medical education are insufficient and are often not recognized as QI activities (Blouin, 2019). In the study carried out by Blouin (2019), the perceived levels of quality improvement implementation were low across programs. The lack of QI was particularly visible in such domains as operations, strategy, as well as knowledge management. It is notable that leadership’s perception of QI implementation was higher than those of teachers and students, which points to a disconnect in the understanding of QI initiatives’ importance and their implementation. For educational institutions to succeed in this area, it is crucial that the programs being implemented embrace the notion of QI, and their execution should rely on the resources that can help embed quality into organizational culture.
It is notable that today, there is no universal method aimed at improving healthcare quality, and there are a lot of overlapping approaches described in the research literature. The plan-do-study-act is the most widely applied QI tool, which seeks to improve clinical pathways by identifying change ideas and measures of interest, implementing an intervention, measuring subsequent changes, and scaling up the intervention based on the acquired result. Other basic QI skills that medical students are usually informed about include the use of action effect diagrams that help visualize actions necessary for achieving project goals as well as stakeholder mapping. The latter is concerned with the identification of the individuals that will be affected or will impact the success of a project.
Competing priorities hamper QI teaching at medical universities within medical curricula and the lack of teaching capacity within the faculty (McGeorge et al., 2020). Theory-based teaching from senior experts specializing in QI can often be irrelevant or insignificant when compared to the major priority of educators and students, which entails the clinical skills and knowledge needed to succeed as a doctor. Students may not have an understanding of why QI should be a priority or how they can have an impact as change architects. Therefore, implementing programs that entail near-peer teaching is a unique approach that addresses the barriers of traditional QI training and adds value to both students and tutors.
Purpose of Evaluation
The program was chosen for evaluation because of the need to place emphasis on quality improvement within the medical curriculum. As of now, there is limited evidence available from research to illustrate the implementation of QI training at educational institutions despite the fact that future nurses should have the knowledge and skills concerning this topic in their future practice. So far, there are basic introductory lessons on QI with the lack of practical information and programs implemented to engage students and equip them with adequate skills and knowledge. It is vital that medical students point out the areas for improvement in the healthcare practice as well as decide how they can contribute to these areas.
Even though the curricula of both US and UK medical schools include quality improvement topics, there are significant inconsistencies in the delivery of the teaching at the undergraduate level. Because of this, medical students finish their education with various degrees of exposure to quality improvement training. According to McGeorge et al. (2020), over half of medical students reported lacking exposure to QI training at medical schools even though they recognized its importance for future careers in their respective fields. Therefore, it is imperative that medical schools effectively integrate the professional requirement for QI learning and training within the curriculum. The program implemented at Imperial College Healthcare NHS Trust illustrates a new and effective approach to introducing QI training into the curriculum without putting a strain on the faculty or intimidating students. The near-peer program provides benefits for all stakeholders involved; students are less intimidated by the training because junior tutors are engaged while the latter benefit from improving their teaching capacity.
The stakeholders of the program involved three groups with specific needs and expectations. The first group of stakeholders was represented by the faculty of the educational institution that agreed upon the implementation of the program and provided a setting within which the near-peer training would be carried out (Barger et al., 2019). The core need of the faculty at the educational institution was to improve the QI education of their students without involving the additional resources from instructors that are already busy with the curriculum. Nevertheless, the faculty understood the benefit of a QI initiative and agreed that students would have to engage in it to become better prepared for their future careers in healthcare.
Junior tutors represented the second stakeholder group that was directly involved in the program. Eight junior doctors, each of whom had between one to five years of postgraduate experience. Besides, the stakeholders attended QI teaching sessions and were recruited for participation from various networks on the basis of voluntary involvement. The core need of junior tutors was to expand their skills and capacity of teaching and leading others in the area of quality improvement. They also participated in the program to boost personal and professional confidence, which can significantly improve as a result of assuming the role of educators.
Medical students are the third group of stakeholders that were involved in the program. The students were expected to increase their confidence in applying QI techniques in their medical education and career. The core need of the students was to attain new skills and knowledge on quality improvement without being pressured and intimidated by the program. Since junior tutors were closer to students in experience and knowledge, the overall program was intended to reduce the knowledge gap and prepare future healthcare personnel for their careers in the medical field.
The purpose of evaluation as related to the quality improvement teaching is to determine whether there has been a significant improvement in the curriculum regarding QI teaching efforts at educational facilities. It is necessary to trace the difference in students’ knowledge in QI-related activities before the program and after its implementation (Backhouse & Ogunlayi, 2020). Because many educational facilities fail to include the topic of QI into their curricula, the program evaluation can show educators the importance and relevance of not overlooking this area of teaching (Darling-Hammond et al., 2020). If there is a significant improvement in students’ understanding of QI and its subsequent application in the nursing practice, the program is deemed effective and may be replicated in an array of medical schools. If no significant improvement is seen, the program can be changed to include new educational strategies and implemented again to reach the desired boost in medical students’ knowledge and skills in QI application.
Another critical area to consider throughout the process of program evaluation is concerned with the feedback of students and junior tutors regarding the benefits of applying for the near-peer educational program. There are indications that such a program could improve the confidence of both students and tutors because there is an increased level of rapport and collaboration between individuals whose experiences and knowledge levels are similar. Besides, junior tutors often approach the teaching process differently from higher-level educational staff and are generally more welcoming of students and less intimidating. In the evaluation, it will be necessary to determine the limitations of the project as well as propose recommendations for future improvement.
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