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Dr. Brian Wong & Dr. David Kaplan

Quality to the Core

It’s time quality science was taught as a core part of all health professional training.

No longer should quality improvement be viewed as an esoteric skill or taught as part of the “informal curriculum”, but rather it needs to become part of training for anyone embarking on a career in medicine, nursing or any other health profession.

As was pointed out more than a decade ago, the goal in quality improvement education is for everyone who works in health care to recognize that they have two jobs when they come to work every day: doing the work and improving it.

For its part, Health Quality Ontario – soon to become part of Ontario Health - has highlighted that creating a culture of quality among all involved in delivering health care is a fundamental requirement for building a better quality health care system in Ontario.

Around the world, organizations including the Royal College of Physicians and Surgeons of Canada have written new standards for the medical school curriculum and assessment that include quality concepts. In fact, since 2015, quality and patient safety have become core competencies required of all Canadian physicians.

While this has resulted in the development of new courses which have introduced quality improvement to a new generation of learners, it has also created challenges. Identifying knowledgeable teachers, defining core content and securing time in the curriculum are recurring issues, and educators are now focusing on how best to assess learner competence and evaluate educational efforts in quality improvement.

In addition to learning more traditional topics like anatomy and physiology, health professionals need to learn newer competencies, such as patient safety, quality improvement, resource stewardship and cost consciousness, interprofessional teamwork, shared decision making, and the use of health information technology in order to provide high quality care.

Medical education in Canada has already made significant progress in this direction. At the University of Calgary, the Cumming School of Medicine partnered with the Price Family to develop a curriculum that teaches medical students’ patient safety, teamwork and collaboration and care coordination right from day one. At the residency level, family medicine programs like those at the University of Toronto and Queens University involve all of their residents in quality improvement initiatives. To address the need for more faculty who can supervise and teach QI, the University of Toronto Departments of Medicine, Paediatrics and Surgery teach residents and faculty together using a ‘co-learning’ approach; evaluation of this program has demonstrated significant capacity building among faculty to support QI educational efforts. As a result, other departments at McMaster University, Western University and the University of Alberta have adopted similar co-learning type approaches for QI education and faculty development.

Fostering a culture that encourages medical, nursing and other students to become more involved in learning about quality initiatives is important. As Sharon Yeung, a medical student who participated in two quality improvement conferences last year notes, this can be “a transformative experience,” because quality improvement research is not top of mind in the medical school curriculum.

Yeung has summarized some of the key learnings from a student ambassadorship program offered by Health Quality Ontario showing how this involvement shaped the perspective of herself and other participants as they enter their careers:

  • Integrating health quality work into a clinical career is possible and many types of opportunities for engagement exist or can be created
  • Improving health quality requires perseverance and dedication to projects that are often long-term and multidisciplinary in scope and in which linear approaches to quality improvement will need to evolve to meet the demands of a changing social and technological landscape

Yeung’s comments reflect how learning more about quality improvement during the educational process can reinforce the ability of medical students to be agents of change. A recent study from the University of Dundee, UK found that “undertaking quality improvement projects in clinical practice enhances knowledge, understanding and skills, and allows medical students to see themselves as important influencers of change as future doctors.”

As Health Quality Ontario has stated in a framework document, relying on a lone, heroic leader to champion quality care is not sufficient.

What is needed is a comprehensive leadership development strategy that targets potential leaders at various levels and reinforces quality improvement as something to be instilled during training and continuously reinforced.

Dr. Brian Wong is Associate Professor, Faculty of Medicine and Associate Director, Centre for Quality Improvement and Patient Safety, University of Toronto and Dr. David Kaplan is Chief, Clinical Quality, Health Quality Ontario.


4 comments on article "Quality to the Core"

David Borts

It is very encouraging to realize that the importance of quality improvement is being taught at the earliest stages of medical training. Speaking as a local medical leader I have been very impressed with how many colleagues are interested in quality improvement. There are a few things that I feel can further the integration of this knowledge once these young physicians start their career.

1. Those of us in leadership positions tend to be mid to late career clinicians. It is important that we understand what our younger colleagues are learning and what their expectations are so we can help integrate this knowledge into thei daily practice.

2. It is crucial to be able to operationalise these learnings. Quality is crucial and often times can result in improvement in effieciencies and of course effectiveness and safety. Trying to integrate this can sometimes be a challenge and learning how other similar centres do it would be helpful. This cross fertilisation would be of benefit.

Looking forward to hearing more

David Borts

Dieter Kays

I totally affirm the direction. Having been involved in health care both as clinician, administrator and volunteer on a hospital board I understand the challenge professionals face in a resource strapped system. Nevertheless we continue to fail at one of the most basic low cost common sense aspects - GOOD COMMUNICATION. Having recently lost my mother, we had to confront waiting in emergency rooms for hours without knowing why the delays; commitments from home care providers that were not passed on for fulfilment; confusion about who was responsible for certain patient decisions; professionals who took no time to introduce themselves; assurances of in suite communication logs that never became a reality. If a family does not advocate for a loved one and keep good notes the final journey can become quite difficult. Yet I continue to be grateful for all the caring professionals that were a part of my mother's final days.

Jeanette Kling

As part of Health Care system, receiving and giving for 40 years, I am concerned that Quality Improvement has become another word for Cost Savings! They are Not the same! There are more people collecting Data and fewer persons delivering care and preventing the next tragedy.

Innovation must never take presidence over Patient Care and Patient Education, they should occur together. The system is #, more data collection will not improve it!

They’re working to the Data collector and Not the Patient, how very sad!!

Paula Brauer

I agree, and what is needed is common methods elements, so that all members of health care teams learn a common framework. At Guelph, we have been teaching QI methods in our research project course to our Masters of Applied Nutrition students, who will become Registered Dietitians for several years. Thanks for highlighting the need.

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