An interprofessional postgraduate quality improvement curriculum: results and lessons learned over a 5-year implementation

ABSTRACT

Problem

Quality Improvement (QI) is interprofessional by nature; however, most academic QI programs occur in silos and do not leverage the opportunity to bring interprofessional learners together.

Intervention

To evaluate QI competencies of physician, nursing, pharmacy, behavioral health, and social work residents after participating in a longitudinal QI curriculum. Lessons learned are shared to guide educators in developing QI curriculum for interprofessional learners.

Context

Cohorts of graduate students over 5 years participated in a QI curriculum that aligned with each professions’ core quality competencies. Residents engaged in didactics and experiential learning in primary care clinics.

Impact

All learners (N = 74) demonstrated improvement in QI knowledge measured by the QIKAT-R and applied their skills demonstrated by completion of a QI project presented at the Institute for Healthcare Improvement annual forums. Participation in QI curriculum resulted in knowledge and skill improvement.

Lessons learned

An experiential QI curriculum is a natural place to bring diverse post-graduate learners together to improve QI knowledge and skills. Successful QI curriculum goals are to (a) align projects with institutional and stakeholder goals, (b) include coaches to promote teamwork and project management, (c) narrow project scope, (d) develop an improvement mindset that failures are learning opportunities, and (e) address needs for data access.

Introduction

Quality improvement (QI) is a core competency for pre-licensure and graduate healthcare professional trainees in medicine [1,2] nursing, [3,4] psychology, [5] and pharmacy [6]. Developing and evaluating education models that addresses each profession’s QI competence and the relationship to clinical outcomes is a high priority in interprofessional education [7].

Although QI is a perfect opportunity for interprofessional collaboration, attaining QI competency in academic settings has predominately been accomplished in disciplinary silos. Merely half of published QI educational programs have an interprofessional focus. [8] This paper (1) describes an interprofessional postgraduate program with a longitudinal QI competency-based curriculum, (2) reports learners’ QI competency (knowledge and skill as demonstrated by QIKAT-R scores and presentation of a systems-based project at a national conference, respectively), and (3) provides lessons learned for educators to facilitate the development, delivery, and learner assessment of an interprofessional QI competency-based curriculum.

Problem

Nothing highlights the silo nature of health professional education more than the current approach to QI learning. Although QI competency is required by all disciplines, there are no standard cross-profession QI competencies; each discipline has their own QI competencies (Table 1). The benefits of having interprofessional learners collaborate around QI is well established, including in primary care settings. [7,9–11]

Table 1.

Alignment of the Transforming Outpatient Primary Care (TOPC) center of excellence quality improvement curriculum with each professions’ quality improvement competencies.

TOPC – Curriculum Theme	Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement (PBLI) and Systems Based Practice (SBP)	Nursing Quality and Safety Education for Nurses (QSEN)	American Society for Health Systems Pharmacists (ASHP)	American Psychological Association (APA)
Block 1 QI Relevance and Framing	PBLI 1: Monitors practice with a goal for improvement. SBP 2: Recognizes system error and advocates for system improvement. SBP 3: Identifies forces that impact the cost of healthcare, advocates for, and practices cost-effective care.	Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families. Give examples of the tension between professional autonomy and system functioning. Explain the importance of variation and measurement in assessing quality of care. Describe approaches for changing processes of care. Communicate with team members, adapting own style of communicating to needs of the team and situation. Demonstrate commitment to team goals. Solicit input from other team members to improve individual, as well as team, performance. Initiate actions to resolve conflict.	Competency Area R2: Advancing Practice and Improving Patient Care Goal R2.1: Demonstrate ability to evaluate and investigate practice, review data, and assimilate scientific evidence to improve patient care and/or the medication-use system. (Note: Each resident must participate in at least one quality improvement or research project.) Objective R2.1.1: (Analyzing) Identify changes needed to improve patient care and/or the medication-use systems.	Science Related to the Biopsychosocial Approach: Knowledge and understanding of evidence-based practice and its application to the practice of primary care psychology.• Demonstrates knowledge of research methods for quality improvement initiatives to enhance patient safety, patient satisfaction, and health outcomes.
Block 2 Tools Training and Application	PBLI 2: Learns and improves via performance audit.	Seek information about outcomes of care for populations served in care setting. Seek information about quality improvement projects in the care setting. Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit. Participate in a root cause analysis of a sentinel event. Use quality measures to understand performance. Use tools (such as control charts and run charts) that are helpful for understanding variation. Identify gaps between local and best practice.	Objective R2.1.2: (Creating) Develop a plan to improve the patient care and/or medication-use system. Objective R2.1.3: (Applying) Implement changes to improve patient care and/or the medication-use system. Criteria: • Follows established timeline and milestones. • Implements the project as specified in its design. • Collects data as required by project design. • Effectively presents plan to appropriate audience (e.g., accurately recommends or contributes to recommendation for operational change, formulary addition or deletion, implementation of medication guideline or restriction, or treatment protocol implementation). • Gains necessary commitment and approval for use of treatment guidelines/protocols. • Effectively communicates changes to the formulary, including those resulting from drug shortages. • Demonstrates appropriate assertiveness in presenting pharmacy concerns, solutions, and interests to external stakeholders. • Change is implemented fully.	Research and Evaluation: Awareness of and participation in developing and measuring QI standards in patient care.• Demonstrates the ability to participate in the formal evaluation and assessment of standards for being a National Committee for Quality Assurance (NCQA)-certified Patient Centered Medical Home (PCMH).• Works with clinical leadership and the team to design, implement, and evaluate quality improvement initiatives that impact how care is routinely delivered.• Applies quality improvement processes: identifying errors and hazards in care, implementing basic safety design principles and measures to assess quality of care, and designing and testing interventions to change processes and systems of care. Leadership and Administration: Leads quality improvement initiatives in the clinical and operational domains (e.g., increases use of Patient Health Questionnaire 2 (PHQ2) to screen for depression, or modifies the EHR to track high risk patients and optimize care for chronic disease management).
Block 3 Change Cycles	PBLI 2: Learns and improves via performance audit.	Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act). Practice aligning the aims, measures and changes involved in improving care. Use measures to evaluate the effect of change.	Objective R2.1.4: (Evaluating) Assess changes made to improve patient care or the medication-use system. Criteria: • Outcome of change to medication-use system is evaluated accurately and fully. • Includes operational, clinical, economic, and humanistic outcomes of patient care. • Uses Continuous Quality Improvement (CQI) principles to assess success of implementation of change. • Correctly identifies modifications or if additional changes are needed. • Accurately assesses the impact, including sustainability if applicable, of the project. • Accurately and appropriately develops plan to address opportunities for additional changes.	Leadership/Administration: Contributes to planning and implementing organizational change to optimize service delivery.• Understands systems redesign and approaches to productivity enhancement (e.g., Plan-Do-Study-Act [PDSA].• Examines space utilization and makes recommendations accordingly, with particular attention to impact upon interprofessional team functioning.• Notices an inefficient work process and collaborates with the team to identify and try a new strategy.
Block 4 System Application and Dissemination	PBLI 4: Learns and improves at the point of care.	Appreciate the importance of regularly reading relevant professional journals. Participate effectively in appropriate data collection and other research activities. Adhere to Institutional Review Board (IRB) guidelines. Read original research and evidence reports related to area of practice. Locate evidence reports related to clinical practice topics and guidelines. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice. Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events. Value the need for continuous improvement in clinical practice based on new knowledge.	Objective R2.1.5: (Creating) Effectively develop and present, orally and in writing, a final project report. Criteria: • Outcome of change to medication-use system is reported accurately to appropriate stakeholders(s) and policy making bodies according to department or organizational processes. • Report includes implications for changes to/improvement in pharmacy practice. • Report uses an accepted manuscript style suitable for publication in the professional literature. • Oral presentations to appropriate audiences within the department, organization, or to external audiences use effective communication and presentation skills and tools (e.g., handouts, slides) to convey points successfully.	Interdisciplinary Systems: Appreciates that patient care takes place in the larger ‘healthcare neighborhood’ within the community and social context• Shares literature.• Develops protocols.
Components Across All Four Quarters	SBP 1: Works effectively within an interprofessional team (e.g., peers, consultants, nursing, ancillary professionals and other support personnel). SBP 4: Transitions patients effectively within and across health delivery systems.	Appreciate importance of intra- and inter-professional collaboration.		Leadership and Administration: Consults with colleagues with expertise in industrial-organizational psychology to address systems issues.

The assessment of competency is essential in all professional standards. Miller’s Pyramid [12] frames how learners move from knowledge (‘knows’) to demonstration of the desired behavior (‘does’). Unfortunately, the instruments used to assess QI learning predominately assess knowledge. [13–16] Moving up Miller’s Pyramid to the ‘does’ level is the goal of any curriculum, with the aspirational goal of improving clinical care. However, multiple reviews over the last 20 years have shown that QI curriculum is rarely associated with improvement in skills attainment and ultimately clinical improvement. [8,17,18]

Factors related to effective QI teaching have been identified. Boonyasai and colleagues [17] in a systematic review found the use of established QI tools, coaching, access to clinical performance data, and implementing interventions via small tests of change were important. Wong [18] identified factors including learner buy-in, adequate teacher expertise, mixed teaching methods, adequate curricular time for project completion, and a supportive institutional culture. Starr and colleagues [8] reported that coaching teams and interprofessional teams had a greater impact on clinical outcomes. Goldman and colleagues [19] included the need to connect learner QI outcomes and organizational outcomes, providing time in the curriculum to complete the project, ability, capacity and role clarity of coaches, resources, and a clinical learning environment that supports QI learning.

Context

Quality improvement curriculum description and implementation

Our QI curriculum was embedded in an interprofessional residency program that included five disciplines. The Cleveland’s Transforming Outpatient Primary Care (TOPC) Center of Excellence (COE) residency program included Internal Medicine (MD) and Nurse Practitioner residents (NP) from various institutions, NP students, and School of Pharmacy, Psychology, and Social Work residents from the Cleveland VA Northeast Ohio Health System (VANEOHS). The Center of Excellence in Primary Care initiative was funded by the Veterans Affairs’ Office of Academic Affiliations to develop innovative interprofessional curriculum within the patient centered medical home model and is described elsewhere in detail. [20]

A block immersion model was used from 2014 to 2019 for trainee practice in the primary care clinics and the activities and goals of the VA TOPC COE longitudinal QI curriculum are listed in Table 2. For the MD residents, this entailed a 12-week block of outpatient experience alternating with a 12-week inpatient experience. The NP students worked in 6-month longitudinal blocks and came to clinic twice a week: 1 day for all day clinical workplace learning and 1 day for didactics and panel management. Pharmacy, psychology, and social work residents were in the program for 9 months.

All TOPC COE residents were integrated in the Patient Aligned Care Team (PACT) and had a designated RN care manager, Licensed Practice Nurse (LPN), and clerk assigned to them, in addition to one faculty preceptor. All residents were precepted by dedicated faculty members and NP faculty co-precepted with MD faculty. All learners attended didactic session half day per week together.

Table 2.

Activities and goals of the Cleveland VA’s Transforming Outpatient Primary Care Center of Excellence longitudinal quality improvement curriculum.

	Activity	Goals
Block 1 Relevance and Framing	Discussion of ‘To Err is Human’, ‘Crossing the Quality Chasm’, and Atul Gawande articles ‘The Checklist’, ‘The Cost Conundrum’ and ‘Hot Spotters.’ Chart review team assignment to prepare presentation detailing system-level factors that impacted quality of care for selected groups of patients. Complete QI 102: The Model for Improvement, a web-based module as part of the Institute for Healthcare Improvement Open School offerings. Team assignment to analyze low-acuity ED visits for the preceding 6 months by full panel (3600 patients and 800 visits) and prepare presentation using QI tools and Model for Improvement.	To understand historical development of quality improvement and how it translates to day-to-day practice and health care delivery. [4] To understand checklist approaches to care delivery and the interplay with performance measures and begin team approaches to systems-level QI. To understand basic QI tools and the Model for Improvement. To apply basic QI tools and the Model for Improvement and begin focusing on system-level application. Also continue developing teamwork approaches.
Block 2 Tools Training and Application	Attend Lean Six Sigma Yellow Belt Certification Training – a two-day training course in Lean and Six Sigma methodologies leading to a Yellow Belt Certification upon successful completion. Team assignment to analyze practice data (3600 patients) and identify evidence-based care gaps or system processes that can be targeted for improvement. Teams prepare full background/baseline presentation.	To understand different approaches to improvement currently being used in healthcare operations and to apply more advanced QI tools and methods. To synthesize QI tools and methods to a project of interest and draft a SMART Aim statement.
Block 3 Change Cycles	Teams complete at least one cycle of change using the Model for Improvement and PDSA framework.	To engage clinic operations and interprofessional stakeholders to make improvement to delivery of care.
Block 4 System Application and Dissemination	Draft abstract using the submission format for the Institute for Healthcare Improvement’s Scientific Symposium. Develop storyboard for submission to the Institute for Healthcare Improvement’s Annual Forum.	To apply SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines as a framework for dissemination. To report the process and knowledge arising from a cycle of change.
Components Across All Four Quarters	Mentoring and Coaching As trainees progress through the longitudinal curriculum, they are mentored by the QI faculty and assigned individual coaches from the VA Quality Scholars (VAQS) fellowship program. The coaches provide guidance during the baseline data collection, change cycles, and scholarship components. Panel Management Each block, trainees electronically query their panel patients for various criteria (A1c levels, ED visits, Admissions) and maintain a tracking spreadsheet of patients not meeting targets to chronicle approach, barriers, and outcomes. The spreadsheet is monitored by faculty, and trainees are given feedback. Modelling of and Recognition of Desired Behavior Numerous faculty and clinic staff engage in continuous quality improvement and the clinic setting displays information about various projects. In addition, the learners are exposed to continuous quality improvement thinking and implementation through efforts to engage them to continually improve the curriculum and clinic experiences.	To provide feedback and guidance on applying QI knowledge and skills and reinforcing systems-thinking and identifying appropriate projects and interpretation of those and helping to foster continuous QI perspectives. To integrate data systems to enhance delivery of quality care and develop understanding of and approaches to Practice-based Learning and Improvement. To reinforce the day-to-day applications (seeing it and having it become part of workflow) of QI and systems-level thinking. Broader recognition of the benefits for their panel of patients and the clinic context helps reinforce and motivate.

American Psychological Association (2015): Competencies for Psychology Practice in Primary Care. Retrieved from http://www.apa.org/ed/resources/competencies-practice.pdf; American Society of Health System Pharmacists (2021): Guidance Document for the ASHP Accreditation Standard for Postgraduate Year one (PGY1) Pharmacy Residency Programs. Retrieved from PGY1-Standard-Guidance-Document-March2019-COC-EDITS-2018–0302 (ashp.org); Quality and Safety Education for Nurses (2007): QSEN Competencies. Retrieved from QSEN Competencies; Accreditation Council for Graduate Medical Education (2021): Retrieved from program-director-guide – residency.pdf (acgme.org)

Quality improvement curriculum description

The QI curriculum contained didactic and project-based activities. All residents completed the Institute for Healthcare Improvement (IHI) QI Modules, read the book Fundamentals of Healthcare Improvement, [21] and completed Lean Six Sigma Yellow Belt training and certification. For simplicity, the QI portion of the curriculum occurred in four blocks even though the timing for the blocks varied by profession as explained in the program description. Specific curriculum activities and goals are provided in Table 2. Project topics were determined either by residents or by QI faculty and data were provided from hospital data sources or extracted from the electronic medical record by the program manager. All project teams consisted of three or four interprofessional learners and a QI coach. Coaches followed best practices, attended all team meetings, and provided guidance and clarification on the QI process. [22] Clinic stakeholders were updated on projects and stakeholders were added to project teams to provide project insight, clinic buy-in, and promote a positive learning environment.

The curriculum was evaluated and improved continually to ensure the delivery of high-quality QI education. Evaluation data were obtained from the residents, the faculty, and the coaches, evaluation of the curriculum and changes made were shared with other QI educators in the VA system. This ‘meta’ approach to using QI methods in the administration of the program not only demonstrated to our learners the benefits of using QI methods to continually improve the process, but also ensured that we met curricular objectives.

Intervention

Setting

The TOPC COE was one of the seven VA’s Center of Excellence in Primary Care Education demonstration sites funded by the Office of Academic Affiliations [23]. The purpose of these interprofessional sites was to implement innovative curriculum for future health care professionals while working in a patient-centered medical home model. The continual funding provided staff, nurse practitioner stipends, and resources to develop, implement, evaluate, and continually improve the program. The seven VA Centers of Excellence in primary care education were guided by four common competency domains (performance improvement, shared decision-making, sustained relationships, and interprofessional collaboration). The TOPC COE residents provided care in our local clinic that consists of 13 primary care teams.

Sample

Residents (N = 74) went through an application process that included an interview and selection process. The description of the residents is reported in Table 3.

Table 3.

Number of learners by profession and year.

Profession	MD	NP	Pharmacist	Psychology	Social Work	Total
2014	11	5	0	0	0	17
2015	9	6	0	1	1	18
2016	10	2	4	0	1	21
2017	11	4	2	1	0	20
2018	1	4	1	0	0	8
Total	42	21	7	2	2	74

Measurement

Quality improvement knowledge

The QIKAT-R was used to evaluate the learner QI knowledge [14] in a pre- and post-evaluation. Three scenarios were utilized for the pre-test and three different scenarios were used as the post-test. The scenarios were graded using the provided rubric by two evaluators to ensure high interrater reliability using a set of rules and then 10% of the sample was graded and compared by both graders with strong agreement. The QIKAT-R has a score range of 0–9 for each case for a total possible score of 0–27 with higher scores representing higher QI knowledge application.

Completion of systems-based projects

Demonstration of QI skills was measured by the completion of a QI project that included the following milestones: Baseline assessment, literature review, systems assessment, specific aim, measurement (process, outcome, balancing), and at least one plan-do-study-act cycle that included data. Completion also included the percentage of projects presented at local or national conferences. Project presentation and publications were collected by program managers and recorded in learner profiles.

Data collection

Learners completed the pre-test upon entering the TOPC COE program and the post-test upon program completion. Learners were provided time during didactics to complete evaluations. Data were collected between 2014 and 2019. IRB exempt status was obtained from the Cleveland VA Medical Center for data collected and no informed consents were required.

Statistical analyses

The QIKAT-R pre- and post-tests were analyzed using a paired t-test to determine QI knowledge improvement. A one-way ANOVA was conducted to compare the differences between pre- and post- QIKAT-R score changes by profession. Description of projects and visibility of learners’ QI work were also recorded. Analyses were conducted using Minitab Statistical Software v20.1.

Impact

There was a significant overall increase in QIKAT-R scores between the pre- and post-test for all residents (Table 4). When stratified by profession only, MD and NP had significant increases in QIKAT-R scores. However, differences in improvement between professions was not significant, analyzed using a one-way ANOVA (Table 5). Data collection for 2018 MD learners was incomplete due to a leadership transition. QI-KATr post-data was not collected in an effort to reduce evaluation burden on residents. QI-KATr evaluations were reinstated as part of a comprehensive curriculum evaluation review in 2019.

Table 4.

QIKAT-R paired t-test between pre- and post-curriculum by profession.

Groups	Pre	Post	t-value	Sig (two tailed)
Physician	14.3 (5.5)	17.7 (5.4)	3.2	.003**
Nurse Practitioner	15.2 (6.4)	18.5 (4.8)	2.7	.015*
Pharmacist/Psychology/Social Work	13.7 (4.4)	14.4 (4.7)	.46	.650
Total	14.5 (5.6)	17.4 (5.2)	4.0	<.001***

*p < .05.**p < .01.***p < .001

Table 5.

One-way ANOVA: difference between QIKAT-R scores pre- and post-curriculum by profession.

Measure	MD		NP		Pharmacy/Psychology /Social work		F (2, 71)	η2
	M	SD	M	SD	M	SD
QIKAT-R (Pre-post difference)	3.38	7.0	3.29	5.7	0.64	4.6	0.86	0.02

All interprofessional QI project teams successfully completed a QI project (Table 6) meeting the criteria. All project teams (100%, N = 24) presented a poster at the annual IHI forum and 10% were accepted to the IHI Scientific Symposium, a component of the annual conference that included a presentation.

Table 6.

Select interprofessional projects completed by center of excellence in primary care learners.

Year Project Completed	QI Project Title
2016	Osteoporosis in Men
2016	Underutilization of Cardiac Rehabilitation
2016	A Resident-Led QI Initiative to Reduce Serum Folate Testing in Primary Care Clinic
2016	Workflow-based Interventions to Improve Vaccination of Hepatitis C Patients in a VA Primary Care Resident Clinic
2016	Increasing Appropriate Statin Use in the Resident Primary Care Clinic
2017	Promoting Appropriate Management of Chronic GERD in High-risk Patients in the COEPCE Primary Care Clinics
2017	Improving Care in Patients with Dual Primary care Providers: Vaccination Compliance Project
2017	Lung Cancer Screening
2017	After Visit Summary in Primary Care Clinic
2017	Anticoagulation
2017	Improving Smoking Cessation Counseling in Primary Care
2018	After Visit Summary in Primary Care Clinic
2018	Firearm Safety in Preventing Suicides: Quality Improvement Initiative
2018	Hepatitis B Vaccination in Patients with Diabetes
2018	Improve Slot Utilization in Primary Care
2018	Undertreatment of Osteoporosis
2018	Improving Suicide Risk Assessment in Primary Care
2018	Goals of Care Conversations
2019	Blood Pressure Measurement
2019	Standardizing Blood Pressure Measurement in the VA Primary Care Clinic to Align with Evidence-based Guidelines
2019	Kidney Function in Hypertensive Patients
2019	Integrating Evidence-based Guidelines into home Blood Pressure Measure for Veterans in Wade Park Primary Care Clinic
2019	Urine Collection Adherence Improvements
2019	Timely Follow-up for Hypertension
2019	Turning up the Volume on the Silent Killer: Hypertension Treatment
Year Project Completed	QI Project Title	Project SMART Aim
2016	Underutilization of Cardiac Rehabilitation	Our aim is to increase the primary care provider slot utilization rate by 5% for the Louis Stokes Cleveland VA Wade Park Primary Care clinic from August 2016 to July 2017.
2018	Firearm Safety in Preventing Suicides: Quality Improvement Initiative	To increase the number of gun locks distributed in Wade Park Primary Care Clinic by 300% from June through July 2018.
2018	Hepatitis B Vaccination in Patients with Diabetes	100% of nursing staff will be educated on screening and will be provide vaccine checklist/reminder card by May 8. Diabetes Educator will be educated on Hepatitis B information starting May 1, 2018
2018	Improving Suicide Risk Assessment in Primary Care	All LPNs and PCPs in the Primary Care Clinic will work together to bring the number of missed documented in-visit follow-up/suicide risk evaluation after positive PHQ-2 screen down to zero by June 22, 2018.
2018	Goals of Care Conversations	To increase GOC documentation by 40% (in the electronic medical record CPRS) of high risk patients with CAN scores ≥ 95 in Cleveland VA residents’ primary care clinic from January to April 2018

Lessons learned

The QI curriculum had an impact on all interprofessional learners as they improved in knowledge application and skill. The psychology, social work, and pharmacy learner residents received a lower dose of curriculum exposure (less time in the curriculum may explain the non-significant improvement for these learners). In addition, many of the topics chosen did not apply to the work of psychologists, social workers, or pharmacists possibly impacting buy-in, an essential component for educational success [18,19].

Narrative field notes over the 6 years indicated that residents would put the QI project as secondary work and prioritize clinical work at the expense of achievement of QI competence. We also noted that project management skills were lacking, such as running efficient meetings, meeting deadlines, communication, and prioritizing tasks. Learners were often task-oriented rather than immersing themselves in the QI journey and learning as a team. Projects were delayed when the project did not align well with the clinic’s priority or when stakeholder buy-in was lacking. Learners tended to want to jump to a solution before understanding the context, baseline data, barriers and facilitators, and the process of care.

The implementation of our experiential QI curriculum was supported by coaches as recommended in the literature [8,18,19]. Coaches provided additional QI expertise to the team, facilitated group dynamics, and assisted with project management. Coaches frequently reported problems with role clarity which necessitated the creation of a coaching handbook and establishing ground rules with the learner teams on the role of the coach. Accountability to meeting deadlines was an issue and authority structures were often blurred. Reports in the literature suggest having clinical faculty and staff become co-learners working together to learn to improve patient outcomes [24]. Ensuring faculty competence is an area of future need.

One key factor related to success of our learner projects was aligning topics with institutional goals. Our improvement to our curriculum included partnering with primary care clinic leaders to identify a menu of options that had institutional interest and came with feasible access to data.

A challenge that occurred with every learner team was the need to narrow the scope of the project. Learners were keenly aware of the system problems in organizations and were enthusiastic to solve big problems. The consequence of attempting to solve big problems is usually failure and frustration. The solution we put into place was to spend time assisting learners with scoping the project consistent with a SMART (specific, measurable, achievable, reasonable, and time-bound) aim.

Although not reported in the literature, we experienced learner frustration with addressing the complexity of the healthcare system and experiencing many failures in their attempt to find and test solutions. Adding content in curriculum on the necessary experience of failure is recommended. For instance, adding John Maxwell’s book Failing Forward [25] to the reading list is one approach to address this need.

A key factor to learners achieving QI competence is access to data. Our team expert in data analytics was able to provide data, solutions to displaying data, and dashboards for our learners to monitor data. This component was key in learners’ understanding of the importance of real-time data monitoring, observing patterns with run charts and control charts, and the ability to assess changes in processes and outcomes in response to interventions.

The leaders of the program used a ‘Meta’ approach in which QI methods were used by leaders to assess the effectiveness of the curriculum and implemented changes as is recommended in the Standards for reporting Quality Improvement Reporting Excellence- SQUIRE.edu Guidelines [26]. These changes addressed issues at the student, curriculum, clinic, and organizational levels. Using this ‘Meta’ QI approach was facilitated by the Model for Improvement Plan-Do-Study-Act (PDSA) to ensure the delivery of high-quality education. A future publication on our cycles of change highlighting our use of the PDSA method and describing contextual factors and the longitudinal impact as suggested by the SQUIRE.edu guidelines is forthcoming.

Conclusion

We established that participation in QI curriculum in an interprofessional setting increases knowledge application and skill attainment across professions. The consistency of our findings over 5 years demonstrates that our intervention yielded sustainable results. When provided the right infrastructure and curriculum, interprofessional learners can collaborate around QI learning and improve their knowledge and skills while engaging in meaningful systems improvement.

Funding Statement

This curriculum was part of a larger project made possible by funding from the VA Office of Academic Affiliations’ Centers of Excellence in Primary Care Education (COEPCE) Initiative.

Disclosure statement

No potential conflict of interest was reported by the authors.