Innovation in education for quality of care: a scoping review

doi:10.21203/rs.3.rs-2985309/v1

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Innovation in education for quality of care: a scoping review

https://doi.org/10.21203/rs.3.rs-2985309/v1

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Background:

Ensuring quality-of-care and promoting patient safety is a core competence that healthcare professionals are called to develop. Healthcare contexts are continuously changing advancing with social and technical innovations. The aim of this review is to identify innovative approaches in educational activities on quality of care, quality improvement and education about innovation for health professionals. Seeking evidence about educational strategies that are innovative or target innovation while addressing quality-of-care and quality improvement.

Methods:

A scoping review has been conducted searching for papers published between January 2000 and September 2022. Data bases used were PubMed, APA PsycInfo, SCOPUS, Web of Science and CINAHL using the terms “quality improvement”, “quality of care”, “education”, “teaching”, “innovation” and “healthcare”. Papers included characterized the state of quality training and described interventions on quality education in undergraduate and postgraduate training of healthcare professionals.

Results:

From the 2059 papers found, 11 were included in the study. Authors were mainly from USA and UK; most studies were about undergraduate training. Most interventions described the inclusion of Quality Improvement in the curricula. Papers were analyzed using a proposed innovation lens and classified accordingly. Seven papers were considered as Routine Innovations, one as (potentially) Disruptive, two as Radical and none as Architectural.

Conclusions:

There is a paucity of evidence on innovative educational approaches or education about innovation for quality-of-care, with few studies targeting quality improvement only. Most of the interventions were considered routine innovation. There is an urgent need to include quality-of-care training in undergraduate curricula and doing so in innovative ways; a model to advance this is presented.

Quality Improvement

Quality of care

education

medicine

innovation

healthcare

Education of healthcare workforce relates to their performance in protecting and promoting health.(1) One dimension of performance is the Quality of Care (QoC) in each context. In the present, healthcare workforce deals with deals with two main pressures, one being the shortage of health professionals and their changing in expectations, mainly related with the expansion of non-communicable diseases and the impact of COVID19 pandemic.(2, 3) Context of care is changing to include digital innovation, such as drugs, devices, and digital therapeutics, and social innovation with new workflows, perspectives and interactions between individuals and healthcare, this creates an increasing complexity with high pressure to innovation adoption by professionals.(1, 4) In the work setting, research showed that valuing innovation is associated with professional satisfaction and commitment to work.(5)

The World Health Organization describes quality as a construct that includes several dimensions: effectiveness, efficiency, accessibility, acceptability/patient centeredness, equitability, and safety. (6) Quality improvement in healthcare was defined by Batalden and Davidoff as “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”.(7) The concept of quality of care has been evolving over the years. In 2018, WHO defined quality of care as “the degree to which health services for individuals and populations are effective, safe and people-centred”.(8) Given that the concept of quality of care is an evolving one in a way alongside changes brought by innovation, healthcare workforce needs to be able to promote quality of care using innovation and be co-creators of innovations for health and care.

Innovation has been defined by Joseph Schumpeter as ‘a historic and irreversible change in the method of production of things’. (9) Coming from the business world, Henderson and Clark (10) created a model with four types of innovation. In 1995, Clayton Christensen introduced the term ‘disruptive innovation’. (11) Since then the concept has been reshaped and increasingly used within healthcare, despite the lack of a healthcare contextualized definition. (12)

Pisano has proposed a matrix of innovation types according to innovation theories, that combines different levels of change in business model with different levels of change in technologies and methodologies, covering four types: routine, disruptive, radical, and architectural. (13) Departing from this model a theoretical framework to look at Quality-of-Care, including its educational aspects, has been used by the WHO Athens Quality-of-Care office. Table 1 summarized the key conceptual lens adjusted and described to help look at innovation in the way of educating for Quality-of-Care, including Quality Improvement.

Table 1

Innovative ways of educating for Quality-of-Care/Quality Improvement
New/significant changes to the Business model	(potentially) Disruptive: a new pedagogical approach or experience, even including a new “educational business model” but not necessarily using new technology	Architectural: technological/methodological base is new and there is disruption (or the potential for disruption) in the educational businesses model
No changes to the Business model	Routine/Incremental: pedagogical approaches that slowly build on existing technological capacities and improve process incrementally	Radical: There is a visible effort to create new technology or methodology to educate differently
	Uses establish technology and known (social) methodology	Explores new Technology or new (social) methodology

The aim of this work was not to focus on reviewing routine innovation in health professionals’ education (PBL, flipped-classroom or others) except when that was radical or (potentially) disruptive, neither to focus on reviewing traditional methods on education on QoC and QI.

The recognition of the importance of workforce knowledge and skills on quality as lead to it becoming a core competency for health professionals.(14, 15) The Accreditation Council for Graduate medical Education (ACGME) in the United States considered quality improvement as one of the main competences of physicians.(16) Initiatives to include quality improvement teaching for nurses was also made, including the creation of frameworks.(17) The American Association of Colleges of Pharmacy (AACP) and The Center for the Advancement of Pharmaceutical Education (CAPE) have included in their recommendations the inclusion of quality improvement in the curriculum.(18) Quality improvement was also included as a main competence in the framework of nursing competences of the American Association of Colleges of Nursing (AACN).(19) In some countries, curricular change to include quality improvement in undergraduate and postgraduate training in several professional groups has started to be reported.(20, 21) The European University Association defined quality culture as “an organizational culture that intends to enhance quality permanently and is characterized by two distinct elements: on the one hand, a cultural/psychological element of shared values, beliefs, expectations, and commitment towards quality and on the other hand, a structural/managerial element with defined processes that enhance quality and aim at coordinating individual efforts”.(22)

Medical education establishment has a recognized renitence to change.(23) Several barriers have been identified to the integration of innovation in medical education, including lack of skills and resources. (24–26) Despite some recognizable efforts to include quality of care and quality improvement in education and training of health professionals. There is a lack of innovative approaches in such education and a lack of integration of radical and potentially disruptive innovation for quality of care in that educational process. The aim of this review is to identify educational activities on quality of care, quality improvement and innovation for health professionals. Seeking evidence about educational strategies that are innovative or target innovation while addressing quality of care and quality improvement.

Search strategy

Search strategy was defined by the research team which included 3 members. Initial research on PubMed and Scopus then followed by an analysis of the text words contained in the title and abstract of retrieved papers, and of the index terms used to describe the articles. For the main research the following data bases have been used: PubMed, APA PsycInfo, SCOPUS, Web of Science and CINAHL.

Search terms included “quality improvement”, “quality of care”, “education”, “teaching”, “innovation” and “healthcare” and Boolean operators (AND, OR) were used. In the initial search, terms “disruptive innovation” and “radical innovation” have been included, however, a very short number of studies retrieved so those terms were abandoned in the final search. The search took place for one month (October 2022) by two researchers independently. Initially titles were screened to discard those unrelated to the research question, ensuring a record of the articles that were discarded was kept alongside the reason thereof. Duplicates of studies were removed, and the remaining abstracts were analysed. Full text articles were then reviewed independently against inclusion and exclusion criteria. Two reviewers reviewed the title and abstracts independently, recording their decisions using Covidence.

Inclusion and exclusion criteria

Papers published in peer-reviewed journals, in English, between 1 January 2000 to 30th September 2022 were screened containing the research terms. Were include papers that characterized the state of quality training and papers that described interventions on quality education in undergraduate and postgraduate training, all the papers included the word “innovation” or described an innovative educational tool for quality improvement. Health professional groups included were doctors, nurses/midwifes and pharmacists. Qualitative, quantitative, and mixed method studies were also included. Papers that include other health professions and studies that were not written in English were not included.

Data extraction

Data extraction from the selected papers was extracted independently by two researchers and discussed to a consensus. Scoping reviews have been used to map the current knowledge in a field, to clarify definitions and to identity key concepts. (27) Findings were reported following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. (28)

The first screen included 1978 titles and abstracts and 71 were promoted to full-text review. Fourteen papers met eligibility criteria but in three papers full text was not available, after contacting authors by email. Eleven papers were included in the review (see Fig. 1.)

Studies included have been published between 2012 and 2021, from United Kingdom and North America. In most studies participants were medical students (n = 4) and many interventions were in undergraduate training (n = 6). Most studies described educational approaches related with the promotion of quality of care and quality improvement (n = 8) and one study was directed to faculty. One study was a literature review, and one study was the validation of a quality improvement tool. Table 2 presents a summary of key information about each paper as well as how each were classified as presenting educational approaches /interventions rated as routine, (potentially) disruptive, radical, or architecturally innovative following our proposed framework.

Table 2

Educational strategies for quality of care and quality improvement
Author, Year	Professional group	No. Participants	Graduation	Type of activity/Intervention	Main findings	Conclusions	Innovation type
Brown, 2019 (29)	Medical students	60	Undergraduate	Development and application of a QI scale: Beliefs, Attitudes, Skills, and Confidence in Quality Improvement Scale (BASiC-QI) with three subscales.	Psychometric evaluation of the scale revels positive correlation with previous gold standard (QIKAT-R) indicating validity.	Self-assessment tool that can be used to assess the impact of QI curricula.	Routine
Brown, 2018(30)	Medical students	123	Undergraduate	Program PRIME educational extracurricular activity to facilitate acquisition of basic QI knowledge in pre-clerkship students.	Participation in the program increases knowledge and comfort with QI concepts.	Early exposure to QI content may have an impact in engaging in clinical QI.	Routine
Hulett, 2020(31)	Nursing master students	No	Postgraduate	IHI Basic Quality and Safety Certification (13 courses) included to basic certification entering the master.	Qualitative data indicate that students appreciated the opportunity to enhance resumes, learn foundational knowledge, and earn clinical time for some modules.	IHI course can be an strengthen tool in the programmatic curricula.	Routine
Neeman, 2012(32)	faculty, residents, fellows, medical students, non-physician clinicians and staff	136	Undergraduate and postgraduate	Quality and Safety Challenge (QSIC), a strategic planning retreat to develop strategies that foster QI/OS.	QSIC fostered a culture for innovation in QI/PS among trainees and across the department.	The program promoted collaboration between trainees, faculty, clinicians, and educators.	Routine
Shaikh, 2017 (33)	Physicians	~ 500	Postgraduate	Quiz-based reinforcement system for residents and faculty physicians. Simultaneously or asynchronously.	Knowledge acquisitions improved after the quiz in QI. Learners reported that the system was an effective teaching modality preferred to traditional lectures.	Online quiz was feasible and acceptable, and resulted in improved knowledge. Can be used as a supplement to formal curriculum.	Radical
Levitt, 2012(34)	Medical students	8	Undergraduate	QI curriculum in a year-long longitudinal integrated clerkship for third year in which students created a self-direct project by addressing a QI gap and propose an intervention.	Measurements of QI knowledge did not show improvement. Attitudes and confidence on QI skills improved. Reported lack of mentorship.	Self-direct learning may be insufficient in this domain.	Routine
Reese, 2021(35)	Micellaneous	88	Undergraduate and postgraduate	Massive Open Online Course (MOOC), open access, five-week duration.	Significant increase in knowledge, attitude, self-efficacy about the importance of interdisciplinary teamwork in learning QI processes. Learners were very satisfied.	Virtual, easily accessible, and free education. Useful when faculty do not have expertise.	Radical
Runnacles, 2013 (36)	Physicians	39	Postgraduate	Survey to create a tailored QI experiential learning program in medical postgraduate training.	Preprogramme and post program evaluation has demonstrated an improvement in knowledge, skills and behavior, and participants perceived the program to be a valuable learning experience.	This type of program can accelerate change of service delivery.	Routine
Shah, 2020 (37)	Medical students	185	Undergraduate	Student led workshops to improve QI based in the IHI Chapter. Voluntary participation.	Students understood the utility of learning QI/PS skills at such an early stage in their medical training and were receptive to teaching from peers in a hands-on interactive setting	Can be used to rapidly develop a curriculum and the self-direct peer-to-peer teaching	Routine
vanSchaik, 2019 (38)	Faculty	35	NA	Team based approach for faculty development on QI.	One year after the program participants reported to have expanded their QI teaching and mentoring.	Suggests that this strategy is an effective and efficient way to rapidly expand the number of faculty with expertise in this area.	(potentially)Disruptive

Educational strategies

Several studies described the need to include more on quality of care and quality improvement in the curriculum of health professionals (30, 32–34, 36). A fan of educational activities are described as innovative, from the inclusion of a predefined course as Institute for Healthcare Improvement (31) to peer led activities (37).

Early experiential learning for medical students on quality improvement has been described in one study. (30) In this work, a twelve-week extracurricular program was offered to first year medical students, applied to their educational experiences in pre-clerkship to identify a “quality gap” in the context of their education. A subsequent analysis of the results in an explanatory mixed-methods study showed that this pre-clerkship education led to knowledge acquisition and that can potentially be transferred to clinical context. Additionally, they identified program components that can promote the creation of a positive environment to learning QI such as continuous support, team-based learning, and access to educational tools on QI. The same authors building on previous results, reported in another study the creation and evaluation of a new psychometric instrument to measure quality improvement which has been pre-clerkship medical students but aimed to be suitable to any stage of training and any context. This tool includes three domains (attitudes and beliefs; knowledge of QI and QI skills) and has been compared with gold standard with positive correlation. Its use has been described as potentially beneficial as a baseline understanding of knowledge and skills that can be used to inform curriculum planning and training.(29)

Hulett and colleagues(31) reported curricular integration of the Institute for Healthcare Improvement modules Basic Quality and Safety Certification in master nursing curriculum. Results from qualitative reported students’ satisfaction with the modules included.

Medical students have been involved in addressing curriculum gaps on QI, a pilot intervention developed by student leaders included hands-on workshops and curriculum development on case-based experiential learning. Data showed that after the workshops students that participate were more prone to engage with QI projects and facilitators were positively evaluated. (39)

One paper reported an institutional challenge for innovation in quality that encouraged the formation of interdisciplinary teams that included medical students, faculty, residents, and staff. The aim was to develop an improvement project across different campuses of the same medical school, projects were presented in a symposium and submitted to awards attribution. Authors described that this project promoted institutional culture on innovation. (32)

One paper described the use asynchronous and distance education to overcome barriers for in person attendance of QI course. An online course has been used for residents and faculty, through an online quiz-based reinforcement system with multiple questions sent twice a week and immediate feedback. Results showed that knowledge retention increased over the exposure to the reinforcement system, additionally learners preferred this approach to education to traditional lectures. (33)

The use of a Massive Online Open Course (MOOC) on quality improvement directed to healthcare providers, students and faculty has been described.(35) It included 10 modules over a period of five weeks of an open and free course distributed online. A pre and post test showed increasing of perceived knowledge, attitude about the importance of interdisciplinary teamwork in learning quality improvement processes. The potential of these courses to contribute to improving healthcare capacity worldwide was highlighted. However, low level of completion rate was reported (1.5%) but no data on the reasons for non-completion has been collected.

Another strategy described was the use of longitudinal integrated clerkships as opportunities to have a deeper knowledge on the clinical context allowing the identification of opportunities for quality improvement. (34)

On postgraduate training, a program for developing doctors in postgraduate training on quality improvement and patient safety as also been described with improvement in knowledge, skills, and attitudes of the trainees. This program was organized in three levels of proficiency from introductory to advanced. Program evaluation showed an improvement in knowledge, skills, and attitudes, it was also described as a valuable learning experience for the participants, with referred impact in clinical practice and patient care.(36)

Faculty training was specifically addressed in one of the papers, which included a faculty development team-based project for quality improvement aiming to expand faculty skills in this area. Faculty members that participated were mostly from medical school but also from nursing and pharmacy, they were from diverse backgrounds and across the institution. Authors noted an increasing number of projects on QI generally, identifying a possible institutional effect of the program that goes over its direct participants. (38)

Professional groups

Different professional groups were studied, with a predominance of studies including medical students(29, 30, 34, 37). Studies involving physicians (33, 36), nursing students and nurses were also included (31). Two studies include a miscellaneous of professionals that is not totally detailed due to their structure. (32, 35) One study was focused on faculty training for promoting quality improvement (38).

Innovative ways of education in quality of care/quality improvement

A literature review conducted in 2012 (40) describing the state of quality improvement in medical education organized quality improvement activities in three groups: formal curricula, educational activities, and engagement in real-life QI. Curricula design included teaching alone, didactic and experiential learning and web-based curricula. Most learners had a positive evaluation of their QI curriculum, however students in very early years seemed to be less interested in engaging on this topic. Assessment was more frequently done through tests of knowledge. Studies methodologies were described as frequently with poor rigor and there was no comparation between different teaching methods. Authors identified three main challenges to amplify QI education, namely, the need to build faculty capacity, accreditation standards and end-of-training certification. Only occasionally authors refer the reasons why their approach is innovative providing more solid evidence for the proposed labelling. Nonetheless, seven papers were considered as Routine Innovations, one as (potentially) disruptive, two as radical and none as Architectural.

Although being different concepts, QoC and QI were both indifferently used in the papers analyzed. However, the use of QI is much more frequent in the literature which may be off a less cope, given that QoC includes the concept of effectiveness, safety and people-centeredness.(41) QoC and QI are occasionally addressed in undergraduate and postgraduate training of health professionals. Still, most studies were focused in undergraduate and in early stages of training. (29)

Overall, in the papers reviewed the concept of innovation is scarcely mentioned. Considering that most studies describe interventions that were extracurricular and voluntary, some papers referred as routine innovation could be interventions with potentially disruptive if expanded to a larger set of students/faculty. It would imply a significant change of educational processes or even the education business model as such. For instance, the intervention described by Shah(39) of students led workshops on QI involved at least 185 medical students but could have an important impact if was included in the formal medical curricula of the medical school. Likewise, paper from Runnacles (36), also talks about potential educational disruption in the sense that integrating formal QI education in medical postgraduate would potentially change the attitude and clinical work performance. vanShaik(38) paper was labeled as radical innovation example because it would imply a significant change of technological base or methodologies, namely because it was targeted to develop faculty skills and this change led one year after the program to reports on expansion of teaching scope in QI.

Online tools have also been used in two papers. One paper addresses the use of innovations such as mobile devices to asynchronously and on-the-go learning. (33) However, the focus should be in methodological innovation rather than technological innovation.

Context is also very important to understand and classify innovation, for example the MOOC described (35) was implemented in 2014, before the technological hype of the pandemic and post-pandemic boost in online learning. In this way, it was classified has a radical innovation despite MOOCs being largely spread in the present and not representing a technological innovation. In adapting the innovation framework, methodologies cannot be split from the geographical, institutional and timeframe context where they are implemented.

Besides trainees and students, faculty and clinical supervisors need to develop suitable competences to promote learning in quality of care. Lack of faculty skills on QI/QoC are highlighted (32, 38).

Context of care is changing to include digital innovation (drugs, devices, digital therapeutics) with an increasing complexity and high pressure for innovation adoption, while workforce stress, lack of professionals and changing patients’ expectations related with non-communicable diseases and a post pandemic era ask for more transformation in healthcare, particularly of professionals’ roles.

Based on this review we hypothesize that healthcare workforce will be prepared for better performance if innovative approaches are used and pre and post are adjusted particularly covering Quality-of-Care at large rather than narrowly understood as Quality Improvement.

A Model for thinking innovation in education for QoC and for education about innovation in QoC is needed. This can start by brining together four important actors (not necessarily well-known to the health and care establishment) : Quality-of-Care and Patient Safety agencies, often from Ministries of Health; Medical/Health professionals School Deans and boards of deans, often operating under the influence of Ministry of Education; and, Innovation Agencies, often fund under the Ministries of Innovation, Modernization, Digitalization or Internal Administration, as well as Academics with experience in innovation and education about innovation, often to be found in Business schools. These four sources of knowledge will need to work around three fundamental questions:

How can innovation be taught to health professionals early in their careers with such packed curricula, via horizontal and dedicated educational activities;

What is the role of innovative educational approached to modernize not just content learning but the way future healthcare workforce things innovatively about the challenges of patient safety and quality-of-care.

What is there room, and what concrete actions can be stimulated in schools, so that methodological as well as technological innovation significantly disrupts the education ecosystem making it more capable of educating for quality an at the same time doing that in more innovative ways.

There is a paucity of evidence on innovative educational approaches or education about innovation for quality-of-care, with few studies targeting quality improvement only.

Most of the interventions found were considered routine innovations. There is an urgent need to include quality-of-care training in undergraduate curricula and doing so in innovative ways.

A model to advance in this area is briefly introduced and needs to be experimented with in countries to see of its applicability and if it will boost much needed innovation in health professionals’ education about quality-of-care.

Disclaimer WHO

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. JB, NA and TZ are staff members of the WHO and HM is a WHO consultant.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Data was collected and gathered using Covidence (https://www.covidence.org/).

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable.

Authors' contributions

All authors JS, TZ, NAM, JB and HM contributed equally to the paper write, data collection was gathered by JS and HM.

Acknowledgements

Not applicable.

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No competing interests reported.

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