Mandatory classes that aim to improve the quality of medical care seem to successfully teach doctors new concepts but don't necessarily improve patient outcomes, suggests a thorough review of articles that examine quality improvement (QI) curricula.
"Identifying and fixing problems is something that doctors have learned to do when faced with diseases, but those problem-solving skills don't necessarily translate into identifying or fixing health care systems in a hospital even after taking special classes," says Romsai Boonyasai, an internist at The Johns Hopkins Hospital and co-author of the review in the Sept. 5 issue of the Journal of the American Medical Association.
QI programs are designed to teach the basics of spotting and addressing problems inherent in complex medical systems, such as lack of standardized processes to reduce medical errors or inadequate communication among multiple layers of caregivers to patients whose care is complicated and whose hospital stays are compressed.
For example, even though patients may receive correct diagnoses when they visit a hospital's emergency room, a lack of organization in the hospital's medical records department or a dearth of medical supplies due to mishandled orders could affect a patient's treatment.
As of 2003, training programs for medical residents are required to include QI curricula for medical schools to maintain accreditation. QI classes are also part of training programs for medical students and continuing education programs for working doctors. However, Boonyasai explains, whether QI classes make a difference in physician knowledge or patient outcomes is unknown.
To evaluate the effectiveness of various QI curricula, Boonyasai and his colleagues systematically searched databases of medical articles for those mentioning QI in health care. They narrowed their focus to 39 articles that described teaching students and clinicians QI methods.
When Boonyasai's team evaluated these articles, they found that most of them suggested an improvement in students' and clinicians' knowledge of QI concepts-for example, how well they scored on QI concept tests. However, those articles that evaluated the effect of these training programs on patient outcomes found a mixed bag, with some showing improvement in patient outcomes after QI and some showing no effect at all, the authors say.
The good news is that the researchers found several common characteristics in programs that led to more positive patient outcomes: providing students and clinicians with ongoing access to their own performance; teaching them to address problems with small steps of trial and error; and providing them with active guidance from QI experts throughout the problem-solving process.
Boonyasai notes that the field of QI as it applies to medicine is still in an early state. Yet, he adds, identifying those characteristics that improve patient outcomes can help medical training programs identify more effective QI curricula.
The authors of the JAMA article are members of the Quality Improvement Curriculum Committee appointed by the Society of General Internal Medicine, which provided financial support for this study. Other financial support was provided by the National Heart, Lung and Blood Institute; the National Research Service Award-Health Resources and Services Administration; and the Olser Center for Clinical Excellence at The Johns Hopkins University.