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September 5, 2007

Effectiveness of Teaching Quality Improvement to Clinicians: A Systematic Review

Author Affiliations

Author Affiliations: Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Boonyasai, Feldman, and Bass); Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut (Dr Windish); Department of Internal Medicine, George Washington University School of Medicine, Washington, DC (Dr Chakraborti); and Palo Alto Medical Foundation Research Institute, Palo Alto, California (Dr Rubin).

JAMA. 2007;298(9):1023-1037. doi:10.1001/jama.298.9.1023

Context Accreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI.

Objectives To perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula.

Data Sources The electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies.

Study Selection Two independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design.

Data Extraction Information about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed.

Results Of 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions.

Conclusions Most published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.

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