Customised knowledge-sharing platform to foster resident quality improvement activities, tracking and scholarship

Introduction

Although the Accreditation Council for Graduate Medical Education (ACGME) requires that residency programmes educate, engage and track residents in quality improvement (QI) work,1 many factors hinder resident engagement in QI. Lack of time, training, impact from QI work and understanding of the ‘vision’ of QI are barriers to success.2 Standard QI curricula focus on building QI tools and executing a project.3 4 Given that barriers to QI surpass those addressed in standard curricula, such curricula alone may be insufficient to instill the values of a lifelong improvement mindset, which is part of the stated goal behind the ACGME’s QI requirement.

To address gaps in QI training, novel curricula have educated residents in QI methods, increasing knowledge of, confidence about and participation in QI work.5–10 Other barriers, however, are not addressed solely by education, necessitating a more comprehensive approach. Programmes highlighting successful resident QI work, such as end-of-year celebrations and guidance for including QI in a curriculum vitae,11 may improve resident engagement. Works-in-progress meetings with multidisciplinary working groups, including faculty and other residents, may publicise resident progress in QI,12 13 but such meetings require time and scheduling coordination. An online platform and asynchronous materials may alleviate this burden. It is not known, however, whether a platform to track and publicise resident QI work can be feasibly or acceptably implemented within residency programmes.

We adapted an existing digital knowledge-sharing platform that collates practical information about QI projects across institutions to facilitate sharing of information regarding potential QI mentors and project ideas within a single institution. Our goals in doing so were to first, foster a culture of QI and celebrate those who participated; second, help residents find QI projects and mentors; and third, track resident QI and scholarship to facilitate compliance with ACGME requirements. This platform was modified, and accompanying newsletters and events were created, to meet the needs of a residency programme and improve the accessibility of information about resident QI work and scholarship, including prior projects and mentors.

Methods

This project was conducted within an internal medicine residency programme at a tertiary, academic medical centre in the northeastern USA during the 2020–2021 academic year. Residents, residency leadership and internal medicine faculty were engaged throughout the project. Patients were not involved in this study.

A searchable, digital knowledge-sharing platform was adapted to catalogue QI work for a residency programme. Projects were sourced from resident reports, QI events and literature searches. The literature search was performed monthly in PubMed with all resident names, and abstracts were filtered manually to ensure that a resident from the programme was one of the publication’s authors. An Excel database of projects and other resident scholarship was maintained with these inputs, including all projects, regardless of adjacency to QI. From this database, two projects per week were selected based on adjacency to QI, and profiles were created to provide detailed summaries of resident work with practical information about the project. Other criteria for project selection included prioritising projects with more than one resident coauthor, those where a resident was first author, and those with recent publication. Each standardised profile included a project overview, resident innovator and collaborators, project status and stage of development, measurement metrics, results and major project needs. Residents were offered the opportunity to review and refine these profiles prior to posting. The searchable platform could be accessed via a password-protected website. This website also included a list of prior projects and mentors, in addition to the individual profiles. These listings served a tripartite purpose of highlighting resident work, cataloguing ongoing projects and providing a source of information about which mentors may be working on projects that may be appealing to trainees interested in QI. Updating the project sourcing database, profiling projects for the platform, and sending the newsletter required approximately 2–5 hours of project management time per week. This work was conducted by a medical student with basic training in QI methods and overseen by faculty with extensive QI knowledge. Projects were not retired from the database.

Projects were featured in monthly email newsletters and live events within the residency. Each newsletter highlighted two resident projects and provided links to other resources on the platform, including lists of prior QI projects. The newsletter also included a link for residents to submit their own projects. Two residency-wide events were held, during which several residents were selected to present a range of QI projects. These projects were selected from the database, and the events were used to highlight completed successful projects. Chief residents assisted in the selection of projects that might be of most interest to residents.

The number of projects in the database, the number of projects profiled for the platform, the number of newsletters and newsletter readership were tracked. Newsletter readership was further analysed by the time and day of the week at which it was sent. Descriptive statistics were used to assess outcomes.

Results

In the 2020–2021 academic year, 238 projects or publications were identified. From these projects, 104 summaries of resident QI and related research projects were created and posted to the platform (figure 1). These projects included both those that met strict definitions of QI and those that were QI adjacent, such as health services research. Sample projects featured included an intervention to reduce mood symptoms among intensive care patients and a home pulse oximetry monitoring programme for patients discharged from the emergency department with COVID-19.

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Eleven newsletters highlighted resident work to over 220 recipients, including all current residents and key residency faculty. Average open rates for the newsletters were 31.5% and average click rates were 4.4%, with variability from newsletter to newsletter, particularly in average click rate (figure 2). Newsletters sent on Friday afternoons had the two lowest clickthrough rates, and the newsletters with the three highest clickthrough rates were sent between 13:00 and 14:00 hours.

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Two hybrid-format events highlighted the work of seven different resident QI projects. Example projects featured included an effort to increase colorectal cancer screening in resident primary care panels and workshops to teach residents to place ultrasound-guided intravenous lines.

Discussion

A programme to systematically track, feature and celebrate resident scholarship, with emphasis on QI, was implemented for an internal medicine residency programme. Nearly one-third of residents and faculty engaged with each newsletter, and as many as 10% of readers clicked content in select newsletters. This suggests that the platform and newsletter were acceptable ways to engage the residency. This is a novel approach to resident QI engagement.

Despite this engagement, we encountered several challenges in implementation which should be considered by those seeking to implement similar initiatives. First, our approach to reaching residents required monitoring and modification to accommodate their schedules. Residents were engaged during their downtime or during existing educational sessions such as noon conferences to maximise participation. We suspect that the timing of newsletters during the workday or workweek was a significant factor influencing the variation in click rate seen, although the data we collected were insufficient to address this question. Second, rather than exclusively focusing on QI, we found that many more projects included features of healthcare systems and health services research, which are related but distinct. We, therefore, included both QI and related resident scholarship in our project profiles, increasing the breadth and quantity of projects featured but potentially diluting the QI message. Finally, such a database was feasible to maintain with approximately 2–5 hours of project management time per week. While the project was overseen by faculty members with expertise in QI, management of the database itself did not require extensive training in QI and required minimal faculty time. The time required to maintain the database and perform the monthly PubMed searches could have been decreased with the use of more targeted search terms for QI; this project identified all resident publications and required filtering by hand, which was more time-intensive. Furthermore, there is unaccounted for resident time required for residents who self-reported projects through our online form, although we believe this is a minimal amount given that projects were sourced primarily from either existing data sources from mandatory QI activities or PubMed searches. Projects were not retired from the database because it was intended to serve as a resource for future residents, however, they were rarely updated given that most projects were completed and there was no reliable mechanism for project updates to reach the database manager. Given that newsletters were a primary way in which residents engaged with the platform, we suggest that a platform alone is insufficient without active outreach, such as newsletters and events. Other platforms to track and facilitate resident QI projects have not included these features.14 Increasing visibility of QI may elevate its place among other forms of resident scholarship and at the same time facilitate programme compliance with ACGME regulations.

Generalisability of these findings may be limited beyond tertiary academic medical centres. Notably, however, resident projects were included even if they occurred at sites beyond our primary tertiary academic medical centre, as some resident projects did. A key limitation is that, while residents engaged with the programme, the effect on residency QI scholarship is unknown. Additionally, many confounding factors affect resident QI engagement, including mismatches between required project engagement and resident availability, personal interest in QI versus other fields and availability of faculty to engage with residents around QI. Thus, we did not feel that metrics such as number of projects completed would be appropriate. In future studies or projects, we could adapt engagement markers used in prior studies, such as number of projects presented at conferences.11 Once engagement markers with lesser bias are identified, it may be beneficial to conduct a pre–post study to assess time trends in resident engagement with QI. Finally, data were only collected over 1 year, and our study is insufficient to determine project sustainability beyond that time frame. Next steps include determining which metric might best capture enduring resident QI engagement.

A programme to track and feature resident QI projects and related scholarship engaged residents and faculty via newsletters, events and a searchable platform. This programme was both feasible to implement and acceptable to residency members. We found that interventions must be tailored to engage residents at effective times and via active outreach, which can be challenging. Future work should assess the potential for scaling this approach to additional sites and expanding the scope of project evaluation.