Introduction
Studies replicated around the globe have described the alarming prevalence of adverse events and harm due to medical error. In 2016, the Irish National Adverse Events Study reported that 12.2% of patients experienced an adverse event, of which 70% were considered preventable.1 Concerningly, the economic burden of medical error in the Irish health system is estimated at over €194 million. In recognising that medical error and harm in healthcare is the result of a number of combined, complex factors, quality improvement (QI) is a well-established methodology that can reduce the prevalence of error and enhance the overall quality of care within health systems. Educators have acknowledged the importance of training current and future health professionals in QI and patient safety in order to influence organisational safety culture. In North America, the Canadian Medical Education Directives for Specialists (CanMEDS) and Accreditation Council for Graduate Medical Education (ACGME) have integrated QI into their competency frameworks.2 3 In the UK, the General Medical Council (GMC) is emphasising the need to incorporate QI into undergraduate medical education while it is also being incorporated into postgraduate frameworks throughout Europe.4 5
Educational strategies must be in place to ensure that all future physicians receive exposure to QI during medical school and postgraduate or residency training in order to acquire the foundational QI knowledge that permits an understanding of how to identify and implement changes for the advancement of patient care, patient safety, and overall performance of healthcare systems.6 7 This may be achieved through early and longitudinal integration of didactic and experiential QI training throughout undergraduate and postgraduate medical training. Historically, applied clinical projects have been successful in educating trainees about QI during their clinical years; however, these projects are infrequently available and resource intensive. For students who are in their preclinical stage of training, early engagement to QI is often difficult due to a lack of contextual understanding and exposure to the health system.7 Preclerkship learners spend their first year of medical school adjusting to the new environment and focusing on the acquisition of basic sciences and clinical content and therefore may not be at an appropriate stage to learn and apply principles of clinical QI. Despite their lack of exposure to medicine and health systems, junior medical students are perfectly situated within an already complex system in need of improvement: their own medical education.
PRISM Overview
The Programme for Innovation in Scholarship in Medicine (PRISM; formally known as the Programme for Improvement in Medical Education) aims to foster the early development of QI competencies among medical students by using education as the context for QI applications. Previous evaluations of the programme in a Canadian medical school revealed that first-year medical students were able to transfer their acquired knowledge from the context of education to clinical scenarios at levels comparable to postgraduate residents and that the early exposure to QI fostered later clinical engagement during clerkship.8–10
The Royal College of Surgeons in Ireland (RCSI) is an international degree-awarding health sciences institution, offering medical education programmes that range from 4 to 6 years, with the Graduate Entry Medicine (GEM) programme offering a 4-year medical degree (MB BAO BCh) to those who have already attained a degree. RCSI students come from a variety of backgrounds ranging from the arts to science, and the class size for the GEM programme is approximately 80 students per year. PRISM was first piloted in 2016 with students in the GEM Class of 2019. During the first cycle, PRISM was delivered over three consecutive days, two of which were on a weekend. However, in the two most recent cycles, the programme was condensed over two half-day workshops. Since 2016, four cohorts of GEM students have completed the programme. Despite being offered as an extracurricular programme delivered on the weekend, participation rates were very high over the first three cycles: 76%, 69% and 54%, respectively.
The PRISM workshops are delivered in-person by a Canadian scholar with content expertise in both medical education and QI methods. The first workshop focuses on introducing the fundamentals of QI, including the Institute of Medicine’s 6 dimensions of quality. The purpose of this introductory workshop is to encourage students to begin thinking about ‘quality’ using an established framework so that they can identify quality deficits in the education programme received to date. By the end of the first workshop, students are expected to work in teams to identify and define a ‘quality gap’ in their education. The second workshop focuses on the applications of QI methodologies, namely, the Model for Improvement. During this workshop, students focused on applying the Model for Improvement to their quality gap. Breakout sessions are held so students had time to work on various aspects of the Model for Improvement, including developing: an aim statement; a family of measures (ie, outcome, process and balancing measures); an appropriate intervention or change concept; and an implementation plan using Plan-Do-Study-Act cycles. During the breakout sessions, senior faculty members were available to provide contextual insight into the areas of the curriculum on which students were focusing their improvement efforts while the visiting scholar consults groups on QI concepts. An observed benefit of having the workshop delivered by an individual external to RCSI is that medical students appeared more willing to speak openly about strengths and weaknesses of the curriculum, even with lead faculty members present during the workshop. Further, each participant receives a programme handbook which serves as a resource both during and after the workshop.
Six to eight weeks following the PRISM workshops, the student groups are required to submit a project charter—a QI proposal—that outlines their educational quality gap and how they would use the Model for Improvement to test, implement, spread, and scale an intervention (online supplementary appendix A—PRISM Project Charter). Students are expected to apply QI concepts and terminology in the project charters to provide a detailed QI proposal, including an aim statement, measurement plan, and a detailed strategy for how they would use multiple Plan-Do-Study-Act cycles. Charters for each student group are marked by at least two faculty members and three to four upper year RCSI students who have previously completed the programme. Each charter is assessed by raters using a standardised scoring framework, the Project Charter Assessment Tool (PCAT), which generates mean scores that are then used to rank order the submissions and identify the top groups who are awarded a prize (online supplementary appendix B—PRISM PCAT). Each group receives formative feedback from both faculty members and upper year students that aims to reinforce QI principles and provide insight into the feasibility of their ideas.
During the inaugural offering, 100% (n=53) of participants completed the Beliefs, Attitudes, Skills and Confidence in Quality Improvement (BASIC-QI) instrument prior to and following PRISM.11 Cronbach’s alpha suggested high internal consistency, providing reliability evidence (pre=0.905, post=0.951). Overall, BASiC-QI scores increased 59.28 ± 23.5 following PRISM (p<0.001), suggesting that learner knowledge, skills and attitudes improved following completion of the programme. In addition, 66% (n=35) of students completed an exit survey following the completion of the programme to gather further feedback. 94% (n=33) of students agreed that the workshops were well organised and 94% (n=33) agreed that they obtained enough knowledge from the workshops to develop a project charter aimed at improving the quality of medical education at RCSI. 94% (n=33) agreed that the expectations of the programme were clear and manageable, while 89% (n=31) agreed that PRISM was a valuable learning experience. 91% (n=32) agreed they have a good understanding of what QI is and how to develop interventions that can improve a system. 88% (n=31) agreed they enjoyed learning about QI and have a new interest in QI and 94% (n=33) would recommend future students participate in the programme. Finally, 74% of students said they are more likely to engage in future QI opportunities if offered to them.
