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 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,"
said Romsai Boonyasai, an internist at
The Johns Hopkins Hospital and co-author of the review published
in the Sept. 5 issue of the Journal
of the American Medical Association.
Quality improvement 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
As of 2003, in order for medical schools to maintain
accreditation, training programs for
residents are required to include quality improvement curricula.
QI classes are also part of training
programs for medical students and continuing education programs
for working doctors. However,
Boonyasai says, whether those classes make a difference in
physician knowledge or patient outcomes is
To evaluate the effectiveness of various curricula,
Boonyasai and his colleagues systematically
searched databases of medical articles for those mentioning
quality improvement in health care. They
narrowed their focus to 39 articles that described teaching QI
methods to students and clinicians.
When Boonyasai's team evaluated these articles, they found
that most suggested an
improvement in students' and clinicians' knowledge of QI concepts
— noting, 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 good news, the researchers say, is that they 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
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
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;
National Research Service Award–Health Resources and Services
Administration; and Osler Center
for Clinical Excellence at Johns Hopkins University.