Aligned with calls to integrate quality improvement (QI) and physician life-long learning 1,2,3 the Royal College is collaborating with partners and stakeholders across the health care system to evolve its Maintenance of Certification (MOC) Program. In small, practical increments, this renewed CPD strategy aims to be more relevant, improvement-focused, and user-friendly, enabling physicians to achieve care outcomes and/or continued personal-professional growth important to them and their patients.
Although these collective goals are clear, some specialists may be unfamiliar with QI principles 3,4 and thus have difficulty connecting them to important improvement work they already do. Others might be challenged with identifying how to apply QI towards a specific personal development goal, professional practice role (e.g. clinician, educator, administrator) or transitioning stage of their career.
The following guidance aims to address these issues and provides:
An introduction to understanding Quality Improvement (QI) science
Tools, resources, and illustrative examples to help make connections between QI and existing professional practice.
Help to start planning, implementing, and reporting new QI initiatives in current professional practice.
Direction on claiming QI activities in the MOC program Section 3: Assessment activities (3 credits per hour).
What is QI?
What is QI?
New to QI and need a brief introduction? Maybe you’d like to know how this Essential Guidance to Quality Improvement fits in the current MOC Program. This section introduces the model for improvement (MFI) and its guiding questions to get you started.
Quality improvement (QI) is a generic, robust, and action-oriented problem solving framework that supports you in elevating the current state of your practice, personal, or professional development. Depending where you want to focus improvement efforts, it may mean, for example, improving the delivery of patient and family care, your own mental health, delivering a more effective curriculum, and/ or using resources wisely.
The first part is about you, your team, and/or your health system assessing an area that needs improvement and establishing an aim.
Once you have identified the area of need, the next part is setting a plan of action in motion with the goal of improving the quality of either a process or outcome. For example, reflecting on the outcomes, and planning a course of action to continue the delivery of better patient care are critical pieces in ensuring quality care 5.
Summary: In this 4-minute animated video, Dr. Don Goldmann explains the first step of quality improvement – Finding an aim and problem worthy of your QI efforts. Determining what ticks people off about their practice environment can be key to creating your problem statement.
What is the Model for Improvement and the PDSA cycle?
Familiar with the PDSA cycle? If you have been using MOC Section 3 activities in your professional practice, you have likely already been engaging in quality improvement.
Developed by Associates in Process Improvement, the Model for Improvement (MFI) is the most widely used QI model in health care 5. The MFI starts with you asking yourself three guiding questions that are then used as you test change interventions during various PDSA (Plan, Do, Study, Act) cycles.
Interested in knowing how to get started with QI? Maybe you’d like some new tools or to hear how you’re already engaging in quality improvement via existing MOC Section 3 professional practice improvement activities (e.g. chart audits, direct observation, feedback on teaching etc.)?
This section provides tools and resources to kickstart planning and implementing your quality improvement initiatives now. These tools and guidelines were chosen to be diversely applicable across different practice areas including teaching, academic, and clinical roles.
Concerned about access to or quality of data that informs your QI effort? Our specialist colleagues weigh in on these suggested types and sources of data to consider such as
Patient Medical Records (e.g. physicians orders)
Health Statistics (Federal or Provincial)
Resources and Tools
Choosing Wisely Canada
Looking for best practice standards to help inform your QI plan? Choosing Wisely Canada helps you find an MFI improvement aim or quality outcome to target. This collection of toolkits also provides evidence-based guidelines to help determine and change existing processes. Fully searchable by specific specialty, QI problem or outcome targets (e.g. early catheter removal, safe opiate prescribing) this web resource can assist your clinical QI implementation and evaluation plan.
Completed a COVID-19 practice improvement change and looking to better organize or report it using a quality improvement lens? Developed by Royal College Fellows, this reflective tool helps you describe the practice change and quality domains targeted, in addition to listing data indicators used to measure improvements. Document how you used QI to improve practice in response to the COVID-19 pandemic and receive MOC Section 3: Practice Assessment for 3 credits per hour.
Undergoing an annual performance review and receiving feedback on your professional practice? Annual reviews provide physicians with an opportunity to reflect on past performance goals and establish plans for the coming year.
They can be a great source of data to identify potential QI gaps to target or even highlight any practice strengths you want to stay current with and continually improve upon towards mastery.
How many of your patients with diabetes mellitus are appropriately referred for their annual eye exams? Questions like this are a great starting point for seeking and obtaining feedback from others via chart audit activities.
Chart audit and feedback is an assessment strategy that uses data recorded in a chart or electronic health record to assess the performance of an individual, group or team against one or more measures of performance.
The feedback provided during a chart audit establishes baseline data and can inform the identification of areas for future learning and quality improvement.
Have a trusted clinical peer whose opinion you value? Ever think about soliciting patient feedback on your discharge teaching or getting a colleague to scrub in, observe, and provide some coaching feedback while you do a lap chole?
Direct observation uses supervisors, colleagues or peers to observe a physician performing a regular professional activity to identify whether specific behaviours or competencies were demonstrated.
The coaching feedback provided during direct observation can facilitate the identification of areas for future learning and quality improvement.
Supervising residents in your clinic, teaching an undergrad course, or simply presenting at morbidity and mortality rounds this month? Consider using the Feedback on Teaching tool to summarise evaluations of your teaching completed by students, residents, physicians or health professionals to provide evidence related to the effectiveness and impact of your teaching.
Reviewing these evaluations provides opportunities to identify areas for improvement within this dimension of professional practice.
Reflect on why a patient consultation or procedure went really well or perhaps poorly. What data indicated the good or negative outcome? If you could start again, what would you do again and what processes would you change?
Practice Self-Assessment provides an opportunity to evaluate aspects of your daily work and target quality improvement aims across a variety of CanMEDS Roles. This type of self-assessment is not only for clinical setting and skills, but can be completed for all practice environments (e.g. academic and administrative).
Interested in reading more about QI, hearing about how other fellows are implementing QI, or possibly completing some courses to get QI in healthcare credentialing? Please check out these additional resources below.
Wong, B. M., Baum, K. D., Headrick, L. A., Holmboe, E. S., Moss, F., Ogrinc, G., ... & Frank, J. R. (2020). Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care. Academic Medicine, 95(1), 59-68.
Levinson, W., & Wong, B. M. (2021). Aligning continuing professional development with quality improvement. CMAJ, 193 (18), E647-E648.
Campbell, C., & Sisler, J. (2019). Supporting learning and continuous practice improvement for physicians in Canada: a new way forward. Summary report of the future of medical education in Canada (FMEC) CPD project.
Yousefi, V., Asghari-Roodsari, A., Evans, S., & Chan, C. (2020). Determinants of Hospital-based Physician Participation in Quality Improvement: A Survey of Hospitalists in British Columbia, Canada. Global Journal on Quality and Safety in Healthcare, 3 (1), 6-13.
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., (2014). Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ quality & safety, 23 (4), pp.290-298.