This case outlines the process of using quality improvement tools during the instructional systems design process. The clerkship curriculum of the third year of medical school was undergoing a complete reform in terms of time and content. An instructional designer was utilized to complete a needs analysis and participate in the instructional systems design process. A need for a common understanding of the language of medical education and instructional design drove the team to utilize the Institute for Healthcare Improvement (IHI) Quality Improvement tools. The reform took 11 months, involved six clerkship directors, multiple administrators, and resulted in consensus among the clerkship directors regarding the knowledge, skills, and attitudes appropriate for a third-year medical student curriculum.
TopOrganization Background
The medical school was facing a scarcity of resources, an upcoming accreditation process, complex business processes, and data overload. Third year clerkship directors were time impoverished; took care of patients and worked with an average of 25 students per rotation. Adding to their anxiety, several directors were new or had been in the position three or fewer years. Student satisfaction measures in the Graduation Questionnaire (GQ) collected by the Association of American Medical Colleges (AAMC), were below benchmark levels in perception of quality, and with an upcoming accreditation visit looming, the clerkship directors of the institution were charged with improving these measures by the institutional Dean/President/Provost.
The charge to the clerkship directors was to reduce learner time and improve quality in the traditional third year clerkship of medical school curriculum. The time available between the charge and the implementation was 11 months. Six clerkship directors in the areas of family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery gathered in team meetings to meet this challenge. The diverse group of leaders faced considerable design challenges. These challenges included viewing the curriculum as whole, identifying needs, prioritizing experiences for learners, aligning assessments with the step examinations and institutional competencies. The main task was to identify the knowledge, skills and attitudes appropriate for a third year medical student that would prepare learners to meet the requirements of residency directors hiring the learners upon completion of the four-year program of study.
The large group of clerkship leaders had competing interests, limited time, and varying past measures of quality perception from learners. Past learner performance in cognitive measures of the Step 2 Clinical Knowledge (Step 2 CK), were slightly above the national average. Past measures of clinical performance on the Step 2 Clinical Skills (Step 2 CS) examination, were slightly below the national average. The task was to reduce the time in core clerkships from eight to six weeks, include an elective clerkship for specialty and career exploration. Additionally, the task was to increase opportunities for learners to prepare for Step 2 CS and improve quality perception in all clerkships. A leadership decision to include a full instructional systems design (ISD) process resulted in an effective and peaceful decision-making experience. During the needs analysis phase, the inclusion of the Institute for Healthcare Improvement (IHI) Quality Improvement tools during ISD process enabled consensus building and increased efficiency of group decision-making (Quality Improvement Essentials Toolkit, n.d.). Initial consensus on design decisions resulted in immediate quality perception improvements as well as improvements in key areas for the ongoing clerkships.
The initial needs identified by leadership were a restructuring of the time allotted to each clerkship to allow for a specialty and career exploration clerkship, additional faculty for teaching and coordinators for administrative duties during the clerkships. Co-clerkship directors were identified or hired to serve in a teaching role and the percentage of time allotted to each director was increased. Additionally, co-clerkship coordinators were identified or hired to assist in the administrative duties for the clerkship. A new associate dean for clinical education led the reform effort. New faculty were brought on board with the explicit understanding that they were critical to the reform process and existing faculty now had the bandwidth to orient the new faculty to the educational process due to the support provided by additional coordinators. A new associate dean for program evaluation and assessment and director of assessment were hired to assist in these areas.
The restructuring of time in the clerkships changed from an 8-week structure to a six-week structure for the family medicine, pediatrics, obstetrics and gynecology, psychiatry, and surgery clerkships. The time in Internal medicine clerkship increased from an eight week to a 12-week clerkship to include geriatrics and neurology. The remaining six weeks in the 48-week curriculum contained a career exploration and specialty clerkship. The restructuring would reduce the number of students in each rotation from 25 to 20.