Improving the “Quality” of Quality Improvement Education – ICE Blog

By:  MaryAnn C. Lawlor (, Emily Tsivitse (, Elizabeth Edmiston (, and Melissa Klein (

Caution: we have a low-quality improvement alert! Would you believe that medical professionals are not routinely trained to recognize and address problems in their own, or in each other’s health care settings? In fact, quality improvement and interdisciplinary courses remain absent in a majority of the nation’s medical and nursing colleges. Instead, identifying system flaws and analyzing data for patient outcomes and systems improvement have traditionally been thought to be the responsibility of the higher administration and quality experts. Results are generated and interventions are imposed on a field of workers who weren’t aware there was even an issue. It’s a vicious circle that leaves the notion of “quality” in healthcare an abstract, often unsustainable concept. But would you believe that in fact, our front-line health care workers are the true experts? They have the power, though it is largely unrealized, to improve the quality of quality improvement.

So, how does this happen? How do healthcare professionals become interested in quality improvement (QI)? How do they receive the training they need to permanently improve care? Who is going to provide this training? How do we emphasize the importance of interprofessional teamwork to sustain improvements? The conversation is big, and the answer is not necessarily straightforward, though it likely does involve a shift in our approach to healthcare education, both in college programs and in workforce training of medical professionals. Generally, healthcare providers are exposed to quality improvement in segments, and as problems arise. Their learning is often broken, self-guided, incomplete and occurs in isolation of other professionals – and most importantly does not sustainably impact patient outcomes. Though universities and medical systems are starting to recognize the significant impact of interprofessional quality improvement training, few programs exist nationally that provide a dedicated quality improvement experience with a curriculum that emphasizes interprofessional collaboration.

One program that does, is the Center for Outpatient Education (COE) at the Northeast Ohio Veterans Health Administration, located in Cleveland, Ohio. The COE was established to train new healthcare professionals to participate in and lead quality improvement projects as members of interprofessional teams. Through a highly selective process, residents from various backgrounds and disciplines including medicine, nursing, pharmacy, psychology, and social work are chosen to complete a rigorous interprofessional program. Speaking of interprofessional collaboration, students at the Frances Payne Bolton School of Nursing in Cleveland, Ohio also participate in the COE program and complete a QI project during their undergraduate degree. The COE QI curriculum involves didactic content on the principles of Lean Six Sigma (LSS) and the Model for Improvement by the Institute for Healthcare Improvement, journal clubs, didactic on scholarship components and data analyses, as well as a cumulative QI project. Residents in the COE program are expected to form a team that includes three to four interprofessional learners – where they gain stakeholder support, identify a quality or safety concern in their primary care clinic, and complete a QI project to address this concern. Not only do the residents work in interdisciplinary teams, but these teams are coached by a group of interdisciplinary professionals who have been trained and certified in QI through the VA Quality Scholars program. Coaches are an integral part of QI education and truly enhance the experience of learners.

While this program is flourishing in our local university and hospital system, we still have a quality conundrum. Dedicated and rigorous QI programs and curricula should not be viewed as an extra experience and should not be only for those who apply to specialized programs like the COE. Rather, the enthusiasm for and delivery of QI education should be universal from the start for healthcare students and providers. But how do we convince our academic and institutional stakeholders to include QI in the healthcare education curriculum and encourage opportunities for QI in healthcare careers? And more importantly, how do we get front-line providers excited about teaching and participating in QI together? Again, the answer is not straightforward. But, at the end of the day, quality improvement is everyone’s responsibility, and we ARE the front-line. It is important to acknowledge that there are no healthcare quality issues that exist in isolation of other disciplines – so naturally, we will need to approach this together. However, recognizing the value of what other disciplines have to offer is just the start. Those of us who are already front-line QI experts and enthusiasts need to educate and engage our colleagues in QI at the institutional level, and those of us in positions of power in academia need to continue to push for the integration of QI in the curriculum. Improving the “quality” of quality improvement education is not only necessary, but possible.

About the authors:
MaryAnn C. Lawlor, PhD, MA.Ed., RN Is a VA Quality Scholar Research Nurse in for the U.S. Department of Veterans Affairs in Cleveland, Ohio, United State.

Emily Tsivitse, PhD, APRN Is a Post-doctoral Fellow for Veterans Affairs Quality Scholar (VAQS)  at the Louis Stokes Cleveland VA Medical Center in Cleveland, Ohio. In addition, she is a Graduate Research Assistant at the Case Western Reserve University in the Cleveland/Akron, Ohio Area.

Elizabeth Edmiston, PhD, CCRN Is the Chief Nurse Scientist at the Louis Stokes Cleveland VA Medical Center in Cleveland, Ohio.

Melissa Klein, MD Is a Postdoctoral Fellow at VA Quality Scholars and a Physician at the Louis Stokes Cleveland VA Medical Center in Cleveland, Ohio.

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