What can we learn from COVID-19?: examining the resilience of primary care teams.

Introduction: The COVID-19 pandemic continues to place an unprecedented strain on the US healthcare system, and primary care is no exception. Primary care services have shifted toward a team-based approach for delivering care in the last decade. COVID-19 placed extraordinary stress on primary care teams at the forefront of the pandemic response efforts. The current work applies the science of effective teams to examine the impact of COVID-19-a crisis or adverse event-on primary care team resilience. Methods: Little empirical research has been done testing the theory of team resilience during an extremely adverse crisis event in an applied team setting. Therefore, we conducted an archival study by using large-scale national data from the Veterans Health Administration to understand the characteristics and performance of 7,023 Patient Aligned Care Teams (PACTs) during COVID-19. Results: Our study found that primary care teams maintained performance in the presence of adversity, indicating possible team resilience. Further, team coordination positively predicted team performance (B = 0.53) regardless of the level of adversity a team was experiencing. Discussion: These findings in turn attest to the need to preserve team coordination in the presence of adversity. Results carry implications for creating opportunities for teams to learn and adjust to an adverse event to maintain performance and optimize team-member well-being. Teamwork can act as a protective factor against high levels of workload, burnout, and turnover, and should be studied further for its role in promoting team resilience.

Study protocol: maintaining preventive care during public health emergencies through effective coordination.

BACKGROUND: Screening lies at the heart of preventive care. However, COVID-19 dramatically disrupted routine screening efforts, resulting in excess mortality not directly attributable to COVID-19. Screening rates during COVID varied markedly by facility and clinical condition, suggesting susceptibilities in screening and referral process workflow. To better understand these susceptibilities and identify new practices to mitigate interrupted care, we propose a qualitative study comparing facilities that exhibited high, low, and highly variable performance (respectively) in screening rates before and during the pandemic. We will be guided by Weaver et al.'s multi-team systems (MTS) model of coordination, using cancer and mental health screening rates as exemplars. METHOD: Qualitative analysis of interviews and focus groups with primary care personnel, leadership, and patients at 10 VA medical centers. We will select sites based on rurality, COVID-19 caseload at the beginning of the pandemic, and performance on five outpatient clinical performance indicators of cancer and mental health screening. Sites will be categorized into one of five screening performance groups: high performers, low performers, improvers, plummeters, and highly variable. We will create process maps for each performance measure to create a workflow baseline and then interview primary care leadership to update the map at each site. We will clinician conduct focus groups to elicit themes regarding clinician coordination patterns (e.g., handoffs), strategies, and barriers/facilitators to screening during COVID. We will also conduct patient interviews to examine their screening experience during this period, for context. All interviews and focus groups will be audio-recorded, transcribed, and enhanced by field notes. We will analyze clinician transcripts and field notes using iterative, rapid analysis. Patient interviews will be analyzed using inductive/deductive content analysis. DISCUSSION: Our study represents a unique opportunity to inform the multi-team systems literature by identifying specific forms of information exchange, collective problem solving, and decision-making associated with higher and improved clinical performance. Specifically, our study aims to detect the specific points in the screening and referral process most susceptible to disruption and coordination processes that, if changed, will yield the highest value. Findings apply to future pandemics or any event with the potential to disrupt care.

Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds.

OBJECTIVES: Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds. METHODS: During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary. RESULTS: Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments. CONCLUSIONS: This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria.

Objective: The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants: A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods: The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results: Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions: The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.

Nurse Leader Perceptions of Data in the Veterans Health Administration: A Qualitative Evaluation.

Healthcare systems and nursing leaders aim to make evidence-based nurse staffing decisions. Understanding how nurses use and perceive available data to support safe staffing can strengthen learning healthcare systems and support evidence-based practice, particularly given emerging data availability and specific nursing challenges in data usability. However, current literature offers sparse insight into the nature of data use and challenges in the inpatient nurse staffing management context. We aimed to investigate how nurse leaders experience using data to guide their inpatient staffing management decisions in the Veterans Health Administration, the largest integrated healthcare system in the United States. We conducted semistructured interviews with 27 Veterans Health Administration nurse leaders across five management levels, using a constant comparative approach for analysis. Participants primarily reported using data for quality improvement, organizational learning, and organizational monitoring and support. Challenges included data fragmentation, unavailability and unsuitability to user need, lack of knowledge about available data, and untimely reporting. Our findings suggest that prioritizing end-user experience and needs is necessary to better govern evidence-based data tools for improving nursing care. Continuous nurse leader involvement in data governance is integral to ensuring high-quality data for end-user nurses to guide their decisions impacting patient care.

Strategies to enhance remote monitoring adherence among patients with cardiovascular implantable electronic devices.

Background: Remote monitoring (RM) of patients with cardiovascular implantable electronic devices (CIEDs) (pacemakers and implantable cardioverter-defibrillators) has a Class 1, Level of Evidence A Heart Rhythm Society recommendation. Yet RM adherence varies widely across settings, and factors associated with variation are not understood. Objective: The purpose of this study was to identify strategies for supporting RM across Veterans Health Administration (VHA) facilities. Methods: In a national evaluation, we surveyed and interviewed 27 nurses, medical instrument technicians, and advanced practice providers across 26 VHA facilities (following approximately 15,000 CIED patients). Participants were selected based on overall patient adherence by facility, which ranged from 46%-96%. Questions covered RM adherence strategies, manufacturer resources, organizational characteristics, and workflows for optimizing adherence. Results: All clinicians reported that RM adherence was extremely important (53.8%), very important (34.6%), or important (11.5%) for improving patient outcomes. High performing facilities prioritized consistent patient education about RM and evaluated nonadherence using dashboards and manufacturer web sites. High performing facilities instituted clear standard operating procedures that defined staff responsibilities and facilitated efficient contact with nonadherent patients and then family members by phone and then mail. Clinicians based at high performing facilities spent twice as many hours per week (9.1) on average managing RM adherence compared to other facilities (4.5). Effective communication (internally and with non-VHA care partners) and use of CIED manufacturer resources were essential. Facilities that were not high performing rarely used these strategies. Conclusion: Clinicians can support high RM adherence by emphasizing patient education, regularly assessing and addressing nonadherence using staff protocols, and engaging CIED manufacturers.

Developing and validating a comprehensive measure of coordination in patient aligned care teams.

BACKGROUND/OBJECTIVE: Despite numerous extant measures assessing context-specific elements of care coordination, we are unaware of any comprehensive, team-based instrument that measures the requisite mechanisms and conditions required to coordinate successfully. In this study we develop and validate the psychometric properties of the Coordination Practices Survey, a context-agnostic measure of coordination for primary care teams. METHODS: Coordination items were developed based on a systematic literature review; items from previously developed scales were adapted and new items were created as needed; all items were refined after subject matter expert review and feedback. We collected data from Primary Care teams drawn from 1200 Veterans Health Administration (VHA) medical centers and outpatient clinics nationwide. 1645 primary care team members from 512 patient aligned care teams in the Veterans Health Administration completed the survey from 2015 to 2016. Psychometric properties were assessed after data collection using Cronbach's alpha, intraclass correlations and multilevel confirmatory factor analysis to assess the factor structure. RESULTS: Our findings confirmed the psychometric properties of two distinguishable subscales of coordination: (a) Accountability and (b) Common Understanding. The within- and between-team latent structure of each subscale exhibited adequate fit to the data, as well as appropriately high Cronbach's alpha and intraclass correlations. There was insufficient variability in responses to the predictability subscale to properly assess its psychometric properties. CONCLUSION: With context-specific validation, our subscales of accountability and common understanding may be used to assess coordination processes in other contexts for both research and operational applications.

Increasing physician participation as subjects in scientific and quality improvement research.

BACKGROUND: The twenty-first century has witnessed an exponential increase in healthcare quality research. As such activities become more prevalent, physicians are increasingly needed to participate as subjects in research and quality improvement (QI) projects. This raises an important ethical question: how should physicians be remunerated for participating as research and/or QI subjects? FINANCIAL VERSUS NON-MONETARY INCENTIVES FOR PARTICIPATION: Research suggests participation in research and QI is often driven by conditional altruism, the idea that although initial interest in enrolling in research is altruistic or prosocial, decisions to actually perform study tasks are cost-benefit driven. Thus, the three models commonly employed to appropriately compensate participants (in-kind compensation such as travel reimbursement, paying market rates for the subject's time, and paying market rates for the activity asked of the participant) are a poor fit when the participant is a clinician, largely due to the asymmetry between cost and benefit or value to the participant. Non-monetary alternatives such as protected time for participation, continuing education or maintenance of certification credit, or professional development materials, can provide viable avenues for reducing this asymmetry. CONCLUSION: Research and QI are integral to the betterment of medicine and healthcare. To increase physician participation in these activities as the subject of study, new models are needed that clarify the physician's role in research and QI as a subject. Non-monetary approaches are recommended to successfully and ethically encourage research and QI participation, and thus incorporate these activities as a normal part of the ethical clinician's and successful learning healthcare system's world view.

Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System.

Importance: Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. Objective: To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. Design, Setting, and Participants: This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. Intervention: Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. Main Outcomes and Measures: Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. Results: Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. Conclusions and Relevance: The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.

Acceptability and feasibility of video-based coaching to enhance clinicians' communication skills with patients.

BACKGROUND: Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys. METHODS: The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews. RESULTS: Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients. CONCLUSIONS: Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Purpose, Subject, and Consumer Comment on "Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study".

Zegers and colleagues' study codifies the perceived burden of quality monitoring and improvement stemming from the work by clinicians of registering (documenting) quality information in the medical record. We agree with Zegers and colleagues' recommendation that a smaller, more effective and curated set of measures is needed to reduce burden, confusion, and expense. We further note that focusing on validity of clinical evidence behind individual measures is critical, but insufficient. We therefore extend Zegers and colleagues' work through a pragmatic, tripartite heuristic. To assess the value of and curate a targeted set of performance measures, we propose concentrating on the relationships among three factors: (1) The purpose of the performance measure, (2) the subject being evaluated, and (3) the consumer using information for decision-making. Our proposed tripartite framework lays the groundwork for executing the evidence-based recommendations proposed by Zegers et al, and provides a path forward for more effective healthcare performance-measurement systems.

An evidence-based, structured, expert approach to selecting essential indicators of primary care quality.

BACKGROUND: The purpose of this article is to illustrate the application of an evidence-based, structured performance measurement methodology to identify, prioritize, and (when appropriate) generate new measures of health care quality, using primary care as a case example. Primary health care is central to the health care system and health of the American public; thus, ensuring high quality is essential. Due to its complexity, ensuring high-quality primary care requires measurement frameworks that can assess the quality of the infrastructure, workforce configurations, and processes available. This paper describes the use of the Productivity Measurement and Enhancement System (ProMES) to compile a targeted set of such measures, prioritized according to their contribution and value to primary care. METHODS: We adapted ProMES to select and rank existing primary care measures according to value to the primary care clinic. Nine subject matter experts (SMEs) consisting of clinicians, hospital leaders and national policymakers participated in facilitated expert elicitation sessions to identify objectives of performance, corresponding measures, and priority rankings. RESULTS: The SMEs identified three fundamental objectives: access, patient-health care team partnerships, and technical quality. The SMEs also selected sixteen performance indicators from the 44 pre-vetted, currently existing measures from three different data sources for primary care. One indicator, Team 2-Day Post Discharge Contact Ratio, was selected as an indicator of both team partnerships and technical quality. Indicators were prioritized according to value using the contingency functions developed by the SMEs. CONCLUSION: Our article provides an actionable guide to applying ProMES, which can be adapted to the needs of various industries, including measure selection and modification from existing data sources, and proposing new measures. Future work should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as operationalizating measures to be meaningful and interpretable across health care settings.

Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration.

OBJECTIVE: The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND: Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD: We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS: We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS: Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION: Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

Value of Interprofessional Education: The VA Quality Scholars Program.

ABSTRACT: Interprofessional collaboration (IPC) has been shown to improve healthcare quality and patient safety; however, formal interprofessional education (IPE) training is insufficient. The VA Quality Scholars (VAQS) program exists to develop interprofessional leaders and scholars in healthcare improvement. The purpose of this study was to examine the impact of integrating interprofessional healthcare learners and designing an interprofessional curriculum for the national VAQS program. VAQS alumni (graduates from 2001 to 2017) across eight national sites (n = 102 [53.1%]) completed a web-based survey to assess alumni perceptions of IPC skill development during the program and IPC skill utilization in their careers. Alumni from 2009 and earlier were physicians; alumni after 2009 came from diverse health professional backgrounds. Overall, IPC and teamwork was identified as the most used skill (n = 82, 70%) during their career. When comparing the pre-IPE period and the post-IPE period, post-IPE alumni identified IPC and teamwork as the area of greatest skill development (n = 38). Integrating interprofessional trainees and robust IPE curricula enhanced an established and successful quality improvement (QI) training program. VAQS alumni endorsed the importance of IPC skills during their careers. The VAQS program is an example of how health professionals can successfully learn IPC skills in healthcare QI.

An Alternative Method of Public Reporting of Comparative Hospital Quality and Performance Data for Transparency Initiatives.

BACKGROUND: Hospital performance comparisons for transparency initiatives may be inadequate if peer comparison groups are poorly defined. OBJECTIVE: The objective of this study was to evaluate a new approach identifying hospital peers for comparison. DESIGN/SETTING: We used Mahalanobis distance as a new method of developing peer-specific groupings for hospitals to incorporate both external and internal complexity. We compared the overlap in groups with an existing method used by the Veterans' Health Administration's Office for Productivity, Efficiency, and Staffing (OPES). PARTICIPANTS: One hundred twenty-two acute-care Veterans' Health Administration's Medical Facilities as defined in the OPES fiscal year 2014 report. MEASURES: Using 15 variables in 9 categories developed from expert input, including both hospital internal measures and community-based external measures, we used principal components analysis and calculated Mahalanobis distance between each hospital pair. This method accounts for correlation between variables and allows for variables having different variances. We identified the 50 closest hospitals, then eliminated any potential peer whose score on the first component was >1 SD from the reference hospital. We compared overlap with OPES measures. RESULTS: Of 15 variables, 12 have SDs exceeding 25% of their means. The first 2 components of our analysis explain 24.8% and 18.5% of variation among hospitals. Eight of 9 variables scaling positively on the first component measure internal complexity, aligning with OPES groups. Four of 5 variables scaling positively on the second component but not the first are factors from the policy environment; this component reflects a dimension not considered in OPES groups. CONCLUSION: Individualized peers that incorporate external complexity generate more nuanced comparators to evaluate quality.

Improving team coordination in primary-care settings via multifaceted team-based feedback: a non-randomised controlled trial study.

BACKGROUND: Coordination is critical to successful team-based health care. Most clinicians, however, are not trained in effective coordination or teamwork. Audit and feedback (A&F) could improve team coordination, if designed with teams in mind. AIM: The effectiveness of a multifaceted, A&F-plus-debrief intervention was tested to establish whether it improved coordination in primary care teams compared with controls. DESIGN & SETTING: Case-control trial within US Veterans Health Administration medical centres. METHOD: Thirty-four primary care teams selected from four geographically distinct hospitals were compared with 34 administratively matched control teams. Intervention-arm teams received monthly A&F reports about key coordination behaviours and structured debriefings over 7 months. Control teams were followed exclusively via their clinical records. Outcome measures included a coordination composite and its component indicators (appointments starting on time, timely recall scheduling, emergency department utilisation, and electronic patient portal enrolment). Predictors included intervention arm, extent of exposure to intervention, and degree of multiple team membership (MTM). RESULTS: Intervention teams did not significantly improve over control teams, even after adjusting for MTM. Follow-up analyses indicated cross-team variability in intervention fidelity; although all intervention teams received feedback reports, not all teams attended all debriefings. Compared with their respective baselines, teams with high debriefing exposure improved significantly. Teams with high debriefing exposure improved significantly more than teams with low exposure. Low exposure teams significantly increased patient portal enrolment. CONCLUSION: Team-based A&F, including adequate reflection time, can improve coordination; however, the effect is dose dependent. Consistency of debriefing appears more critical than proportion of team members attending a debriefing for ensuring implementation fidelity and effectiveness.

Development of a Hybrid, Interprofessional, Interactive Quality Improvement Curriculum as a Model for Continuing Professional Development.

Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in-and eventually, lead-QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner's Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners-wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams-can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.

Examining changes in interprofessional attitudes associated with virtual interprofessional training.

Interprofessional care is essential in healthcare, but prior work has shown that physicians and nurses tend to have different perceptions about working interprofessionally (interprofessional attitudes). Although training has been shown to improve interprofessional attitudes, providing traditional face to face training is logistically challenging in the healthcare setting. The current study examined whether a virtual interprofessional training program could improve interprofessional attitudes for nurses and physicians. Among a sample of 35 physicians and nurses, results suggested that engagement in a virtual interprofessional training program was associated with improvements in interprofessional attitudes (i.e., perceived ability to work with, value in working with, and comfort in working with other professions) (p = .002), with attitudes improving an average of 0.25 points on a six-point scale (Cohen's d = 0.52). As a secondary aim, results showed that the magnitude of change in interprofessional attitudes did not differ significantly between physicians and nurses. Altogether, results suggest that virtual interprofessional training appears to be a suitable way to begin to improve interprofessional attitudes for both physicians and nurses.