Performance Data Advocacy for Continuing Professional Development in Health Professions.

ABSTRACT: Efforts to optimize continuing professional development (CPD) are ongoing and include advocacy for the use of clinician performance data. Several educational and quality-based frameworks support the use of performance data to achieve intended improvement outcomes. Although intuitively appealing, the role of performance data for CPD has been uncertain and its utility mainly assumed. In this Scholarly Perspective, the authors briefly review and trace arguments that have led to the conclusion that performance data are essential for CPD. In addition, they summarize and synthesize a recent and ongoing research program exploring the relationship physicians have with performance data. They draw on Collins, Onwuegbuzie, and Johnson's legitimacy model and Dixon-Woods' integrative approach to generate inferences and ways of moving forward. This interpretive approach encourages questioning or raising of assumptions about related concepts and draws on the perspectives (i.e., interpretive work) of the research team to identify the most salient points to guide future work. The authors identify 6 stimuli for future programs of research intended to support broader and better integration of performance data for CPD. Their aims are to contribute to the discourse on data advocacy for CPD by linking conceptual, methodologic, and analytic processes and to stimulate discussion on how to proceed on the issue of performance data for CPD purposes. They hope to move the field from a discussion on the utility of data for CPD to deeper integration of relevant conceptual frameworks.

Implementation of structured feedback in a psychiatry residency program in Canada: a qualitative analysis study.

Introduction: Structured feedback is important to support learner progression in competency-based medical education (CBME). R2C2 is an evidence-based four-phased feedback model that has been studied in a range of learner contexts; however, data on factors influencing implementation of this model are lacking. This pilot study describes implementation of the R2C2 model in a psychiatry CBME residency program, using the Consolidated Framework for Implementation Research (CFIR). Methods: The study was carried out in three phases: planning, implementation and evaluation. After receiving training, 15 supervisors used the R2C2 feedback model with residents. Semi-structured interviews explored (n = 10) supervisors' experience of the model. CFIR was used to identify factors that influence implementation of the R2C2 model when providing feedback to residents. Results: Qualitative data analysis revealed four key themes: Perceptions about the R2C2 model, Facilitators and barriers to its implementation, Fidelity to R2C2 model and Intersectionality related to the feedback. The CFIR implementation domains provided structure to the themes and subthemes. Conclusion: The R2C2 model is a helpful tool to provide structured feedback. Structure of the model, self-efficacy, in-house educational expertise, learning culture, organizational readiness, and training support are important facilitators of implementation. Further studies are needed to explore the learner's perspective and fidelity of this model.

A Qualitative Study to Understand the Cultural Factors That Influence Clinical Data Use for Continuing Professional Development.

INTRODUCTION: The use of data to inform lifelong learning has become increasingly important in continuing professional development (CPD) practice. Despite the potential benefits of data-driven learning, our understanding of how physicians engage in data-informed learning activities, particularly for CPD, remains unclear and warrants further study. The purpose of this study was to explore how physicians perceive cultural factors (individual, organizational, and systemic) that influence the use of clinical data to inform lifelong learning and self-initiated CPD activities. METHODS: This qualitative study is part of an explanatory sequential mixed-methods study examining data-informed learning. Participants were psychiatrists and general surgeons from Canada and the United States. Recruitment occurred between April 2019 and November 2019, and the authors conducted semistructured telephone interviews between May 2019 and November 2019. The authors performed thematic analysis using an iterative, inductive method of constant comparative analysis. RESULTS: The authors interviewed 28 physicians: 17 psychiatrists (61%) and 11 general surgeons (39%). Three major themes emerged from the continuous, iterative analysis of interview transcripts: (1) a strong relationship between data and trust, (2) a team-based approach to data-informed learning for practice improvement, and (3) a need for organizational support and advocacy to put data into practice. CONCLUSION: Building trust, taking a team-based approach, and engaging multiple stakeholders, such as data specialists and organizational leadership, may significantly improve the use of data-informed learning. The results are situated in the existing literature, and opportunities for future research are summarized.

Moving beyond 'think leadership, think white male': the contents and contexts of equity, diversity and inclusion in physician leadership programmes.

The lack of both women and physicians from groups under-represented in medicine (UIM) in leadership has become a growing concern in healthcare. Despite increasing recognition that diversity in physician leadership can lead to reduced health disparities, improved population health and increased innovation and creativity in organisations, progress toward this goal is slow. One strategy for increasing the number of women and UIM physician leaders has been to create professional development opportunities that include leadership training on equity, diversity and inclusivity (EDI). However, the extent to which these concepts are explored in physician leadership programming is not known. It is also not clear whether this EDI content challenges structural barriers that perpetuate the status quo of white male leadership. To explore these issues, we conducted an environmental scan by adapting Arksey and O'Malley's scoping review methodology to centre on three questions: How is EDI currently presented in physician leadership programming? How have these programmes been evaluated in the peer-reviewed literature? How is EDI presented and discussed by the wider medical community? We scanned institutional websites for physician leadership programmes, analysed peer-reviewed literature and examined material from medical education conferences. Our findings indicate that despite an apparent increase in the discussion of EDI concepts in the medical community, current physician leadership programming is built on theories that fail to move beyond race and gender as explanatory factors for a lack of diversity in physician leadership. To address inequity, physician leadership curricula should aim to equip physicians to identify and address the structural factors that perpetuate disparities.

Exploring Systemic Influences on Data-Informed Learning: Document Review of Policies, Procedures, and Legislation from Canada and the United States.

INTRODUCTION: Despite the support for and benefits of data-driven learning, physician engagement is variable. This study explores systemic influences of physician use of data for performance improvement in continuing professional development (CPD) by analyzing and interpreting data sources from organizational and institutional documents. METHODS: The document analysis is the third phase of a mixed-methods explanatory sequential study examining cultural factors that influence data-informed learning. A gray literature search was conducted for organizations both in Canada and the United States. The analysis contains nonparticipant observations from professional learning bodies and medical specialty organizations with established roles within the CPD community known to lead and influence change in CPD. RESULTS: Sixty-two documents were collected from 20 Canadian and American organizations. The content analysis identified the following: (1) a need to advocate for data-informed self-assessment and team-based learning strategies; (2) privacy and confidentiality concerns intersect at the point of patient data collection and physician-generated outcomes and need to be acknowledged; (3) a nuanced data strategy approach for each medical specialty is needed. DISCUSSION: This analysis broadens our understanding of system-level factors that influence the extent to which health information custodians and physicians are motivated to engage with data for learning.

A mental health framework from the voices of refugees.

BACKGROUND: Refugee groups fleeing war and violence and resettling in the West are one of the population groups that are poorly understood. Understanding their mental health challenges and providing effective and evidence-based interventions continue to be formidable challenges. AIM: This study presents a refugee mental health framework [RMHF] that was developed to address the gaps in understanding and responding to the needs of refugee populations by prioritizing their voices, and incorporating lessons learned from working with these refugee communities into the development of the framework. METHOD: A RMHF was developed, presented and refined with input from refugee communities, multiple stakeholders and an expert panel. RESULTS/CONCLUSIONS: This paper presents the process and finalized framework, and discusses its utility as a mapping, planning and intervention tool in supporting refugee communities with their resettlement and promoting mental wellbeing.

Examining Associations Between Physician Data Utilization for Practice Improvement and Lifelong Learning.

INTRODUCTION: Practice data can inform the selection of educational strategies; however, it is not widely used, even when available. This study's purpose was to determine factors that influence physician engagement with practice data to advance competence and drive practice change. METHODS: A practice-based, pan-Canadian survey was administered to three physician subspecialties: psychiatrists (Psy), radiation oncologists (RO), and general surgeons (GS). The survey was distributed through national specialty society membership lists. The survey assessed factors that influence the use of data for practice improvement and orientation to lifelong learning, using the Jefferson Scale of Physician Lifelong Learning (JeffSPLL). Linear regression was used to model the relationship between the outcome variable frequency of data use and independent predictors of continuous learning to improving practice. RESULTS: A total of 305 practicing physicians (Psy = 203, RO = 53, GS = 49) participated in this study. Most respondents used data for practice improvement (n = 177, 61.7%; Psy = 115, 40.1%; RO = 35; 12.2%; GS = 27, 9.4%) and had high orientation to lifelong learning (JeffSPLL mean scores: Psy = 47.4; RO = 43.5; GS = 45.1; Max = 56). Linear regression analysis identified significant predictors of data use in practice being: frequency of assessing learning needs, helpfulness of data to improve practice, and frequency to develop learning plans. Together, these predictors explained 42.9% of the variance in physicians' orientation toward integrating accessible data into practice (R = 0.426, P < .001). DISCUSSION: This study demonstrates an association between practice data use and perceived data utility, reflection on learning needs and learning plan development. Implications for this work include process development for data-informed action planning for practice improvement for physicians.

Data and Lifelong Learning Protocol: Understanding Cultural Barriers and Facilitators to Using Clinical Performance Data to Support Continuing Professional Development.

Continuing professional development (CPD) can support delivery of high-quality care, but may not be optimized until we can understand cultural barriers and facilitators, especially as innovations emerge. Lifelong learning (LLL), linked with quality improvement, competence, and professionalism, is a core competency in medical education. The purpose of this study is to examine cultural factors (individual, organizational, and systemic) that influence CPD and specifically the use of clinical data to inform LLL and CPD activities. This mixed-method study will examine the perceptions of two learner groups (psychiatrists and general surgeons) in three phases: (1) a survey to understand the relationship between data-informed learning and orientation to LLL; (2) semistructured interviews using purposive and maximum variation sampling techniques to identify individual-, organizational-, and system-level barriers and facilitators to engaging in data-informed LLL to support practice change; and (3) a document analysis of legislation, policies, and procedures related to the access and the use of clinical data for performance improvement in CPD. We obtained research ethics approval from the University Health Network in Toronto, Ontario, Canada. By exploring two distinct learner groups, we will identify contextual features that may inform what educators should consider when conceptualizing and designing CPD activities and what initial actions need to be taken before CPD activities can be optimized. This study will lead to the development of a framework reflective of barriers and facilitators that can be implemented when planning to use data in CPD activities to support data adoption for LLL.

Bedside nurses' roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals' roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses' interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in-depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty-five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses' absence from morning rounds, one-way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision-making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse-physician interactions and the current context of nursing care.

The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?

PURPOSE: The authors previously developed and tested a reflective model for facilitating performance feedback for practice improvement, the R2C2 model. It consists of four phases: relationship building, exploring reactions, exploring content, and coaching. This research studied the use and effectiveness of the model across different residency programs and the factors that influenced its effectiveness and use. METHOD: From July 2014-October 2016, case study methodology was used to study R2C2 model use and the influence of context on use within and across five cases. Five residency programs (family medicine, psychiatry, internal medicine, surgery, and anesthesia) from three countries (Canada, the United States, and the Netherlands) were recruited. Data collection included audiotaped site assessment interviews, feedback sessions, and debriefing interviews with residents and supervisors, and completed learning change plans (LCPs). Content, thematic, template, and cross-case analysis were conducted. RESULTS: An average of nine resident-supervisor dyads per site were recruited. The R2C2 feedback model, used with an LCP, was reported to be effective in engaging residents in a reflective, goal-oriented discussion about performance data, supporting coaching, and enabling collaborative development of a change plan. Use varied across cases, influenced by six general factors: supervisor characteristics, resident characteristics, qualities of the resident-supervisor relationship, assessment approaches, program culture and context, and supports provided by the authors. CONCLUSIONS: The R2C2 model was reported to be effective in fostering a productive, reflective feedback conversation focused on resident development and in facilitating collaborative development of a change plan. Factors contributing to successful use were identified.

Faculty Development for Continuing Interprofessional Education and Collaborative Practice.

This article proposes a framework for faculty development in continuing interprofessional education (CIPE) and collaborative practice. The framework is built on best practices in faculty development and CIPE. It was informed by local experience in the development, delivery, and evaluation of a faculty development program to promote capacity for dissemination of concepts relating to interprofessional education (IPE) and interprofessional collaboration (IPC) in health care environments. Interprofessional education has been demonstrated in clinical contexts to enhance interprofessional collaboration, patient care, and health outcomes. With curriculum design, teaching methods, and educational strategies in faculty development, it is possible to enhance the impact of IPE in clinical contexts. Faculty development activities themselves can model effective interprofessional education methods and practice. An IPE curriculum and teaching and education strategies are outlined. Strategic planning, including the application of a systems approach, attention to the principles of effective learning, and an outcomes-based curriculum design are recommended for the development of continuing IPE faculty development programs that enhance interprofessional collaboration.

Incorporating Lifelong Learning From Residency to Practice: A Qualitative Study Exploring Psychiatry Learners' Needs and Motivations.

INTRODUCTION: There has been an increased focus on lifelong learning (LLL) as a core competency to develop master learners in medical education across the learner continuum. The purpose of this study was to explore the perceptions of psychiatry residents and faculty about LLL implementation, motivation, and training needs. METHODS: This qualitative study was conducted in a large, urban, multisite psychiatry training program as part of a larger mixed methods study of LLL in psychiatry education. Using a purposive sampling approach, psychiatry residents were recruited to participate in focus groups; early career psychiatrists and psychiatry educators were recruited to participate in semistructured interviews. Content analysis of interviews and focus groups was done using the iterative, inductive method of constant comparative analysis. RESULTS: Of the 34 individuals participating in the study, 23 were residents, six were psychiatry educators, and five were early career psychiatrists. Three predominant themes were identified in participants' transcripts related to (1) the need for LLL training in residency training; (2) the implementation of LLL in residency training and practice; and (3) the spectrum of motivation for LLL from residency training into practice. DISCUSSION: This study identified the lack of preparation for LLL in residency training and the impact of this gap for psychiatrists transitioning into practice. All participants described the importance of integrating LLL training within clinical rotations and the importance of grounding LLL within the clinical workplace early in residency training to support the delivery of effective, high-quality patient care.

The role of morbidity and mortality rounds in medical education: a scoping review.

CONTEXT: There is increasing focus on how health care professionals can be trained effectively in quality improvement and patient safety principles. The morbidity and mortality round (MMR) has often been used as a tool with which to examine and teach care quality, yet little is known of its implementation and educational outcomes. OBJECTIVES: The objectives of this scoping review are to examine and summarise the literature on how the MMR is designed and delivered, and to identify how it is evaluated for effectiveness in addressing medical education outcomes. METHODS: A literature search of the PubMed, MEDLINE, PsycInfo and Cochrane Library databases was conducted for articles published from 1980 to 1 June 2016. Publications in English describing the design, implementation and evaluation of MMRs were included. A total of 67 studies were identified, including eight survey-based studies, four literature reviews, one ethnographic study, three opinion papers, two qualitative observation studies and 49 case studies of education programmes with or without formal evaluation. Study outcomes were categorised using Donald Moore's framework for the evaluation of continuing medical education (CME). RESULTS: There is much heterogeneity within the literature regarding the implementation, delivery and goals of the MMR. Common design components included explicit programme goals and objectives, the case selection process, case presentation models and some form of case analysis. Evaluation of CME outcomes for MMR were mainly limited to learner participation, satisfaction and self-assessed changes in knowledge. CONCLUSIONS: The MMR is widely utilised as an educational tool to promote medical education, patient safety and quality improvement. Although evidence to guide the design and implementation of the MMR to achieve measurable CME outcomes remains limited, there are components associated with positive improvements to learning and performance outcomes.

Where is the client/patient voice in interprofessional healthcare team assessments? Findings from a one-day forum.

There is a growing interest in interprofessional care (IPC) as a way to provide better healthcare. However, it is difficult to evaluate this mode of healthcare delivery because identifying the appropriate measurement tool is a challenge, given the wide diversity in team composition and settings. Adding to this complexity is a key gap in the IPC evaluation research: the client/patient perspective. This perspective has generally not been included in the development of IPC healthcare team evaluations. The authors received a Canadian Institute for Health Research Planning Grant to host a one-day forum with 24 participants from across Canada representing health professions such as social work, medicine, occupational therapy, and physical therapy, in addition to researchers, client/patient advocates, and hospital administrators. The overarching goal of the forum was to create a demonstration project that supports the development of an IPC assessment tool for healthcare teams that includes clients/patients. Using a concept mapping methodology, participants discussed client/patient inclusion in IPC assessments, and through a consensus process, chose a demonstration project for further development.

Simulation in Undergraduate Psychiatry: Exploring the Depth of Learner Engagement.

OBJECTIVES: Simulation-based methodologies are increasingly used in undergraduate medical education to expand students' exposure to complex clinical scenarios. Engagement of students in these simulation-based methodologies is a key determinant of their success in learning. Thus, the authors conducted a systematic review to (1) identify simulation methods in use within the undergraduate psychiatry curriculum and (2) assess learner engagement using these methods. METHODS: Following a PRISMA methodology, the authors searched MEDLINE, ERIC, and PsychINFO databases from 1977 to 2015. Studies applying simulation in undergraduate psychiatric education were reviewed. The depth of learner engagement was assessed using Kolb's four-stage learning cycle. RESULTS: Of 371 publications identified, 63 met all the inclusion criteria: 48 used standardized patients and 16 used online or virtual learning case modules. Only one study used high fidelity mannequins. Three studies satisfied multiple stages in Kolb's Learning Cycle, including a single study that addressed all four domains. CONCLUSIONS: Despite the varied uses of simulation across other health disciplines, there were few novel or innovative uses of simulation in undergraduate psychiatric education since the last review in 2008. Expanding on the use of simulation to improve communication, build empathy, and decrease stigma in psychiatry is essential given the relevance to all facets of medical practice. Given the complexity of psychiatry, simulation interventions should extend beyond communication scenarios. Medical students need more opportunities to reflect and debrief on simulation experiences and integrate learning into new contexts. Faculty development should focus on these novel approaches to simulation to deeply engage learners and enhance outcomes.

The Relationship Between Academic Motivation and Lifelong Learning During Residency: A Study of Psychiatry Residents.

PURPOSE: To examine the relationship between lifelong learning (LLL) and academic motivation for residents in a psychiatry residency program, trainee factors that influence LLL, and psychiatry residents' LLL practices. METHOD: Between December 2014 and February 2015, 105 of 173 (61%) eligible psychiatry residents from the Department of Psychiatry, University of Toronto, completed a questionnaire with three study instruments: an LLL needs assessment survey, the Jefferson Scale of Physician Lifelong Learning (JeffSPLL), and the Academic Motivation Scale (AMS). The AMS included a relative autonomy motivation score (AMS-RAM) measuring the overall level of intrinsic motivation (IM). RESULTS: A significant correlation was observed between JeffSPLL and AMS-RAM scores (r = 0.39, P < .001). Although there was no significant difference in JeffSPLL and AMS-RAM scores based on respondents' level of training (senior vs. junior resident), gender, or age, analysis of AMS subdomains showed that junior residents had a significantly higher score on the extrinsic motivation identification domain (mean difference [M] = 0.38; 95% confidence interval [CI] [0.01, 0.75]; P = .045; d = 0.44) compared with senior residents. Clinician scientist stream (CSS) residents had significantly higher JeffSPLL scores compared with non-CSS residents (M = 3.15; 95% CI [0.52, 5.78]; P = .020; d = 0.57). CONCLUSIONS: The use of rigorous measures to study LLL and academic motivation confirmed prior research documenting the positive association between IM and LLL. The results suggest that postgraduate curricula aimed at enhancing IM, for example, through support for learning autonomously, could be beneficial to cultivating LLL in learners.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning.

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2).

PURPOSE: To develop and conduct feasibility testing of an evidence-based and theory-informed model for facilitating performance feedback for physicians so as to enhance their acceptance and use of the feedback. METHOD: To develop the feedback model (2011-2013), the authors drew on earlier research which highlights not only the factors that influence giving, receiving, accepting, and using feedback but also the theoretical perspectives which enable the understanding of these influences. The authors undertook an iterative, multistage, qualitative study guided by two recognized research frameworks: the UK Medical Research Council guidelines for studying complex interventions and realist evaluation. Using these frameworks, they conducted the research in four stages: (1) modeling, (2) facilitator preparation, (3) model feasibility testing, and (4) model refinement. They analyzed data, using content and thematic analysis, and used the findings from each stage to inform the subsequent stage. RESULTS: Findings support the facilitated feedback model, its four phases-build relationship, explore reactions, explore content, coach for performance change (R2C2)-and the theoretical perspectives informing them. The findings contribute to understanding elements that enhance recipients' engagement with, acceptance of, and productive use of feedback. Facilitators reported that the model made sense and the phases generally flowed logically. Recipients reported that the feedback process was helpful and that they appreciated the reflection stimulated by the model and the coaching. CONCLUSIONS: The theory- and evidence-based reflective R2C2 Facilitated Feedback Model appears stable and helpful for physicians in facilitating their reflection on and use of formal performance assessment feedback.