really good stuff prescribing errors, communication lapses during inpatient to out-patient transitions, and lack of timely laboratory follow-up. What lessons were learned? At the end of the rotation, all residents agreed it was a useful initiative that should be continued. Comments included ‘. . .gave a new perspective to approaching medical errors’, ‘. . .extremely relevant, engaging, intriguing. . .’, and ‘. . .excellent that education on this topic is being formalised’. We encountered several barriers in developing this programme. We were limited by the number of medical error submissions: although we have an online database to submit reports, it is underutilised, entries are anonymous, and few ambulatory cases are included. We learned about cases through word of mouth and it proved difficult to find unique and timely issues to address on a monthly basis. However, as the conference evolves, more residents and faculty staff are reporting cases. In addition, the residents felt it required a large time commitment, although we did schedule time for them to work on these projects. Although there was initial concern about this culture change, clinic leadership has been extremely supportive. After each conference, we meet with leadership to determine which action plans are feasible to implement. We are generating a database of cases, which includes root cause analyses and proposed solutions; we plan to utilise these results to develop quality improvement projects that residents can pursue during their subsequent ambulatory care block. REFERENCE 1 Caverzagie KJ, Iobst WF, Aagaard EM et al. The internal medicine reporting milestones and the next accreditation system. Ann Intern Med 2013;158 (7): 557–9. Correspondence: Jennifer Rockfeld, Department of Medicine, New York University School of Medicine, Bellevue Hospital, Amb Care 2D, 462 First Avenue, New York, New York 10016, USA. Tel: 00 1 917 439 8449; E-mail: [email protected] doi: 10.1111/medu.12438

Using continuous quality improvement to enhance professional behaviour Marie Trontell, James Galt, Peter Amenta & Carol Terregino1 What problems were addressed? From 2008 to 2011, a higher than national average percentage of

Robert Wood Johnson Medical School (RWJMS) students reported on the Association of American Medical Colleges (AAMC) Graduation Questionnaire that they had been mistreated. Clinical faculty staff were perceived as a major source of this mistreatment. What was tried? The school enhanced anonymous electronic student evaluation tools, convened a special task force and educated faculty staff, all measures which failed to achieved significant improvement. We then applied a continuous quality improvement (CQI) approach to student-generated ratings of faculty professional behaviour, using data from anonymous online end-of-clerkship evaluations. In the academic year of 2008–2009, a survey item was added to the RWJMS Clerkship Activity Tracking System (CATS) survey that students are required to complete after clerkships in family medicine, internal medicine, obstetrics and gynaecology, paediatrics, psychiatry, and surgery. In this very comprehensive survey, students were asked to report their level of agreement, on a 5-point Likert scale, with the statement: ‘Faculty displayed professional demeanour towards patients, their families, peers, trainees, and staff.’ An optional text box for commentary followed this item. The CATS surveys were shared with department chairs, but the voluminous data included in each end-of-clerkship report made it difficult to identify patterns and trends. We extracted the responses to the item on faculty professionalism from each CATS report and created bar graphs to display the means and ranges of professionalism ratings, as well as the number of negative free-text comments, for named faculty members in each department. The intent of this approach was to draw attention to the small number of faculty staff who were perceived by students to act unprofessionally and to facilitate change over time. Starting in 2011, these data were analysed via CQI and de-identified ratings of professionalism were graphed and shared with the departments involved. Individual faculty staff and their chairs knew the coded identifiers. Over the next 2 years, reports were shared twice yearly via e-mail and department meetings. Faculty discussions of the reports were constructive and generally positive. On the 2012 and 2013 AAMC Graduation Questionnaires, RWJMS scored lower than the national average for the percentage of students experiencing mistreatment by faculty staff, and student evaluations for 2012–2013 reveal no repeat faculty offenders. What lessons were learned? We believe our CQI approach to decreasing student mistreatment by

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really good stuff clinical faculty staff helped improve the learning environment at RWJMS in several ways. With respect to faculty staff, this approach to changing behaviour is familiar to clinicians, demonstrates the high priority placed on this issue by the school, highlights individual performance with respect to benchmarks and the performance of peers, and has the potential for inclusion in faculty staff portfolios and incentive systems. With respect to students, it shows that their feedback is valued and that professional behaviour is expected of all physicians. We acknowledge that factors other than the CQI approach may have contributed to the decrease in reports of mistreatment because the school continued its special task force and faculty education efforts. We intend to continue this approach and to expand its use to include residents. Correspondence: James Galt, Office of Graduate Medical Education, Robert Wood Johnson Medical School, 125 Paterson Street, RM 587, New Brunswick, New Jersey 08901, USA. Tel: 00 1 732 235 3369; E-mail: [email protected] doi: 10.1111/medu.12465

Online tool to promote medical student professionalism and moral decision making Sigall K Bell, B Price Kerfoot & Elizabeth Gaufberg What problems were addressed? Educators seek ways to understand and address professionalism barriers in clinical learning environments. Innovative social technologies offer new opportunities to explore the hidden curriculum. Online spaced education (SE) has been extensively studied and validated as a method of promoting enhanced knowledge acquisition, retention and behavioural change,1 but its role as an educational tool for developing professionalism has not yet been explored. What was tried? We created an online curriculum for Year 3 medical students at four hospitals at one academic centre to examine how students react to professionalism-related moral dilemmas. We developed nine cases reflecting speaking-up challenges. Examples include: a student is asked to perform a procedure for which he or she is ill prepared; a student observes an error but is asked by a resident to ‘keep this between us’; a student feels complicit in the use of derogatory language about patients, and a student witnesses the falsification of medical records. Using the Qstream SE platform

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(www.qstream.com/solutions/healthcare/), students were sent one or two new cases each week and asked to explain in a 140-character, open-ended response what they would specifically do or say in each situation. Upon submitting their answer, students were presented with a list of potentially equivalent responses previously submitted by other students. Qstream created the list through a keyword-matching process designed to aggregate similar free-text responses. Students selected an equivalent answer or submitted their own unique response, and then received immediate feedback from faculty members, as well as access to information on how their peers had responded. One week later, students were given the same case again but this time the 10 most popular responses were aggregated as answer options. This second presentation allowed students to reconsider the case, refine their thinking, and see common ways in which their peers had approached the problem. After responding, students again received faculty staff feedback to reinforce professionalism and communication principles. The study was approved by the institutional review board at our medical school. What lessons were learned? Eighty-four of 165 students (51%) participated in the voluntary programme. Following the course, 92% of surveyed students indicated they were interested in learning more about communication strategies for navigating the hidden curriculum. The majority (88%) felt Qstream was an effective way to learn about professionalism, and 89% found it a unique way to facilitate online collaborative learning. Many (85%) reported that they had experienced something similar to the course cases during medical school, and 75% felt that the Qstream curriculum addressed issues in a way that did not occur elsewhere in their education. Many (85%) found it helpful to see how peers responded to speaking-up challenges, and 60% reported that they considered adopting a colleague’s approach. Asked what was the ‘best thing about Qstream’, the majority of students commented on the opportunity to see other students’ responses. Many (94%) would recommend the experience to a peer. Strategies to help students speak up in clinical situations of unprofessionalism are needed. Innovative social technologies may provide a safe space in which students can individually and collectively explore such challenges. Technologies such as Qstream can serve as both learning interventions and research vehicles to map moral decision making in the clinical learning environment, and help educators detect areas in need of focused attention.

ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 522–548

Using continuous quality improvement to enhance professional behaviour.

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