Instruction and Assessment of the Practice-Based Learning and Improvement Competency

In response to societal expectations that healthcare be efficient, effective, affordable and safe, at the level of the individual and outcomes for populations, the Accreditation Council for Graduate Medical Education organization changed from their focus on process to outcomes. By implementing their Next Accreditation System (NAS), that adds a timeline and benchmarks for achieving competencies, and Clinical Learning Environment Review (CLER) program, gathers evidence on the learning environment, a fundamental goal of residency education could be fostered, development of life-long learning skills. Life-long learning skills are fundamental to the ACGME Practice-Based Learning and Improvement (PBLI) competency and demonstrated when residents continuously improve their patient care based on constant self-evaluation and life-long learning. One type of resident education program, believed to develop PBLI competence, uses Quality Improvement (QI) activities that often incorporate a method referred to as Plan-Do-Study-Act (PDSA). These programs are often implemented in a resident continuity clinic since it allows longitudinal or multiple observations as well as immediate outcomes and could demonstrate that a resident maintains their skills over time or successfully implements PDSA/QI in different clinical contexts. Those multiple observations support an outcome that indicates learning and a change in behavior, exemplified as the life-long learning and indicative of PBLI competence, occurred. However, a systematic review of the literature (residency programs that used PDSA/QI to develop PBLI competence) showed that residents learned PDSA/QI methodology, but long-term, longitudinal outcomes were not measured so, a persistent change in behavior to support their development of PBLI competence, could not be demonstrated. Further exploration of this complex and multifaceted healthcare learning environment required a conceptual focus that viewed PDSA/QI as implementation of an innovation. Using implementation theory as a framework and a realist review methodology, facilitated exploration of additional factors or constructs that if unaddressed could also impact the desired outcome of a PDSA/QI program, demonstration of PBLI competence. These additional factors or barriers further explained why PDSA/QI methodology could be learned, but PBLI was still unlikely to be identified, even if the one deficiency common to all studies, making the PDSA/QI activity iterative and longitudinal, was addressed.