A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum

Tiffany A. Gardner, Elizabeth K. Breitbach, Julia E. Limes, Geoffrey R. Connors, Andrew R. Berry, August A. Longino, Sneha Shah, Brandon Fainstad, Tyler M. Miller, Carolina Ortiz-Lopez, and Michelle Fleshner

Summary

This study highlights the application of quality improvement (QI) methods to the design and implementation of a novel point-of-care ultrasound curriculum within a large internal medicine residency program. Through the utilization of QI techniques such as process mapping, plan–do–study–act cycles, and qualitative interviews, the study identified areas for improvement and conducted timely tests of change. The results showed that the QI methods led to a significant reduction in the time required for feedback and the identification of time traps and errors in image archives and quality assurance cards. This pilot study demonstrates the potential for QI methodologies to enhance curricular development beyond clinical processes and suggests that such an approach may increase resident engagement in QI efforts.

Interview

KP: Why did you decide to initiate a quality improvement project involving point-of-care ultrasound (POCUS) in your internal medicine residency program, and what were the primary goals or motivations behind this choice?

TG: During my Chief Resident year, I had protected time to work on quality improvement efforts. I've always had an interest in ultrasound and medical education so I wanted to combine those interests for my quality improvement work and demonstrate that the methodology we use in QI is broadly applicable but particularly useful in curriculum development and implementation.

KP: Can you share insights into the challenges or lessons learned when applying quality improvement (QI) methods to the development and quality assurance of your POCUS curriculum?

TG: This process highlighted for me that regardless of how well-thought-out an intervention is, there will always be unexpected limitations so it's important to be intentional around the timing of assessing your intervention, getting feedback, and being flexible. We had a small cohort of faculty performing Quality Assurance (QA) and needed to change our QA workflow several times to accommodate their complex schedules in a way that allowed for timely feedback to residents.

KP: Based on your pilot study's findings, what recommendations can you provide for other medical residency programs looking to integrate POCUS into their curricula while maintaining quality assurance?

TG: There is growing momentum and enthusiasm for POCUS from both faculty and residents. Harnessing that enthusiasm and local expertise was instrumental to the success of our pilot. It was also incredibly helpful to have mentorship from our QI leadership with clear goals and means of assessing the impact of our intervention.

KP: How did you decide on the content and structure of the quality assurance cards mentioned in the abstract, and how do you think it contributed to the success of your program?

TG: Our QA cards were initially modeled after the imaging requirements described in the SHM-CHEST POCUS Certificate of Completion, but modified to include what we considered to be core competencies for internal medicine residents. The goal was to reinforce critical image acquisition and interpretation skills and provide an opportunity for feedback from our local experts. The early versions of our QA cards focused on checklists which neither the faculty nor residents found particularly helpful, so they changed over time to include more commentary feedback.

KP: Resident–reviewer interpretation concordance was present in 80.7% of submissions. How did you measure and assess the accuracy of resident interpretations of POCUS images, and what steps were taken to improve concordance?

TG: For each image submitted, the resident submitted a QA card and answered a series of questions to better understand their interpretation. These questions focused on what structures were visible, if they could see specific pathology such as a pleural effusion, or make a qualitative assessment of ejection fraction. POCUS faculty then reviewed each submission and provided feedback on the interpretation. We used this information to track which content most frequently had discordant interpretations and subsequently modify our didactic content.

Blog Post Author

Krunal H Patel, MD completed his medical school training at Ross University School of Medicine in Dominica. He then pursued his interests in Internal Medicine in Brooklyn, NY at SUNY Downstate Health Sciences University where he also completed his Chief Residency focused on medical education in Point of Care Ultrasonography. He is currently a fellow in Pulmonary and Critical Care at Temple University Hospital. His interests remain in medical education, critical care, and lung transplantation.

Twitter: @MDKrunalP

Article Author

Tiffany Gardner, MD completed medical school at Oregon Health & Sciences University prior to moving to Colorado where she completed Internal Medicine Residency and Chief Residency, where she focused on Quality Improvement and Ultrasound education. She is currently a first year Pulmonary & Critical Care Fellow at the combined MGH/BI PCCM Fellowship program in Boston. Her career interests include Critical Care Medicine, Ultrasound, and Pulmonary Hypertension.

Twitter: @TiffanyG_MD