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ARTICLE ORIGINAL / ORIGINAL ARTICLE INTEGRATING QUALITY and PATIENT SAFETY CONCEPTS in MEDICALCURRICULA Baseline Assessment in Lebanon http://www.lebanesemedicaljournal.org/articles/60-2/original3pdf Nabil NATAFGI 1 , Miriam SALIBA 2 , Rami DAYA 1 , Fadi El-JARDALI 1 INTRODUCTION The Institute of Medicine (IOM) revealed in 2000 that in the United States alone there were up to 98,000 mortali- ties per year due to medication errors [1]. This appalling figure incited a significant amount of changes to meet the new challenges of healthcare systems. The changes taking place in healthcare, however, are rarely aligned with sim- ilar changes and redesigns in medical education and aca- demic environment [2]. In fact, the main focus of medical education, especially among undergraduate students, is disease diagnosis and management; whereas little atten- tion is given to the proper management of healthcare sys- tems and quality improvement [3]. Medical students learn and train in highly complex Natafgi N, Saliba M, Daya R, El-Jardali F. Integrating quality and patient safety concepts in medical curricula: Baseline assess- ment in Lebanon. J Med Liban 2012 ; 60 (2) : 77-87. Natafgi N, Saliba M, Daya R, El-Jardali F. Intégration des con- cepts de qualité et de sécurité des patients dans le cursus médical : Evaluation de base au Liban. J Med Liban 2012 ; 60 (2) : 77-87. ABSTRACT • PURPOSE : Hospital accreditation places emphasis on the role of health professionals in quality of patient care. Training physicians in quality and pa- tient safety influences quality improvement efforts in healthcare. Little is known about the attitudes and knowledge of medical students towards the concepts of quality of care, patient safety and accreditation. The objective of this study was to determine the extent to which Lebanese medical students are aware of and familiar with these aforementioned concepts. METHODS : The study adopted a cross-sectional re- search design on a sample of (148 participants) gradu- ating medical students from four major universities in Lebanon. A semi-structured self-completion ques- tionnaire was developed to assess students’ knowledge towards : A) Quality concepts ; B) Quality tools ; C) Pa- tient safety & Risk management ; D) Accreditation ; and E) Policies & Procedures/Guidelines. Two statis- tical tests, MANOVA (parametric) and Kruskal-Wallis (nonparametric) were used to analyze the data. RESULTS : Study results showed that 85% of medi- cal students did not receive any course about quality and patient safety, although 93% considered them to be important and called for their integration into curricula. Lowest mean scores were recorded for the theme on quality concepts and tools (1.60 ± 0.81 and 1.49 ± 0.71 respectively). Respondents from sampled universities showed a general lack of knowledge of the themes studied. CONCLUSIONS : Quality, patient safety and accredi- tation are important disciplines that need to be incor- porated into medical curricula. This would be a posi- tive step towards enabling future physicians to meet the changing needs of the constantly evolving health- care system. RÉSUMÉ • OBJECTIF : L’accréditation des hôpitaux met l’accent sur le rôle des professionnels de la santé dans le domaine de la qualité des soins prodigués aux patients. La formation des médecins influence les efforts d’amélioration de la qualité des soins hospita- liers et de la sécurité des patients. Les attitudes et le niveau de connaissances des étudiants en médecine con- cernant les concepts qualité des soins, sécurité des pa- tients et accréditation restent méconnus. L’objectif de cette étude était de déterminer dans quelle mesure les étudiants en médecine libanais sont au courant de ces concepts et s’ils leur sont familiers. MÉTHODES : L’étude a adopté le modèle de recherche transversale impliquant un échantillon de diplômés en médecine (148 participants) de quatre grandes univer- sités au Liban. Un questionnaire semi-structuré et com- plété individuellement a été développé pour évaluer les connaissances des étudiants concernant : A) Concepts de qualité ; B) Outils de qualité ; C) Sécurité des patients et Gestion des risques ; D) Accréditation, et E) Politiques et procédures/Lignes directrices. Deux tests statistiques MANOVA (paramétrique) et Kruskal-Wallis (non para- métrique) ont été utilisés pour analyser les données. RÉSULTATS : L’étude a démontré que 85% des étu- diants en médecine n’ont reçu aucun cours de qualité des soins et sécurité des patients, alors que 93% consi- dèrent ces concepts importants et appellent à leur inté- gration dans les programmes. Les thèmes concernant les concepts et les outils de qualité ont eu les scores les plus bas (1,60 ± 0,81 et 1,49 ± 0,71 respectivement). Les participants parmi les universités choisies ont révélé un manque général de connaissances sur les thèmes étudiés. CONCLUSIONS : La qualité des soins, la sécurité des patients et l’accréditation sont des disciplines impor- tantes qui doivent être intégrées dans le cursus médi- cal. Ce serait une mesure positive qui permettrait aux futurs médecins de répondre aux besoins qu’entraîne l’évolution continuelle du système de santé. Departments of 1 Health Management and Policy, American University of Beirut (AUB); 2 Emergency Medicine, AUB-Medical Center, Beirut, Lebanon. Correspondence to: Dr. Fadi El-Jardali. Department of Health Management and Policy. Faculty of Health Sciences. American University of Beirut. P.O. Box 11-0236 - Riad El Solh. Beirut 11072020. Lebanon. e-mail: [email protected] Fax: +961 1 744 470 Tel: +961 1 350000 ext. 4692

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AARRTTIICCLLEE OORRIIGGIINNAALL//OORRIIGGIINNAALL AARRTTIICCLLEEINTEGRATING QUALITY and PATIENT SAFETY CONCEPTS in MEDICAL CURRICULABaseline Assessment in Lebanonhttp://www.lebanesemedicaljournal.org/articles/60-2/original3pdf

Nabil NATAFGI1, Miriam SALIBA2, Rami DAYA1, Fadi El-JARDALI1

INTRODUCTION

The Institute of Medicine (IOM) revealed in 2000 that inthe United States alone there were up to 98,000 mortali-ties per year due to medication errors [1]. This appallingfigure incited a significant amount of changes to meet thenew challenges of healthcare systems. The changes takingplace in healthcare, however, are rarely aligned with sim-ilar changes and redesigns in medical education and aca-

demic environment [2]. In fact, the main focus of medicaleducation, especially among undergraduate students, isdisease diagnosis and management; whereas little atten-tion is given to the proper management of healthcare sys-tems and quality improvement [3].

Medical students learn and train in highly complex

Natafgi N, Saliba M, Daya R, El-Jardali F. Integrating qualityand patient safety concepts in medical curricula: Baseline assess-ment in Lebanon. J Med Liban 2012 ; 60 (2) : 77-87.

Natafgi N, Saliba M, Daya R, El-Jardali F. Intégration des con-cepts de qualité et de sécurité des patients dans le cursus médical :Evaluation de base au Liban. J Med Liban 2012 ; 60 (2) : 77-87.

ABSTRACT • PURPOSE : Hospital accreditation placesemphasis on the role of health professionals in qualityof patient care. Training physicians in quality and pa-tient safety influences quality improvement efforts inhealthcare. Little is known about the attitudes andknowledge of medical students towards the concepts of quality of care, patient safety and accreditation. The objective of this study was to determine the extentto which Lebanese medical students are aware of andfamiliar with these aforementioned concepts.

METHODS : The study adopted a cross-sectional re-search design on a sample of (148 participants) gradu-ating medical students from four major universities in Lebanon. A semi-structured self-completion ques-tionnaire was developed to assess students’ knowledge towards : A) Quality concepts ; B) Quality tools ; C) Pa-tient safety & Risk management ; D) Accreditation ; and E) Policies & Procedures/Guidelines. Two statis-tical tests, MANOVA (parametric) and Kruskal-Wallis(nonparametric) were used to analyze the data.

RESULTS : Study results showed that 85% of medi-cal students did not receive any course about qualityand patient safety, although 93% considered them to be important and called for their integration intocurricula. Lowest mean scores were recorded for thetheme on quality concepts and tools (1.60 ± 0.81 and1.49 ± 0.71 respectively). Respondents from sampleduniversities showed a general lack of knowledge of thethemes studied.

CONCLUSIONS : Quality, patient safety and accredi-tation are important disciplines that need to be incor-porated into medical curricula. This would be a posi-tive step towards enabling future physicians to meetthe changing needs of the constantly evolving health-care system.

RÉSUMÉ • OBJECTIF : L’accréditation des hôpitauxmet l’accent sur le rôle des professionnels de la santédans le domaine de la qualité des soins prodigués auxpatients. La formation des médecins influence lesefforts d’amélioration de la qualité des soins hospita-liers et de la sécurité des patients. Les attitudes et leniveau de connaissances des étudiants en médecine con-cernant les concepts qualité des soins, sécurité des pa-tients et accréditation restent méconnus. L’objectif decette étude était de déterminer dans quelle mesure lesétudiants en médecine libanais sont au courant de cesconcepts et s’ils leur sont familiers.

MÉTHODES : L’étude a adopté le modèle de recherchetransversale impliquant un échantillon de diplômés enmédecine (148 participants) de quatre grandes univer-sités au Liban. Un questionnaire semi-structuré et com-plété individuellement a été développé pour évaluer lesconnaissances des étudiants concernant : A) Concepts dequalité ; B) Outils de qualité ; C) Sécurité des patients etGestion des risques ; D) Accréditation, et E) Politiques etprocédures/Lignes directrices. Deux tests statistiquesMANOVA (paramétrique) et Kruskal-Wallis (non para-métrique) ont été utilisés pour analyser les données.

RÉSULTATS : L’étude a démontré que 85% des étu-diants en médecine n’ont reçu aucun cours de qualitédes soins et sécurité des patients, alors que 93% consi-dèrent ces concepts importants et appellent à leur inté-gration dans les programmes. Les thèmes concernantles concepts et les outils de qualité ont eu les scores les plus bas (1,60 ± 0,81 et 1,49 ± 0,71 respectivement).Les participants parmi les universités choisies ontrévélé un manque général de connaissances sur lesthèmes étudiés.

CONCLUSIONS : La qualité des soins, la sécurité despatients et l’accréditation sont des disciplines impor-tantes qui doivent être intégrées dans le cursus médi-cal. Ce serait une mesure positive qui permettrait auxfuturs médecins de répondre aux besoins qu’entraînel’évolution continuelle du système de santé.

Departments of 1Health Management and Policy, American University of Beirut (AUB); 2Emergency Medicine, AUB-MedicalCenter, Beirut, Lebanon.

Correspondence to: Dr. Fadi El-Jardali. Department of Health Management and Policy. Faculty of Health Sciences. AmericanUniversity of Beirut. P.O. Box 11-0236 - Riad El Solh. Beirut 11072020. Lebanon.

e-mail: [email protected] Fax: +961 1 744 470 Tel: +961 1 350000 ext. 4692

78 Lebanese Medical Journal 2012 • Volume 60 (2) N. NATAFGI et al. – Quality and safety concepts in medical curricula

healthcare organizations. However, they lack adequatecompetencies and skills to help them deal with complexi-ties and barriers, analyze and assess managerial problems,and improve the system in place [2]. The notion of involv-ing medical students in ensuring patient safety has beenrather frail, although these students are members of thehealthcare team and are qualified to recognize medicalerrors [4].

When trying to achieve quality in healthcare, it is pru-dent to tackle the way healthcare professionals are edu-cated [2]. From that perspective, the World Health Organ-ization (WHO) has augmented its efforts to improvehuman resources for health through actively advocatingreform and improved medical education [5]. These effortswere expanded to improve education in quality measuresand accordingly the WHO’s World Alliance for PatientSafety has published in 2009 the ‘WHO Patient SafetyCurriculum Guide for Medical Schools’ in response to thefindings that showed that medical students themselveshave identified quality and safety of care as an importantarea of instruction [6].

Regional and Lebanese contextThe concepts of accreditation, quality and performanceimprovement are the interest and focus of many healthcareservices and organizations globally. In 2003, the WHOpublished a review indicating the scarcity of accreditationprograms in the Eastern Mediterranean Region (EMR) [7],which opened the door for a major reform in this sector inthe region. Thus, quality of care was transformed to one ofthe priorities of health policy agendas of governments inthe EMR [8]. In the Arab Region, numerous attempts weremade to establish national and/or regional accreditationschemes. Lebanon was a pioneer in this area by develop-ing and updating a national accreditation scheme for hos-pitals that was shaped and implemented by the Ministry ofPublic Health (MoPH) [9]. The most recent update of thisscheme was the addition of two new chapters to the stan-dards: (i) Patient Safety and (ii) Evaluation of ProfessionalPractice [10]. The successful implementation of the latterchapter entails a direct cooperation and coordination fromthe physicians who are the primary care providers to pa-tients. The literature attests, however, that physicians con-stitute a major obstacle to the process of implementation of standards especially those linked to quality and patientsafety [11]. A study to assess the patient safety culture inLebanese hospitals revealed that almost 60% of the partic-ipants, including physicians, did not report any adverseevent within a year [12]. Moreover, physicians reportedless adverse events than nurses and had a poorer percep-tion of safety [13]. This could be attributed to the lack ofemphasis on quality concepts in the curricula of the med-ical schools [11] and calls for empowering physicians toenhance their patient safety culture.

Indeed, it was found that one of the main concerns ofpolicy-makers in the EMR is the lack of updates in curric-ula and educational programs for health human resources,especially with concerns about the quality of nurses’ and

physicians’ education and its consequent effect on patientcare – which renders the quality and efficiency of such pro-grams highly questionable [14]. An exception was found inLebanon, where in 2008, the Syndicate of Private Hospi-tals and in collaboration with the Ministry of Education(MoE) succeeded in incorporating a mandatory course onquality management and accreditation in the curricula ofNursing Schools in Lebanon [15]. Despite this fact, Leb-anese Medical Schools are still lacking such courses intheir curriculum. To specifically examine the curricula ofLebanese Medical Schools, the Academic Catalogues pub-lished on the internet were investigated.** Our reviewrevealed a lack of a dedicated course for quality and/orpatient safety in all medical schools, with the exception ofone. Extensive research is required to analyze the currentsituation and to identify key areas for improvement. Manyworldwide studies are calling for reform in medical curric-ula and investigating different strategies that help medicalstudents acquire the appropriate quality and patient safetyeducation necessary to meet the changes in the healthcaresystem [16-21]. However, to our knowledge, studies con-cerning the incorporation of quality care and patient safetyconcepts into the curricula of medical schools in the EMRare deficient. Moreover, very little is known about the atti-tudes of medical students towards the concepts of qualityof care, patient safety and accreditation.

Study objectivesThe main objective of this cross-sectional research studyis to conduct a baseline assessment in Lebanon to deter-mine the extent to which graduating medical students areaware of and familiar with the concepts of quality careand patient safety in healthcare. This study also attemptsto sense the importance of those concepts for the medicalstudents.

METHODS

Study design, population and samplingThis research study adopted a cross-sectional design. Theselected approach enabled us to understand the currentfamiliarity of the future physicians entering the marketwith the concepts of quality, patient safety, and accredita-tion in healthcare.

The targeted population included all Lebanese graduat-ing medical students from four universities in Lebanon intheir final two years. These students perform regular clin-ical rounds and are in direct contact with patients. Theyalso resemble the future generation of physicians practic-ing in the medical field.

In Lebanon, seven medical schools exist. Our samplingframe (Figure 1) included a list of four medical schoolsthat represent the oldest and most developed American,**The reference is the Academic Catalogue of each of the follow-ing universities: American University of Beirut (AUB), University of Balamand (UofB), Beirut Arab University (BAU), LebaneseAmerican University (LAU), and Saint Joseph University (USJ) -Faculties of Medicine published on their respective websites.

N. NATAFGI et al. – Quality and safety concepts in medical curricula Lebanese Medical Journal 2012 • Volume 60 (2) 79

French and Egyptian medical teaching systems in Leb-anon. We randomly sampled 50% of the total number ofmedical students in their final two years of general medicaleducation from the following universities: the AmericanUniversity of Beirut (AUB) [American System]; SaintJoseph University (USJ) and the Lebanese University(LU) [French System]; and Beirut Arab University (BAU)[Egyptian System]. This sampling frame allowed the rep-resentation of diverse student bodies from different educa-tional backgrounds with diverse medical curricula. This, inturn, allowed for appropriate analysis to evaluate and com-pare different teaching systems. The target sample size was284 participants. Upon the completion of the data collec-tion process, a total of 148 surveys were collected with aresponse rate of 52.1%.

MeasuresIn this research study, a semi-structured self-completionquestionnaire was developed to assess the knowledge ofmedical students towards the concepts of quality, patientsafety and accreditation (See Appendix). The question-naire was designed based on the competencies of theWHO curriculum guide, the ACGME and the GMC [22-24]. It was mainly composed of quantitative close-endedquestions with a single qualitative open-ended question.

The quantitative part included several conceptual vari-ables divided into five themes:

[A] Quality concepts[B] Quality tools [C] Patient safety and Risk management (RM)

[D] Accreditation[E] Policies and Procedures/Guidelines.The conceptual variables were measured using a five-

point Likert scale:1: Strongly disagree2: Disagree3: Neutral4: Agree5: Strongly agree. Thus, each participant was asked to choose the most

suitable score according to his/her level of knowledge ofthe studied concepts. Such questions boosted the compara-bility of responses, facilitated the data-coding operationand were easy for respondents to complete. On the otherhand, the inclusion of an open-ended question allowed forthe emergence of responses that were not encompassed inthe fixed alternative close-ended questions.

ProceduresAfter securing the administrative approval from the deans,or their designees, of the four involved medical schools,we started the process of data collection. We utilized dif-ferent methods to approach the participants based uponthe request of individual universities. At the AmericanUniversity of Beirut (AUB), and since the targeted stu-dents do not have academic classes at their faculty, threeways were utilized in parallel to approach the participants:(i) send the consent and the survey to all Med III and Med IV students by email, (ii) keep some enveloped hardcopies for the participants at the Saab Medical Library

FIGURE 1. Sampling Procedure and Response Rate

80 Lebanese Medical Journal 2012 • Volume 60 (2) N. NATAFGI et al. – Quality and safety concepts in medical curricula

(SML) and assign the librarian the responsibility of pro-viding Med III and Med IV students with the surveys, (iii)personally seek them at their rotation departments at theAmerican University of Beirut Medical Center (AUBMC)and at SML. The results of the first and second methodswere almost negligible; hence, the researchers opted topersonally reach the targeted students at AUBMC andSML and inform them orally about the study and theirrights before providing them with the surveys. At theLebanese University (LU), the researchers approachedparticipants at their clinical rotation sites since LU medicalstudents also do not have academic classes on campus. Thefollowing sites, covering in total 50% of the students, werechosen: Sahel Hospital, Rizk Hospital, Hospital of Leba-non and Rafik Hariri University Hospital (RHUH). Sur-veyors approached the participants directly in their respec-tive departments. At the Beirut Arab University (BAU),and since medical students in their final two years of gen-eral medicine continue to attend classes in their faculty at BAU, the most suitable way for data collection was toorally inform the targeted students of the study objectives,their rights and provide them with the surveys directly after their class. At Saint Joseph University (USJ), the researchers reached medical students at ‘Hôtel-Dieu deFrance’ Hospital to survey the participants during twogatherings managed by the students’ representatives.n Ethical considerations

The proposal of this research study secured the AUBInstitutional Review Board (IRB) approval prior to datacollection. Since the nature of the research required col-laboration of different medical schools, contact was estab-lished with those schools to ensure their consent to carryout this research among their medical students. After weobtained this administrative consent, we orally informedall students participating in the survey about the researchtopic, its objectives and their rights as participants prior tosurvey administration. Both consents of the school andparticipants ensured the basic elements of completeness,disclosure, understanding, voluntariness and consent. Thenature of data collection ensured that all gathered data wasconfidential and did not allow the identification of therespondents, since we did not record the names of the par-ticipants and the names did not appear on the survey.

Data analysisAfter the completion of the data collection process, wecoded the data, entered it, cleaned and analyzed it usingSPSS 18.0. In addition, we carried out all analyses at alevel of significance of 0.05. n Analysis of the demographic information

We performed a descriptive analysis to summarize thedemographic information presented in the study. We com-puted the overall sample size, as well as the sample sizesand percentages of the different subgroups (universities,gender, age groups, medical education years and weeklyhours involved in medical care) using SPSS 18.0.n Analysis of the bivariate variables

To assess the importance of quality and patient safety

concepts from the perspective of medical students andwhether or not they call for integrating a quality courseinto their curriculum, two ‘Yes/No’questions were includ-ed in the questionnaire. Cross tables were used to analyzethe difference in responses of medical students to each ofthe scale items. Pearson χ2 was used to examine the asso-ciation between survey items, that is, to test whether the‘Yes/No’ answers were independent or not of the univer-sities. n Analysis of the multivariate variables

We analyzed the 5-point Likert Scale questions usingboth descriptive and inferential statistics. The descriptiveanalysis represented, for each university, the means corre-sponding to the five themes studied in the questionnaire.The inferential analysis allowed making conclusions fromthe presented data through examining whether significantdifferences exist between the four universities studied, inrelation to each of the five themes. Thus, we utilized twostatistical tests: parametric One-way Multivariate Analysisof Variance (MANOVA) test and non-parametric Kruskal-Wallis. MANOVA and Kruskal-Wallis met the same pur-pose: comparing the universities in relation to the fivestudied themes. Kruskal-Wallis test, however, is specifi-cally suitable for small size samples and when MANOVAassumptions are not met. As for the multiple comparisonstest, we chose the Bonferroni procedure. n Analysis of the open-ended question

We interpreted qualitatively the open-ended questionpresented at the end of the survey through a thematic

TABLE IDESCRIPTIVE STATISTICS ON STUDY SAMPLE

N %Total Sample Size 148 100

Gender Female 70 47.3Male 78 52.7

Age Group 20-24 133 89.925-30 13 8.8Missing 2 1.3

Medical Education Year Med III (6e) 79 53.4Med IV (7e) 69 46.6

Weekly Hours Involved in 5-19 29 19.6Medical Care 20-39 35 23.6

40-59 53 35.960-80 22 14.9Missing 9 6.0

Respondents per University AUB 35 23.6BAU 42 28.4LU 24 16.2USJ 47 31.8

Total Population of Medical AUB 166 29.3Students per University BAU 94 16.5

LU 168 29.6USJ 140 24.6

AUB: American University of Beirut BAU: Beirut Arab UniversityLU: Lebanese University USJ: Saint Joseph University

N. NATAFGI et al. – Quality and safety concepts in medical curricula Lebanese Medical Journal 2012 • Volume 60 (2) 81

analysis. We entered the responses of participants in a tableand analyzed them qualitatively. Responses were brokendown into related concepts and then coded into themes.

RESULTS

As observed in Table I, the sample was equally distributedbetween Medicine III (53.4%) and Medicine IV (46.6%)students and between males (52.7%) and females (47.3%).Also, more than 50% of the surveyed medical studentswere involved in direct patient medical care for more than40 hours per week.

Bivariate analysisn Course on quality in healthcare

The vast majority (85%) of the medical students indi-cated having never taken a course or covered material onquality in healthcare during their previous or current yearof medical education. Responses to this question were sig-nificantly different across surveyed universities (p-value <0.001). Results show that 85.7% of all the medical studentswho indicated taking a course were from USJ (Table II). n Importance of quality concepts and their integration

in the existing curriculumThe vast majority of the participants (93%) acknow-

ledged the importance of quality and patient safety; 88%of whom called its incorporation of such concepts in their

existing curriculum. However, results also showed thatresults were independent from the four participating uni-versities for both questions (p-value of 0.454 and 0.161respectively) (Table III).

Multivariate analysisn Knowledge of specific quality and patient safety concepts

To assess the knowledge of medical students on quali-ty and patient safety concepts, we performed aggregatedescriptive analyses (Table IV) for the four universities onthe five main themes studied.

TABLE IIDISTRIBUTION OF STUDENTS GIVEN A QUALITY COURSE

ACROSS UNIVERSITIES

COURSE ON QUALITY IN HEALTHCARE

University Yes No p-valueN (%) N (%)

AUB 2 (9.5) 33 (27.0) < 0.001

BAU 0 (0.0) 38 (31.1)

LU 1 (4.8) 23 (18.9)

USJ 18 (85.7) 28 (23.0)

AUB: American University of Beirut BAU: Beirut Arab UniversityLU: Lebanese University USJ: Saint Joseph University

TABLE IIIIMPORTANCE OF QUALITY CONCEPTS AND THEIR INTEGRATION IN THE EXISTING CURRICULUM

IMPORTANCE OF QUALITY AND PATIENT SAFETY CONCEPTS INTEGRATING A QUALITY COURSE INTO THE CURRICULUM

University Yes No p-value Yes No p-value

N (%) N (%) N (%) N (%)

AUB (American University of Beirut) 31 (22.6) 4 (40) 0.454 27 (22.5) 4 (25) 0.161

BAU (Beirut Arab University) 41 (29.9)* 1 (10) 39 (32.5) 1 (6.3)

LU (Lebanese University) 21 (15.3) 2 (20) 17 (14.2) 4 (25)

USJ (Saint Joseph University) 44 (32.1) 3 (30) 37 (30.8) 7 (43.8)

*A single student answered ‘YES’ to the question on importance of quality & patient safety concepts but failed to answer the subsequent question on integratinga quality course into the curriculum.

TABLE IVCOMPARISON OF MEANS FOR COMPOSITE SCORES ACROSS UNIVERSITIES

UNIVERSITIES MEAN (SD)*AUB BAU LU USJ Total p-value

A. Quality Concepts 1.84 (0.86) 1.57 (0.79) 1.42 (0.73) 1.55 (0.82) 1.60 (0.81) 0.217

B. Quality Tools 1.61 (0.70) 1.6 (0.77) 1.25 (0.67) 1.44 (0.67) 1.49 (0.71) 0.188

C. Patient Safety & Risk Management 2.94 (1.17) 2.57 (1.05) 2.81 (1.15) 2.84 (1.14) 2.78 (1.12) 0.545

D. Accreditation •s 2.47 (1.16) 2.03 (1.01) 2.00 (1.37) 2.97 (1.48) 2.43 (1.32) 0.002

E. Policies & Procedures/Guidelines •© t 4.03 (0.98) 2.75 (1.32) 2.88 (1.52) 3.53 (1.38) 3.32 (1.39) < 0.001

* SD: Standard Deviation •Significant difference between BAU & USJ s Significant difference between LU & USJ© Significant difference between AUB & BAU t Significant difference between AUB & LU AUB: American University of BeirutBAU: Beirut Arab University LU: Lebanese University USJ: Saint Joseph University

82 Lebanese Medical Journal 2012 • Volume 60 (2) N. NATAFGI et al. – Quality and safety concepts in medical curricula

The comparison of the mean scores highlighted that theknowledge of students was the lowest in the themes ofQuality Tools [B] and Quality Concepts [A], with a meanscore of 1.49 (± 0.71) and 1.60 (± 0.81) respectively. The highest mean score was observed for the knowledgeof Policies and Procedures/Guidelines [E] (Mean: 3.32, SD: 1.39).

These results showed that medical students at the fouruniversities surveyed were not introduced to the conceptsand tools of quality. However, medical students have beenintroduced to concepts of policies and procedures andclinical-based guidelines. Concerning patient safety, riskmanagement and accreditation, it seemed that the medicalstudents were hesitant whether they were introduced tothese concepts during their education. n Comparing knowledge towards quality and patient

safety concepts among different universitiesThe results of Kruskal-Wallis test showed a significant

difference in knowledge of concepts of Accreditation [D]and Policies and Procedures/Guidelines [E] among themedical schools of the four universities (Table V). Indeed,MANOVA results (Table IV) validate these results ofKruskal-Wallis. The Post-Hoc test of Bonferroni identi-fied that in theme [D] Accreditation, the knowledge ofUSJ medical students on accreditation concepts (meanscore of 2.97) was significantly higher than that of BAU(mean score of 2.03) and LU (mean score of 2.00). More-over, for the theme [E] Policies and Procedures/Guide-lines, the knowledge of AUB medical students (meanscore of 4.03) was significantly higher than that of LU(mean score of 2.88) and BAU (mean score of 2.75).

Qualitative analysisAnalysis of the answers of the open-ended question, ask-ing the students to share any further information or notesregarding the research topic or survey questions, revealedcommon themes.

On one hand, few students confirmed their unfamiliar-ity with the ‘names’ of the concepts and tools studied inthe survey. Furthermore, they stated that during their med-ical practice, they perform their duties with a high senseof quality of care and patient safety. This could imply thatsome of the students may actually be familiar with the

concepts raised but not the terms used in the questionnaireper se. In their opinions, such concepts should not consti-tute a priority for medical students because of time short-age, the presence of clinical guidelines, and minimal in-volvement of physicians in administrative or institutionalroles.

On the other hand, a significant group of medical stu-dents expressed a different opinion. They revealed that theconcepts and tools studied in the questionnaire were unfa-miliar and were not included in any previous course. Themajority of students agreed that the five themes of the sur-vey were of great importance. In addition, they highlight-ed that these themes must be incorporated in the medicalcurricula. The same group of students emphasized the dire necessity to inform the Deans of the medical schoolsabout the results so they can act accordingly.

DISCUSSION

The findings of our study conformed to previous studies[25] showing that medical residents admitted the need forbetter patient safety, although they declared their lack ofknowledge on how to undertake such improvements.

As per the results mentioned above, it was evident that the majority of medical students did not receive anycourse about quality in healthcare, and this validated thecurriculum review conducted for each university. Wenoted the only exception in the study sample in USJ,where 39% of the medical students attested taking acourse about quality of care. Although it was the highestobserved, this percentage is still considered low despitethe partial coverage of some of the tackled themes as partof a course at USJ. This might be attributed mainly tothree items: (i) not all USJ medical students recalled tak-ing such a course or its competencies, or (ii) they may notconsider it related to quality, or (iii) because these themeswere only part of a course and they did not consider itenough. Thus, these findings suggest that the vast major-ity of the imminent physicians of the future may lack thesatisfactory level of knowledge about quality and patientsafety concepts, which might in turn reflect negatively ontheir patient outcomes at some instances.

Moreover, a high percentage of medical students con-

TABLE VKRUSKAL-WALLIS TEST

[A] [B] [C] [D] [E]Quality Concepts Quality Tools Patient Safety & Accreditation Policies & Procedures

Risk Management Guidelines

AUB 87.76 81.39 77.18 77.36 95.90

BAU 71.51 76.72 62.55 62.18 55.40

LU 64.58 54.65 71.41 57.04 61.27

USJ 70.72 71.12 73.40 88.55 82.38

p-value 0.105 0.053 0.454 0.004 < 0.001

AUB: American University of Beirut BAU: Beirut Arab University LU: Lebanese University USJ: Saint Joseph University

MEAN RANKS

N. NATAFGI et al. – Quality and safety concepts in medical curricula Lebanese Medical Journal 2012 • Volume 60 (2) 83

sidered quality concepts to be important. This could beattributed to a multitude of reasons. First, they were neveracquainted with such issues or concepts before whichenticed them to discover – especially that they deal withpatient safety and performance improvement which areattracting increasing attention. It could be hypothesized, aswell, that physicians are perceived to have a comprehen-sive understanding about virtually everything related tothe practice of medicine and patients. This in turn calls onthem to consider these concepts important to be learnedsince they lack sufficient knowledge about it. Similarresults were found in a study conducted at Li Ka ShingFaculty of Medicine in Hong Kong to assess the percep-tion of undergraduate medical students towards patientsafety. Although 25% of students argued that ‘errors cannever be made by competent physicians,’ more than 80%of students showed positive attitudes regarding the intro-duction of a new patient safety curriculum [26]. Addition-ally, medical students like to contribute to the healthcareteam and be more involved in the patient care process. Butseveral factors may hinder and discourage them from erroridentification and communication. These factors may berepresented by the students lack of sufficient experience,the fact that they are not licensed to practice yet, hesitan-cy to speak up, and the medical hierarchy. Another expla-nation to this finding is possibly the fact that medical students witness and sometimes are directly involved inunsafe care, errors, or adverse events [17] which mightdrive them to consider such concepts important to be stud-ied and incorporated in their curricula.

Among all four universities, the lowest means record-ed were for quality concepts and quality tools. In fact, thisfinding conforms to evidence from the literature that phy-sicians usually strive for providing highest quality of carewhile they lack knowledge about it; and do not know howto define ‘quality’ or even measure it [27]. One reasoncould be that most of these concepts are theoretical innature. But the only way to duly understand such conceptsis by direct application. This implies that medical studentsought to be included in quality improvement initiativesand apply quality improvement tools and concepts.

As per the results of the multivariate analysis, all theuniversities showed a general lack of knowledge of thethemes with an average of less than three; the only excep-tion was the theme related to Policies & Procedures/Guidelines, found to be highest in USJ followed by AUB.MANOVA further validated this finding and proved thatAUB and USJ scored significantly higher means in thesection of Policies & Procedures/Guidelines compared toother universities. This could be attributed to the fact thatthe students conducted their clinical clerkships in teachingmedical centers which emphasized the importance of evi-dence-based guidelines and practices based on establish-ed clinical protocols. Another intriguing finding in theMANOVA was that although the scores of AUB and USJwere relatively low on knowledge about accreditation,they were still higher compared to other universities. Thiscould be justified by the presence of a course that includ-

ed principles about accreditation at USJ and the imple-mentation of the Joint Commission International (JCI)accreditation standards at AUBMC.

LimitationsTwo limitations for this study should be recognized. Onebasic limitation in the study was the relatively small sam-ple size. We were not able to achieve more than 52% ofthe target number of participants due to the difficulty inreaching medical students – who were in most cases dis-persed in different hospitals. Nevertheless, this is compa-rable to the average US medical student’s response rate of50% [28] and somehow represented the different medicalschools involved. Another significant limitation in thestudy was the absence of other universities in the study.One of which had an established course about qualitygiven to medical students. It would have been interestingto compare the findings of this university with other uni-versities. The strength of this study, however, is that itassessed the oldest and most developed medical curriculain Lebanon.

ImplicationsAt a national level, the results of this study will help pro-vide evidence for stakeholders and policy makers aboutthe scope of coverage of quality concepts in medical edu-cation. Consequently, policies and interventions shall beimplemented to promote amendments of the current med-ical curricula. A recent article published in the Lancetcalled for a transforming education to achieve more equi-table and better performing health systems with conse-quent benefits for patients and populations [29]. Though,this reform calls for pooling of efforts and expertise frommore than one stakeholder. Therefore, our recommenda-tions are at three levels: micro, meso and macro.

From a micro-level, it is critically important to includethe medical students themselves in this change. If studentsdo not comprehend the importance of this reform and en-dorse it, it would not have a significant impact. In thatsense, the Lebanese Medical Students’ International Com-mittee (LeMSIC) can play an active role in advocatingmedical schools to incorporate these materials. It also hasan important role in delivering the voice of medical stu-dents to the stakeholders.

At the meso-level, it is advised that medical schools,hospitals, the Order of Physicians and the Syndicate ofHospitals combine efforts to achieve a unified aim throughdifferent approaches. First, it is recommended that medi-cal schools establish an additional course to the exist-ing curriculum, dedicated to quality and patient safety inhealthcare. The course should be given prior to commenc-ing clinical rotations so the students would be alreadyknowledgeable about the essential concepts before beingin direct patient care. Knowing that medical students areoverwhelmed with tremendous amounts of courses andmedical material, a good approach is to enhance the exist-ing medical curriculum by integrating quality care learningobjectives into the pre-existing medical courses. This

84 Lebanese Medical Journal 2012 • Volume 60 (2) N. NATAFGI et al. – Quality and safety concepts in medical curricula

would be in direct conformity with the ‘WHO curriculumguide for medical schools’ (Figure 2) which is highly en-couraged to be contextualized and applied in the Lebaneseculture. In fact, the literature highlights several success sto-ries related to incorporating quality into medical curric-ula. At the University of Connecticut Medical School, the administration incorporated quality improvement intothe curriculum of medical students [30]. Students reportedgaining more appreciation towards Continuous Quality Im-provement (CQI) and its favourable outcomes on patientcare after attending seminars and patients’chart-abstractionsessions [31].

It is meaningful to transfer the learning to the workplaceso that theories and education would result in practice.Thus it is advised to encourage medical students to applythe concepts and tools learned into their medical practice.This is achievable through including a rotation in the qual-ity department as part of the clinical clerkship. This step isintended to acquaint students about the importance of qual-ity and show them when and how quality and patient safe-ty knowledge can be applied. Yet, the quality department isnot the only place where students can apply their acquiredknowledge and skills. In fact, medical students have to bemotivated to practice safe and high quality medicine in anyclinical environment and patients interactions. Also at ameso-level, the Order of Physicians and the Syndicate ofHospitals can organize seminars or conferences for med-ical students to deliver continuous and up to date know-ledge on the different quality and patient safety themes.Indeed, the number of physicians and medical studentsreporting errors increases by integrating quality care con-ferences in the hospital’s quality improvement plan [31].

Finally, at a macro-level, policy makers are encourag-ed to reform and improve the medical education processwith the aim of enhancing future quality and patient safetypractices, thus reflecting positively on patients’ health andwellbeing. This is critically important since several Min-istries of Health in the region are mandating the imple-mentation of national and international accreditation stan-dards in healthcare organizations. The Ministry of Educa-tion (MoEd) and the Ministry of Public Health (MoPH)

have the jurisdiction to enforce minimum educational re-quirements on these concepts that all universities shouldincorporate in their curricula. Such ministries can play arole in unifying the course that can be compiled with thehelp of professionals in the field and given to all students.They can also play an important role in enhancing the hos-pitals’ environments to encourage safe practices.

At a regional level, this study constitutes an initiativefor other countries in the EMR to further assess existingmedical curricula. Extensive research in this field is inevi-table especially that review of published literature hasexposed the scarcity of information and research abouthealth professional education [29].

CONCLUSIONS

On a concluding note, this study proved that medical stu-dents across the three different medical teaching systemsin Lebanon (the French, American and Egyptian) did not present a well established and sufficient knowledgeabout Quality, Patient Safety and Accreditation. Thesedisciplines are important and need to be incorporated inthe medical curricula to graduate well-rounded and com-petent physicians. Extensive efforts from all stakeholdersneed to take place across the three medical education sys-tems to achieve a meaningful theoretical as well as practi-cal change.

ACKNOWLEDGMENTS AND DISCLOSURES

The authors would like to thank all the universities repre-sented by the Deans and their delegates that facilitatedthe access to their student body to partake in this researchstudy. The American University of Beirut (AUB), BeirutArab University (BAU), Lebanese University (LU) andSaint Joseph University (USJ) identified to be leadinguniversities that took a daring step to assess the know-ledge of the students and showed interest for the study, itsfindings and its recommendations. The authors also areheartily thankful to Mrs. Diana Jamal for her generousassistance.

WHO CURRICULUM GUIDE TOPICS FOR MEDICAL SCHOOLS

Topic 1 What is patient safety?Topic 2 What is human factors and why is it important to patient safety?Topic 3 Understanding systems and the impact of complexity on patient careTopic 4 Being an effective team playerTopic 5 Understanding and learning from errorsTopic 6 Understanding and managing clinical risk Topic 7 Introduction to quality improvement methods Topic 8 Engaging with patients and carersTopic 9 Minimizing infection through improved infection controlTopic 10 Patient safety and invasive proceduresTopic 11 Improving medication safety

FIGURE 2

N. NATAFGI et al. – Quality and safety concepts in medical curricula Lebanese Medical Journal 2012 • Volume 60 (2) 85

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APPENDIXSURVEY TOOL • Semi-structured self-completion questionnaire

N. NATAFGI et al. – Quality and safety concepts in medical curricula Lebanese Medical Journal 2012 • Volume 60 (2) 87