Developing quality improvement awareness, skills, and emerging leadership behaviors through clinical audits in postgraduate medical education

BACKGROUND: Quality improvement (QI) is a crucial competency for medical residents navigating the complexities of modern healthcare systems. This study explores the impact of experiential learning, through clinical audits, on residents' QI awareness, QI skills and emerging QI leadership behaviors within their clinical learning environment. METHODS: A retrospective multiple embedded case study was conducted within two departments of a University Medical Centre in the Netherlands. We interviewed residents (n = 11), supervisors (n = 7), training program directors (n = 2), and a quality officer within two years after the clinical audit. Data analysis involved within and cross-department analysis to identify factors influencing the development of QI awareness, QI skills and emerging QI leadership behaviors in residents. RESULTS: Residents develop QI awareness and QI skills through increased experiential knowledge, by presenting audit data and inspiring colleagues to implement change, by being aware of shared QI responsibility, demonstrating emerging QI leadership behaviors legitimized by the clinical audit and its outcome, and by striving to complete the full clinical audit cycle, including implementation and re-evaluation. Challenges for the successful implementation of clinical audits include the following: (1) Recognizing the value of clinical audits by residents and shared responsibility at work for auditing and improving patient care, (2) Department leadership's support in ensuring commitment from all healthcare professionals to clinical audits as a QI Instrument, (3) Faculty role modeling in line with the department leadership's goal that quality improvement is an integral part of daily practice, and (4) Healthcare professionals' commitment to fostering teamwork and collaborative learning. CONCLUSIONS: This study shows that clinical audits can support residents in developing QI awareness and QI skills; however, this effectiveness was variable. Progression beyond data collection and analysis towards implementing improvements and demonstrating emerging QI leadership behaviors was limited and strongly shaped by the clinical learning environment. Effective development of these skills and behaviors therefore depends on a supportive environment in which medical staff values clinical audits, actively participates in the audit process, and embeds audits within departments' clinical governance.