A century after Codman’s pioneering work to introduce outcome based medicine into healthcare and 30 years after the introduction of quality improvement, it is gratifying that more medical schools are including these concepts in their curricula and approaches for teaching and assessing students [34]. Ideally, these concepts are taught at the beginning of student clinical experiences and become an integral part of the ongoing development of physicians’ clinical improvement skills [34]. Some medical schools have implemented focused QI electives for students in the clinical years [35]. The World Health Organization (WHO) emphasizes that patient safety and QI should be taught to medical students [36]. In contrast, the standards of the Liaison Committee on Medical Education, which accredits US and Canadian medical schools, do not yet include formally mention curricular elements or require competence in healthcare quality and safety [37]. Recommendations from the National Patient Safety Foundation (NPSF) on enhancing patient safety call for medical schools to emphasize the ACGME/ABMS competencies, patient-centered care, and working in interdisciplinary teams [38]. The NPSF also has recommended that teaching about patient safety should begin on the first day of medical school and should encompass the science of error causation and mitigation, the study of human factors, safety improvement science, systems theory and analysis, and systems design [38].

Graduate medical education is the phase of the educational continuum during residency and fellowship training where much of physicians’ education about healthcare quality and safety occurs. While many of the first QI curricula targeted medical students, a few were aimed at both students and residents. In 2002, recommendations called for a broader approach to teaching QI to physicians, including expanded curricula, a focus on creating an organizational culture conducive to improvement and assessing outcomes at the individual and program levels [39]. Early efforts focused on non-mandatory “QI electives” [40], while more recent implementation of QI in the residency curriculum entails mandatory QI rotations and experiences for all residents [41–43].

Some teaching efforts have used active engagement in projects that integrate didactics with the application of what is learned [44]. This is based on the principles of experiential learning [45, 46]. The underlying theory is that teaching should be grounded in learners’ experiences and that these experiences themselves represent a valuable educational resource [46]. Learning by doing and “just in time training,” are related approaches that have been found useful in teaching QI principles and practices to learners across a range of health professions [47]. Efforts have also focused on the creation of templates that guide learners through the QI process, and that allow QI efforts to be recorded like other scholarly projects [48].

Currently, five approaches are commonly used for teaching residents PBLI, SBP and related concepts: (1) didactic sessions, including lectures, case studies, journal clubs and on-line self-study modules; (2) incorporating QI principles and concepts into clinical events such as morbidity and mortality (M&M) and clinical case conferences, and morning report [49–51]; (3) resident-initiated quality improvement projects [52, 53]; (4) resident participation in program-level QI projects; and (5) participation in multi-disciplinary institutional QI efforts [54]. Readily implementable modules, some of which are online, are being used to facilitate improvement in outcomes for common diagnoses such as diabetes and asthma are being used particularly in ambulatory and primary care settings [55–57]. Some improvement efforts have a longer term focus, multiple PDSA cycles, and include a focus on spread and sustainability of improvement [58]. A matrix that crosslinks the Institute of Medicine (IOM) aims with the ACGME competencies has also been used to make QI concepts meaningful to residents [59]. Efforts to involve residents in larger department or institutional QI efforts are less common. Some examples include addressing waiting times in pediatric urgent care [60]; improving patient flow in a resident continuity clinic [40]; use of practice data to enhance compliance with immunization guidelines [61]; standard order sets for patients with community-acquired pneumonia [62]; and a resident-led initiative to improve communication between the inpatient medical staff and ambulatory physicians [63]. The AAMC’s Teaching for Quality report offers broad recommendations for medical schools and teaching hospitals to incorporate the principles and practice of Quality Improvement and Patient Safety (QI/PS), including learning experiences and use of these concepts in the assessment of physicians across the continuum of education and practice [64].

Since the 1970s, medicine, nursing and several other health professions require continuing education to maintain a professional license [65]. To ensure the effectiveness and quality of continuing education for physicians, providers of continuing medical education must be accredited by the Accreditation Council for Continuing Medical Education (ACCME) [66]. A review of the literature on the effectiveness of continuing medical education (CME) found a positive effect on attitude and practice behaviors, and some improvement in outcomes [67]. At the same time, the value of traditional CME is being challenged, with critics noting that CME is mostly delivered in lectures, with little post-participation assessment beyond learner reactions and self-reported changes in behaviors [68, 69]. In contrast, interactive learning, and participating in multiple activities focused on the same topic are effective in producing moderate to significant change in participants’ behavior [70, 71]. A 2010 IOM report on redesigning continuing education in the health professions noted flaws in existing approaches that include narrow curricula, a failure to focus education on individual and collective knowledge and capability gaps [72], and gaps related to quality and safety of care.

The responsibility for assessing ongoing professional development of physicians in practice lies with the member boards of the American Board of Medical Specialties (ABMS). Board certification grew out of concerns about the quality of physician education and preparation for practice at the turn of the twentieth century, resulting in the establishment of the Advisory Board of Medical Specialties, the precursor of the American Board of Medical Specialties in 1933 [73].

Initially, board certification was achieved by passing a secure written and for some specialties and oral examination at the end of formal training and was valid over a physicians’ entire career. Starting in the 1970s, several ABMS boards, acknowledging that medical knowledge changes rapidly over the course of a physician’s career initiated a process of periodic re-certification through repeat secure knowledge examinations. Over time all member boards gradually moved from life-time certificates to time-limited certificates and periodic repeat examinations [74, 75]. The American Board of Family Medicine has required periodic recertification since its inauguration in 1969 [76]. Research on the effect of board certification has found a positive and statistically significant association between specialty board certification and greater compliance with recommended treatments and improved outcomes. Certification for internists is associated with improved patient care [77], and prevention of medical errors [78]. Examples from the surgical field include lower mortality and complication rates for surgical procedures, including carotid endarterectomies and aortic aneurysm surgery [79], colon surgery [80], and surgery for peptic ulcers [81].

In 1999, prompted by documented gaps in quality and safety of care in almost all areas of medicine and a growing focus on improving care, the ABMS redesigned the certification process to ensure ongoing competence by including expectations that all diplomates engage in measuring and improving the quality of care they provide, using the framework of the six competencies first developed by the ACGME and adopted by ABMS [73]. Over the past decade, certifying boards have moved from assessing professional development primarily based repeated assessment of medical knowledge through a secure examinations and participation in CME to use of self- and peer assessments of other competencies such as communication, professionalism, actual delivery of care, the ability to function in complex systems and the ability to assess and improve quality of care in practice [74]. The resulting four part Maintenance of Certification® (MOC) framework became official ABMS policy in 2000 and by 2006 all 24 member specialty boards had established time lines for implementing MOC [74].

The MOC has four components. Part I requires physicians maintain an unrestricted medical license [74], and surgeons must document they have privileges or a staff appointment in a hospital accredited by the Joint Commission [82]. Part II requires completion of a specified amount of CME or acquisition of specialty specific medical knowledge, some of which must relate to the physician’s clinical practice [83]. Part III, “Cognitive Expertise,” consist of a completing a periodic secure specialty examination, and Part IV, “Performance in Practice,” requires physicians to assess their practice performance, with some boards requiring improvement data for a sample of patients, such as data extracted from medical records and clinical databases, or results of patient surveys [74]. Physicians may use Web-based improvement modules, such as the Patient Safety Improvement Program developed by the ABMS [84], or the improvement modules developed by the American Board of Pediatrics, American Board of Family Medicine and the American Board of Internal Medicine. Physicians are encouraged to aggregate their performance data into a portfolio that documents how their diagnostic and clinical decisions and outcomes compare to those of peers and available national comparisons. For surgeons, the MOC Part IV offers credit for ongoing participation in a national, regional or local outcomes registry or quality assessment program, and the American Board of Surgery requires that this improvement program address areas specific to the individual physician’s practice [82]. The concept of continuous professional development integrated with PBLI is considered important in helping surgeons improve the care they provide to patients [85].

Physicians are encouraged to participate in proven QI efforts that have been shown to improve care to address gaps in quality in areas in need of improvement. Part IV activities in several specialties use Practice Improvement Modules (PIMs), which facilitates collaborative, QI efforts within practices and across practices [86, 87]. An added advantage of PIMs is that they can be used in teaching settings to collect longitudinal improvement data for individual residents [86, 87]. Several of the MOC programs also award Part IV MOC credit for diplomate participation in approved ongoing QI efforts in their practice setting. Some of these efforts are multi-center prospective ongoing QI networks that have demonstrated significant improvement in outcomes of care and at times reduction in cost of care [88]. Other examples include medication reconciliation [89], prevention of childhood obesity [90], and prevention and management of cardiac disease [91], among others. Some boards have made significant gains in introducing improvement activities into the professional development of practicing physicians while for other specialties MOC is still early in its implementation. Fifteen of the ABMS boards have agreed to common standards for awarding credit for MOC Part IV to diplomates who participate in organizationally sponsored QI efforts through the Multi-Specialty Portfolio Program [92]. Data on the effectiveness of MOC in improving the safety and quality of care is growing and can be tracked on the ABMS website (http://​www.​ABMS.​org).

Physicians’ role in institutional healthcare improvement requires a new skill set for individuals who function as institutional leaders in quality and safety, with a formal description of the role and its responsibilities [93], and the requisite knowledge and training, including implementation science and policy work [94, 95]. Examples of programs for training these quality experts are found in the Department of Veterans Affairs [96], Dartmouth College [97], and George Mason University [98].

Given the variability in how and to what degree curricula and educational approaches in health professions education emphasize improving quality and patient safety, one solution that has been proposed is interprofessional education, which has been generally found to enhance quality and reduce cost in healthcare [99]. The value of interprofessional education has been emphasized since the 1970s [100], and beginning in 2013, the LCME standards require medical schools to prepare students to function collaboratively on teams that include other health professionals in training and practice [101].

The “Retooling for Quality and Safety” initiative of the Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement has developed a curriculum focused on interprofessional training, involving both medical and nursing students [102]. The initiative fostered integration of improvement and patient safety curricula in undergraduate medical and nursing education, emphasizing the value of interprofessional learning because the didactic curriculum is taught the same way actual improvement occurs, in interprofessional teams addressing quality problems in a real clinical setting. The advantage of this approach is that “learning how to do quality improvement and actually carrying out quality improvement are essentially one and the same; both are special forms of experiential learning” [103]. A few successful models exist for the pre-licensure phase of education [104], and there is a need to expand this work to the continuum of health professions formation.

Curricula for interprofessional learning have included train-the-trainer exercises that facilitate hands-on training [105]. For patient safety, curricular components have included patient safety basics, developing academic leadership, improving the culture of practice, changing the response to error, and applying principles of interprofessional teaching and learning [106]. Interprofessional learning is also being proposed for continuing education in the health professions. A 2010 IOM report on the redesign of continuing education recommended that it be carried out in interprofessional teams that mirror the team composition in the healthcare setting [107]. A recommendation for advancing team-based learning and practice also has called for the development of community learning sites to serve as venues for interprofessional learning and practice [108]. This type of interprofessional learning and practice does not yet occur in many settings, although there are efforts to conduct e-learning activities that provide a matched curriculum to multiple health professions, to promote interprofessional learning [109]. In addition the IHI Open School modules are suitable for use across difference health professions [31], and many of the quality improvement efforts approved for MOC Part 4 credit involve interdisciplinary care teams [74].