title: Incorporating performance improvement methods into a needs assessment: experience with a nutrition and exercise curriculum.
abstract: BACKGROUND
  Clinical guidelines recommend that physicians counsel patients on diet and exercise; however, physician counseling remains suboptimal.
  
  
  OBJECTIVE
  To determine if incorporating performance improvement (PI) methodologies into a needs assessment for an internal medicine (IM) residency curriculum on nutrition and exercise counseling was feasible and enhanced our understanding of the curricular needs.
  
  
  METHODS
  One hundred and fifty-eight IM residents completed a questionnaire to assess their knowledge, attitudes, and practices (KAP) about nutrition and exercise counseling for hypertensive patients. Residents' baseline nutrition and exercise counseling rates were also obtained using chart abstraction. Fishbone diagrams were created by the residents to delineate perceived barriers to diet and exercise counseling.
  
  
  METHODS
  The KAP questionnaire was analyzed using descriptive statistics. Chart abstraction data was plotted on run charts and average counseling rates were calculated. Pareto charts were developed from the fishbone diagrams depicting the number of times each barrier was reported.
  
  
  RESULTS
  Almost 90% of the residents reported counseling their hypertensive patients about diet and exercise more than 20% of the time on the KAP questionnaire. In contrast, chart abstraction revealed average counseling rates of 3% and 4% for nutrition and exercise, respectively. The KAP questionnaire exposed a clinical knowledge deficit, lack of familiarity with the national guidelines, and low self-efficacy. In contrast, the fishbone analysis highlighted patient apathy, patient co-morbidities, and time pressure as the major perceived barriers.
  
  
  CONCLUSIONS
  We found that incorporating PI methods into a needs assessment for an IM residency curriculum on nutrition and exercise counseling for patients at risk of cardiovascular disease was feasible, provided additional information not obtained through other means, and provided the opportunity to pilot the use of PI techniques as an educational strategy and means of measuring outcomes. Our findings suggest that utilization of PI principles provides a useful framework for developing and implementing a medical education curriculum and measuring its effectiveness.
authors.affiliation: Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA. shelly-ann.fluker@emory.edu
authors.forename: Shelly-Ann
authors.initials: SA
authors.lastname: Fluker
authors.forename: Ursula
authors.initials: U
authors.lastname: Whalen
authors.forename: Jason
authors.initials: J
authors.lastname: Schneider
authors.forename: Paul
authors.initials: P
authors.lastname: Cantey
authors.forename: Jada
authors.initials: J
authors.lastname: Bussey-Jones
authors.forename: Donald
authors.initials: D
authors.lastname: Brady
authors.forename: Joyce P
authors.initials: JP
authors.lastname: Doyle
mesh_terms: D002983:Clinical Competence; D003479:Curriculum; D004032:Diet; D037001:Directive Counseling; D004503:Education, Medical, Graduate / Q000379:methods; D015444:Exercise; D005240:Feasibility Studies; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D009043:Motor Activity; D020380:Needs Assessment; D015596:Nutrition Assessment; D009752:Nutritional Status; D058996:Quality Improvement; D011795:Surveys and Questionnaires