Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system.
BACKGROUND
Critical reflection by faculty physicians on adverse patient events is important for changing physician's behaviors. However, there is little research regarding physician reflection on quality improvement (QI).


OBJECTIVE
To develop and validate a computerized case-based learning system (CBLS) to measure faculty physicians' reflections on adverse patient events.


METHODS
Prospective validation study.


METHODS
Staff physicians in the Department of Medicine at Mayo Clinic Rochester.


METHODS
The CBLS was developed by Mayo Clinic information technology, medical education, and QI specialists. The reflection questionnaire, adapted from a previously validated instrument, contained eight items structured on five-point scales. Three cases, representing actual adverse events, were developed based on the most common error types: systems, medication, and diagnostic. In 2009, all Mayo Clinic hospital medicine, non-interventional cardiology, and pulmonary faculty were invited to participate. Faculty reviewed each case, determined the next management step, rated case generalizability and relevance, and completed the reflection questionnaire. Factor analysis and internal consistency reliability were calculated. Associations between reflection scores and characteristics of faculty and patient cases were determined.


RESULTS
Forty-four faculty completed 107 case reflections. The CBLS was rated as average to excellent in 95 of 104 (91.3%) completed satisfaction surveys. Factor analysis revealed two levels of reflection: Minimal and High. Internal consistency reliability was very good (overall Cronbach's α=0.77). Item mean scores ranged from 2.89 to 3.73 on a five-point scale. The overall reflection score was 3.41 (standard deviation 0.64). Reflection scores were positively associated with case generalizability (p=0.001), and case relevance (p=0.02).


CONCLUSIONS
The CBLS is a valid method for stratifying faculty physicians' levels of reflection on adverse patient events. Reflection scores are associated with case generalizability and relevance, indicating that reflection improves with pertinent patient encounters. We anticipate that this instrument will be useful in future research on QI among low versus high-reflecting physicians.
Department of Internal Medicine, Division of General Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Wittich.Christopher@mayo.edu
Christopher M
CM
Wittich
Francisco
F
Lopez-Jimenez
Lindsay K
LK
Decker
Jason H
JH
Szostek
Jayawant N
JN
Mandrekar
Timothy I
TI
Morgenthaler
Thomas J
TJ
Beckman
D000328:Adult; D002983:Clinical Competence / Q000592:standards*; D005180:Faculty, Medical / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D008875:Middle Aged; D010820:Physicians / Q000592:standards*; D016730:Program Development / Q000379:methods / Q000592:standards*; D011795:Surveys and Questionnaires / Q000592:standards