title: Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.
abstract: OBJECTIVE
  Residents' reflections on quality improvement (QI) opportunities are poorly understood. The authors used the Mayo Evaluation of Reflection on Improvement Tool (MERIT) to measure residents' reflection scores across three years and to determine associations between reflection scores and resident and adverse patient event characteristics.
  
  
  METHODS
  From 2006 to 2009, 48 Mayo Clinic internal medicine residents completed biannual reflections on adverse events and classified event severity and preventability. Faculty assessed residents' reflections using MERIT, which contains 18 Likert-scaled items and measures three factors-personal reflection, systems reflection, and event merit. ANOVA was used to identify changes in MERIT scores across three years of training and among factors, paired t tests were used to identify differences between MERIT factor scores, and generalized estimating equations were used to examine associations between MERIT scores and resident and adverse event characteristics.
  
  
  RESULTS
  The residents completed 240 reflections. MERIT reflection scores were stable over time. Individual factor scores differed significantly (P < .0001), with event merit being the highest and systems reflection the lowest. Event preventability was significantly associated with MERIT factor scores and overall scores (beta = 0.415; CI = 0.186-0.643; P = .0004). No significant associations between MERIT scores and resident characteristics or event severity were identified.
  
  
  CONCLUSIONS
  Residents' reflections on adverse events remained constant over time, were lowest for systems factors, and were associated with adverse event preventability. Future research should explore learners' emphasis on systems aspects of QI and the relationship between QI and event preventability.
authors.affiliation: Department of Internal Medicine, Division of General Internal Medicine, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Wittich.Christopher@mayo.edu
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Wittich
authors.forename: Darcy A
authors.initials: DA
authors.lastname: Reed
authors.forename: Monica M
authors.initials: MM
authors.lastname: Drefahl
authors.forename: Furman S
authors.initials: FS
authors.lastname: McDonald
authors.forename: Kris G
authors.initials: KG
authors.lastname: Thomas
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Halvorsen
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Beckman
mesh_terms: D004521:Educational Measurement / Q000379:methods*; D005163:Factor Analysis, Statistical; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D008137:Longitudinal Studies; D008910:Minnesota; D058996:Quality Improvement; D015203:Reproducibility of Results; D012308:Risk Management; D012647:Self-Assessment