Teaching improvement science to paramedicine students: protocol for a systematic scoping review

While a definition of paramedicine is still a subject of debate within this young healthcare discipline [1], it is clear that one of the core functions of paramedics is the provision of effective and safe out-of-hospital care. The relatively young age of the paramedicine profession and associated lack of research capacity, combined with the complexities of conducting data collection in a mobile health care setting, have meant that out-of-hospital practice has generally been based on relatively weak evidence [2‐5]. However, research progress is being made and has real and future potential to substantially expand and raise the evidence for out-of-hospital systems and care [4, 6, 7]. Besides the production of evidence, one of the most important challenges for any healthcare service in this century is the implementation of research evidence into routine practice [8]. Ambulance services are no exception, and thus, with the evidence base expected to grow as well as pressure to function in progressively complex and demanding environments [9], the success of out-of-hospital care systems is becoming increasingly dependent on effective implementation and broader quality improvement strategies.

Successful improvement efforts rely not only on the knowledge, experience and intuitions of subject matter experts, but, to be most effective, these insights must be framed scientifically and tested [10]. Therefore, in modern healthcare services, the unceasing efforts to advance the quality of care and to find effective solutions to problems are underpinned by a science of its own domain—improvement science. It entails system thinking, understanding variation, psychology of change, and the theory of knowledge that are applied to improve the performance of processes and organizations [10]. Improvement science is an evolving field which can be considered the scientific foundation of quality improvement, exploring how it can be best conducted [11]. It uses robust scientific methods to understand and evaluate the quality improvement process. In principle, improvement science aims to ensure that quality improvement efforts are based as much on evidence as the best practices they seek to implement [12].

Quality improvement is not new to the health services though and has its roots in the work of Avedis Donabedian, a physician and researcher most famous for the development of the widely applied Donabedian Model [13]. Further evolution of quality improvement in health care was greatly influenced by other industries, most notably manufacturing [14]. W. Edwards Deming, significantly contributed to what became known as total quality management. In the 1990s, Toyota’s Lean and Motorola’s Six Sigma methods influenced how quality was managed in health care and contributed towards a shift from quality assurance to continuous quality improvement [14, 15]. In 1999, the Institute of Medicine published To Err is Human: Building a Safer Health System: Building a Safer Health System, a report on adverse events in health care [16]. Similar research was conducted in countries other than the USA with equally concerning occurrence rates [17, 18]. Research into adverse events in health care gave patient safety and quality improvement further momentum and placed increased pressure on health care organizations to demonstrate that patients could trust in the safety and quality of the services they provide.

Traditionally, ambulances services had been considered predominantly as a call-handling and transportation service, encompassing some aspects of pre-hospital care [19]. This operational focus combined with the paucity of evidence for clinical interventions has contributed to paramedicine somewhat lagging behind in applying improvement methods compared to the hospital-based healthcare services [20‐22]. A scoping review of quality indicators for out-of-hospital care suggests that a specific definition of quality in the context of paramedicine remains elusive and many metrics used to evaluate it remain focused on traditional ideologies [23]. A recent study investigating the adoption of quality programs in ambulance services throughout the USA found a high degree of variability in the tracking of performance measures and demonstrated the need for better access to quality improvement tools, guidance on how to adopt best practice, and staff development [24]. Timely conveyance of patients with urgent and emergency care needs to an appropriate health care facility remains a primary function of modern ambulance services. However, the scope of out-of-hospital care and coverage that ambulance services provide has evolved significantly [25‐29]. Although modern ambulance services can simply be seen as one part of the larger healthcare system, out-of-hospital and mobile health care remains unique in many ways [20], not least of which is the physical environment in which it is provided. These factors may make the application of general improvement principles challenging, highlighting the need for ambulance service leadership to have the knowledge and skills of scientific quality improvement. In other healthcare disciplines, it has been argued that improvement science is now as essential to good practice as the human life sciences that is taught during undergraduate training [30].

In light of the growing body of evidence for out-of-hospital systems and care, the need for this evidence to be implemented, as well as the required scientific approach to do this effectively, it would appear that it is now more important than ever to equip paramedic students, the likely future managers and leaders of ambulance services, with the knowledge and skills of improvement science. Effective teaching requires a repertoire of teaching methods that will engage students actively in learning [31]. Although the range and effectiveness of methods used for teaching improvement science to clinicians and healthcare students has been systematically reviewed in other healthcare disciplines such as medicine and nursing [32‐35], the evidence regarding the specific sub-group of paramedicine students has yet to be fully explored and synthesized in the literature. The aim of this scoping review is to systematically explore and critically appraise the current state of evidence regarding strategies to teach improvement science to paramedicine students. To achieve this overall aim, the review will:

There are a number of reasons why a scoping review, rather than a more traditional type of systematic review, might be conducted [36]. In the current study, the scoping review methodology was considered most suitable because it aims to explore and examine the extent, range, and nature of research activity in the area of interest and, in doing so, identify research gaps in the existing literature. Scoping reviews may be especially relevant to disciplines or areas with incipient evidence as they include a variety of study designs from both published and gray literature [37]. Quality improvement science, especially applied in the paramedicine discipline, is an emerging concept and unpublished sources which do not meet rigorous academic standards may still provide important information and insights. Beyond underpinning future systematic review or research, scoping reviews can also inform practice [38]. This scoping review could potentially provide a considerable evidence base to aid in the development of teaching curricula and selection of teaching methods in paramedicine programs.

This review protocol was developed using the PRISMA-Protocols (PRISMA-P) 2015 checklist (Additional file 1: Table S1) [39], and the final review output will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [40]. Considering the iterative nature of scoping review methodology, any amendments to the protocol will be reported explicitly (i.e., date, description, and rationale) in the final review output. Currently, scoping reviews are not eligible for registration on the international prospective register of systematic reviews (i.e., PROSPERO). This review was exempt from human research ethics review at Western Sydney University.

Not applicable.

To the knowledge of the authors, this is the first review that will systematically explore and critically appraise the current state of research evidence regarding strategies to teach improvement science specifically to paramedicine students. It is anticipated that the findings of this review will help to inform academic staff, developers of paramedicine teaching curricula, and researchers planning projects in this area.