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Table 1 Level of learning achieved by students based on Kirkpatrick’s (K) teaching evaluation pyramid

From: Sustainability in quality improvement (SusQI): a case-study in undergraduate medical education

Kirkpatrick Level Rating Description Implications Illustrative quotes
K1: How did learners engage with the session? ++ Students valued the session, liked the resources and interactive group-based activities. The teaching was well designed and delivered. “Definitely the best Hub [session] we’ve had so far.” V9
“It was something that I anecdotally told other people about because it kind of impacted on me so much.” E3
“It [was] great that there [were] so many resources like presentations and videos and worksheets”. B3
K2: What did students learn?
1. Knowledge
2. Skills
3. Attitudes
++ Students developed knowledge and skills; were motivated; developed a ‘SusQI gaze’; their professional identity was congruent with SusQI values; they viewed the NHS as dynamic; saw quality improvement as valuable. The experience built a new lens through which to view healthcare, and a triad of positive reframing. Knowledge domain:
“I suppose you just want to think about the future and the fact that you want whatever you’re doing now it’s be available X number of years down the line, to make sure that [your resource] doesn’t run out. I think in the in the Hub session, we did talk about things like whether ambulances could be made more environmentally friendly, so carbon emissions, literally from vehicles, to hospitals. So it’s sort of thinking about all different aspects of the hospital rather than, like not just within the hospital.” A3
“You’re not just doing things for the sake of doing them or because people have always done it that way. You’re actually actively thinking about what is necessary and what isn’t and then what you can do to change that.” D1
Skills domain:
“[You’ve got] that QI-head on your shoulders, [asking] what can I do? What can I improve? Why is this the way it is?” C2
“It did make me, kind of, more aware of the protocol for during one and you know that... That wheel... The um, “Plan study act”, whatever it was [PDSA cycle].” C3
Attitudes domain:
“I always saw quality improvement as like, pretty dull and boring. And I just didn’t really care about it [but] quality improvement isn’t just about improving healthcare, it’s also about improving, like sustainability as well and bringing that into the forefront. I think that’s important because you’re gonna get a lot more people, a lot more doctors, also a lot more nurses and even porters, care more about sustainability, and I think it’s worth utilising that.” D1
“It’s just highlighted the fact that the NHS will be an ever evolving system, there’s always going to be something that doctors or students or anyone can do to improve it. And so I guess I’ll just be more on the lookout as I go through the ranks as to what things can be changed and what I can actually do to make it better.” A3
K3: Did students apply (or intend to apply) their learning? + Few projects were undertaken. For some, motivated intentions could not overcome barriers. The workplace environment does not naturally support students to enact SusQI “I spoke to my CTF (clinical teaching fellow) afterwards actually, and he sent me some... It was like a ‘e-learning’ thing about QI projects, which was really good. It’s sort of like, helped me get to grips with how to actually run one.” D2
“I remember feeling at the time quite inspired to... Well, I did actually get involved in a sustainability QI project... But it got squashed [by the COVID-19 pandemic] … We were sort of in the process of developing it … we were gonna tag on to the desflurane anaesthetic gas reduction project one in [name of hospital]. We were sort of gonna help spearhead that.” D2
“We were trying to do something in [name of hospital] but I think we’ve binned it because we got sent home obviously [due to COVID-19]. But we were gonna try and get more recycling bins around the hospital.” B4
K4: Did applying their learning realise sustainable value for services? No successful SusQI projects completed by the time of focus groups. Significant improvements must be made before SusQI education creates impact on NHS sustainability. N/A