In 1999, the Institute of Medicine's report on medical errors, "To Err Is Human," turned public attention to the importance of measuring health care quality and outcomes.1 In its follow-up report, "Crossing the Quality Chasm," the Institute of Medicine went on to highlight the pervasive nature of quality problems in health care and how medicine often does not meet its potential.2 The report made a series of recommendations for redesigning systems of care, including preparing the future workforce to better serve patients in a world of rapid change. Thus, health care professionals in training are expected to gain competency in quality and safety and to provide leadership in improving health care in conjunction with learning the traditional skills of their specific discipline.3

More than a decade since these reports were published and despite mandates by the American Association of Medical Colleges,4 the Quality and Safety Education in Nursing, and the Accreditation Council for Graduate Medical Education to incorporate quality improvement (QI) in the curriculum, health care educators still struggle with how best to do this. Some of the reasons for the slow adoption of QI learning include the traditional rigid health care curriculum, lack of faculty with quality and safety expertise and interest in QI, overwhelming student workload, and the absence of students' understanding of how QI applies to their education.5,6 In addition, quality curricula have a unique set of teaching challenges, given their focus on interdisciplinary learning and an almost prerequisite to work in teams when compared with traditional health care education that is very discipline specific and has been organized around concepts such as autonomy, independent work, and silos. Because educators, both nationally and internationally, are struggling with "trying to fit a square peg in a round hole" phenomenon when it comes to quality education, we are very excited to bring to you this special education issue of QMHC.

This special issue provides innovative curricular examples from different disciplines across the learning continuum. A variety of learning methods are proposed to deliver quality content such as lectures, small groups, seminars, Web based, and simulations. The authors' contributions are testimony to the established belief that no one method is sufficient to teach quality and that didactics and lectures may set the foundation, but experiential learning with mentored field projects is imperative.7

The issue begins with a historical journey tracing Case Western Reserve University's quality and safety education, highlighting 3 successful programs that are fully integrated in health care curriculum. The authors identify key elements that are needed for an institution to initiate and sustain long-term QI courses in an ever-changing environment. The issue contains 4 articles that emphasize interprofessional learning. The curricular content is delivered in small group sessions as described by Hall, while Margalit presents it in a seminar series. Cox leads an article that takes interprofessional learning to the next level by highlighting professional student group differences in attitudes and skills in patient safety and quality care. Interestingly, one difference they found is that nursing students were more likely than medical students to believe that punishment should follow error, that competent providers do not make mistakes, and that an effective strategy for reducing errors is to exercise more vigilance.

In the articles by Margalit and Kirsh, faculty are encouraged to "think outside the box" in relation to the environment in which QI education occurs. Margalit suggests health care professionals move out of their traditional silos to learn to work more collaboratively. Kirsh argues that one of the biggest barriers to interprofessional education is the lack of clinical practice models and reports on shared medical appointments as an arena to facilitate team and interprofessional learning.

In their respective contributions, Huntington, Jones, and Hall address the importance of experiential learning in QI in which students engage in clinical QI projects in addition to small group, didactic learning, or use a workbook to guide them. Hall points out that the projects identified by students had a significant impact on care delivered. Watts and her coauthors raise the question "Does the current environment in which quality and safety is taught send mixed messages?" They point out that the constant question in the literature of the clinical value of pay for performance and other quality indicators may play a role in perceived lack of buy-in from trainees regarding the importance of QI education. Specifically, their article highlights that health care mandates, built with a perceived lack of attention to the individual patient provider dynamics, create an environment of frustration for providers and add to the lack of interest and resistance to learning QI.

We believe that there is promise in quality education when it comes to innovative curriculum; however, there is much work to be done in the evaluation realm of such curriculum. Overall, the evaluation in these articles is predominantly descriptive and ranges from mostly qualitative to very little quantitative evaluation. Dycus and McKeon highlight this problem and present a tool to measure quality and safety knowledge, skills, and attitudes for pediatric oncology nurses.

The issue highlights the growing need for valid and reliable instruments for the evaluation of quality education. A paucity of literature exists on the effectiveness of teaching quality as highlighted in a recent review of the literature.8 We believe that rigorous evaluation of quality education calls for the development of instruments to measure teamwork, interprofessional learning, and outcomes such as the success of QI projects. Furthermore, these newly developed instruments must be tested and disseminated to the larger academic community to advance the scholarship of quality education.

Measurement and evaluation of effectiveness of QI learning thus appear to be the next steps in the continuous improvement cycle of QI education. In some ways, this journal issue is a testament to QI principles because it provides one small Plan-Do-Study-Act (PDSA) cycle in the education curriculum. To facilitate future P-D-S-A cycles, this issue includes a list of resources to further opportunities for curricular innovation and rigorous evaluation.

Given the many academic barriers to quality education, this issue reflects the dedication of many faculty and clinical partners. We are confident that such dedication to QI education coupled with rigorous evaluation methods will help shape the next cycle of preparing health care professionals to better serve patients in a world of rapid change.

We would like to thank the following guest reviewers: Margunn Aaestad, Sandra Amin, DeWitt C. Baldwin, Barbara Brandt, Linda Cronenwett, Daniel Duffy, Stuart Gilman, Gwen Halaas, Christine Hudak, Judith Halstead, Pamela Ironside, Katherine Jones, David Kaelber, Marilyn Lotas, Shirley M. Moore, Deborah Nadzam, Klara Papp, Gwen Sherwood, Mark Splaine, Elaine Smith, Dori Sullivan, Nancy Tinsley, and Daniel R. Wolpaw.

Mary A. Dolansky, PhD, RN

Mamta K. Singh, MD, MS

Issue Editors

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