Table 2

Summary of contexts and mechanisms associated with successful outcomes of QI curricula

Contexts	Description of contexts	Contexts commonly associated with successful curricula
Level of training	The level or stage of medical training where QI curricula was embedded into the core curriculum or where learners had the opportunity to participate in QI curricula.	Curricula at the postgraduate level of training (longitudinal curricula with experiential, project-based learning); scholarly concentrations at the undergraduate level or involvement of medical students in pre-existing or ongoing, heavily mentored projects aligned with the health system priorities.
Curriculum strategy	The primary strategies for teaching QI to medical learners in the core curriculum.	Longitudinal curricula spanning multiple years that combined didactic with experiential learning.
Setting for QI curricula	The setting or system for QI curricula to be integrated into and QI concepts to be applied to.	Ambulatory clinics, particularly resident continuity clinics (if available).
Organisational culture	The broader culture towards QI at an institution and/or its affiliated healthcare system.	Alignment of the curriculum with healthcare system priorities.

Mechanisms	Description of mechanisms	Mechanisms commonly associated with successful curricula
General mechanisms	Factors that supported the overall success of the QI curriculum.	Structured curricula with clear expectations (eg, minimum number of Plan-Do-Study-Act cycles and project completion by end of residency) and deliverables (eg, submission of a project charter and final reports). Protected time for both learning QI (ie, integrating QI teaching into the core curriculum) and to work on QI projects. Mentors: QI-trained faculty, chief resident of quality and safety, resident champion, or senior resident. QI curriculum leadership (faculty or chief resident of quality and safety). Academic (eg, continuing education credits) or financial incentives for faculty leaders, mentors, and learners.
Learning mechanisms	Factors that supported QI learning and project progression as learners could apply their growing knowledge and skills to their projects.	Content delivery strategies (eg, just-in-time learning and flipped classroom) to reinforce QI principles and apply concepts to the stage of the project.
Project mechanisms	Factors that specifically supported QI project progression, sustainability and impact.	Project screening tools (eg, scoring frameworks and reviewing project charters) to ensure projects are appropriate in scope and alignment with the local health system priorities. Frequent meetings (eg, an hour per month during protected academic time) to maintain project momentum. Access to data (eg, National Surgical Quality Improvement Program data) and help analysing data. Project handover mechanisms (eg, project handover tools) to promote continuity and sustainability for short-term projects. Working in teams on QI projects, with other members of the health team, other medical learners, and other health professions trainees. Incentives or recognition for top-performing groups or projects.

Outcomes	Description of outcomes	Contexts or mechanisms commonly associated with positive outcomes
Educational outcomes	Outcomes relating to the impact of the curriculum on learner knowledge, skills and attitudes towards QI.	General mechanisms (particularly structure and protected time). Learning mechanisms (particularly content delivery strategies).
Health system outcomes	Improvements to processes and/or outcomes in the healthcare system as a result of the QI curriculum.	Longitudinal, experiential QI curricula with team-based projects in the ambulatory setting with project and learning mechanism embedded into the curriculum. Learning mechanisms (particularly just-in-time learning strategies). Project mechanisms (all, particularly project screening tools and access to data).

High-level summary of the contexts, mechanisms, and outcomes most commonly associated with successful QI curricula for medical learners. See online supplemental appendix C for a comprehensive outline of each context, mechanism, and outcome identified in this realist synthesis and the references affiliated with each construct.
QI, quality improvement.