Example and Explanation of Each SQUIRE-EDU (Standards for Quality Improvement Reporting Excellence for Education


Example of text in a manuscript


EDU 1. Indicate that the manuscript concerns efforts to improve health professions education systems and learning

Student-Focused Improvements in a Preclinical Medical Physiology Course


EDU 2. Keywords include a focus on education and learning

medical education, physiology, educational improvement, flipped classroom


EDU 3. Description of the nature and significance of the need for change in the local educational system

Based on student feedback and national trends, the medical school preclinical physiology course started a multi-year transformation to a flipped classroom experience. This shift was initiated because of low student satisfaction from the lecture-based class structure.

The course director undertook a major, iterative redesign because the current structure was not meeting the needs of the students. Student dissatisfaction is the local gap that was addressed using educational improvement

EDU 5. Identify the guiding theory (learning, change, implementation, or other) and how it aligns with the need for change in the local educational system

Adult Learning Theory supports that by flipping the pedagogy to a student-centered model, medical students will develop a deeper understanding of the material and be more able to apply their learning to patient care.

This statement encompasses both the rationale for the change as well as the learning theory (adult learning theory) that were key components of the design of this educational improvement project.

EDU 7a. Contextual elements for learning (e.g., setting, program, people, resources, social, geopolitical influences) before the intervention(s)


EDU 7b: The interrelationships between the contextual elements and the local educational and healthcare systems before the intervention(s)

Physiology is one of eight foundational science courses at the SOM. Each course is led by a faculty member who has oversight of the course and leads approximately 75% of the sessions. For the past 12 years, the course has used mostly large group lecture format.

A new course director was named in 2014. The SOM matriculates 125 students each year and recently completed its accreditation visit. Although it received

This description gives the reader a sense of the education program structure, the recent history of leadership in the course, volume of students, and relationship of the course to external influences, such as the dean and the accreditation committee. A reader gets a sense of what the authors believed to be important in starting the work to improve the physiology course and can determine how similar or different it is to his or her own context.

EDU 8a .Description of the primary interventions and co-interventions (e.g., faculty or tool development)

The physiology course is divided into four different sections. The respiratory physiology section leader created the initial flipped classroom experience in 2014 by making online recordings of the lectures from the previous academic year.


This section describes the initial planned change with a recognition that most curricular changes require multiple interventions.

EDU 8b. Specify how the interprofessional education team (e.g., faculty, staff, patients, and learners) was part of the design of the intervention

Students’ evaluation provided data that they wanted more pre-work prior to class, so to use class time in a more interactive way. The lecture recordings were processed by the course assistants to be used as the pre-work for students to watch prior to class so that they could work on respiratory physiology questions and problems in groups during the class session. Instructional designers and faculty collaborated to build the in class sessions.

In educational improvement, it is common to have students feedback serve as a catalyst for initiating improvement. Other input, such as care gaps identified by patients or families would be included in this section. Specify the specific individuals who helped to build the interventions.

EDU 9a. Approach used to understand the impact of the educational intervention(s) on the learner and beyond, such as impact on patients, families, the community, faculty, educational program, or the healthcare system

In order to monitor the development of the changes to the course, four students who were enrolled in the course were recruited each year to gather field notes. After training to ensure reliable data gathering, the students wrote down observations and reflections about the design and execution of the flipped classroom activities. The students wrote these anonymously during the course. Field notes were not part of the students’ grade and were important data that were assessed after grades were finalized.

This is one example of how a team might study the intervention while the intervention is being implemented. By enlisting students to provide detailed feedback, the teaching team is able to gather first-hand information about the efficacy of the intervention. This approach differs from course feedback that occurs subsequent to the intervention and may only provide insight into satisfaction with the learning experience.

EDU 9b. Approach to assess the fidelity of and the iterative changes to the planned intervention(s) over time

Data from the student field notes were used to modify the flipped classroom experience in each subsequent iteration.

Field notes are one way to gather detailed, deep, and real time data about a change process.

EDU 10. Quantitative and/or qualitative measures chosen to assess the educational processes and outcomes on learners, faculty, educational programs, patients, families, healthcare systems, or communities

The physiology course assessed the changes to the curriculum across several domains. Achievement in physiology was measured with scores on the written quizzes, final exam, and on USMLE Step 1 physiology scores. Student satisfaction was assessed through the usual course feedback system. Field notes from selected students tracked the impact and fidelity of the iterative changes to the curriculum. Finally, impact on patients was assessed through an observed structured simulation exercise having students react to physiologic changes in high fidelity mannequins.

The variety of data measures in the example allow the teaching team to understand the breadth of impact of the educational changes. A reader of the manuscript will immediately be able to understand whether the changes relate to their own context or not.

EDU 12. Approaches to address vulnerability of learner participants

Improvements in the physiology course were reviewed and approved by the local IRB. Additionally, student participation in gathering field notes was voluntary and clearly communicated as not connected to students’ grades in the physiology course.

Learners are a vulnerable population and require adequate protection from the appropriate institutional ethics review committee. Addressing the perception of coercion is an important element of ethical conduct of educational improvement.

EDU 13a. For each educational intervention and co-intervention, provide details about iterative modifications based on the assessment of the learning

See Table 3. Example of Iterations to the Physiology Course, 2014-17

A table such as the example is not the sole outcome but is intended to complement other identified outcomes.

EDU 14. Connect the findings to the guiding theory (learning, change, implementation, other) used to direct the change in the local educational system

Active learning theory and data guided the iterations of the interventions. While this appeared straightforward at the outset, many unforeseen consequences occurred as the changes were made over the four years. First, faculty development was paramount, and faculty required boosters along the way. As the faculty became more comfortable with the flipped teaching method, the sessions became smoother. Second, students preferred the active learning, but only to a point. Students expressed a desire for a combination of lectures and active learning. These requests were unexpected for the teaching team, but no less important to address in future iterations.

In the example, there is no change in knowledge assessment, some unexpected results from student reactions, and promising application of the knowledge. Together, these findings provide a comprehensive assessment of the development and changes made to the physiology course

EDU 15c. Include the impact of the intervention(s) on learners, faculty, educational program, patients, families, healthcare systems, or communities

Student performance on exams and USMLE national board exams were unchanged. Students performed very well on the simulation exercise, indicating that they were capable of learning complex respiratory and renal physiology and able to apply it in a patient setting. This application of knowledge was a significant step forward for the physiology course and will be explored further in the curriculum

Performance on USMLE was one important data outcome that was carefully tracked. The physiology course team also created a specific assessment (integrated high-fidelity simulation) to determine how the new teaching method might impact patient care. Keeping in mind the impact of health professions education is ultimately on the care provided, this outcome tried to assess the potential effect of the improved physiology course.

EDU 17b. Scalability of the work to other learners and contexts

Although the improvement s in physiology was quite successful over four years, the school has struggled to make similar active learning advances in other courses. The mandate from the dean to increase active learning led to some starts and stops in other courses, but not the sustained effort that was seen in Physiology.

Perhaps included in this section might be the perceived barriers to adoption of the innovative pedagogy in other parts of the curriculum.

EDU 17d. Lessons learned for clinical practice, education, and policy

Others would be wise to ensure that a comprehensive evaluation system is in place so that the teaching team can react to and modify the curriculum as needed. Also, the connection to the integrated physiology simulation assessment created an important motivator for the students. This connection to “real” patient care was vital for the success of this project.

Describing the potential next phases of this work through the “lessons learned” will guide subsequent iterations of educational improvement for the readers.