Planetary Health and Sustainable Health Care Education Through Quality Improvement: A Residency Curriculum Integration Open Access

In 2014, educators in the United Kingdom began to define planetary health and sustainable health care education (SHE) objectives¹  by outlining physician and health professional skills in categories of practitioner, scholar and scientist, and professional. Curricula that equip residents to practice in a future with climate change and highlight the practical relevance of planetary health, regardless of specialty choice, is critical to climate adaptation in health care. Quality improvement (QI) presents an opportunity for SHE in graduate medical education.

A SHE-augmented QI (SHE-QI) curriculum overcomes curricular space limitations, improves applicability, and lowers barriers for educators concerned about lack of expertise in planetary health or SHE by leveraging existing and required QI education. This method underscores the importance of environmental costs and impact on population health in high-value care discussions and encourages residents to think about the potential climate impact of QI projects. SHE-QI is an intuitive extension of resource utilization, population health, and measurement concepts inherent in QI. These skills also encompass the Milestones for QI defined by the Accreditation Council for Graduate Medical Education (ACGME), which span from self-improvement to institution- and community-level needs and implementation capacity.

Our SHE-QI curriculum is a 6-workshop series (30-minute didactic followed by small group project–based activity) designed using Lean principles²  and Institute for Healthcare Improvement tools³ . Four sessions included SHE and planetary health by providing environmentally sustainable health care examples during didactics along with workshop materials emphasizing the consideration of environmental costs in QI project design. Project templates and instructions were distributed for residents to use over the course of the curriculum and for any QI projects they wished to implement.

Prior to the first workshop, residents completed a 12-question assessment and QI Knowledge Application Tool (QIKAT). Six questions covered QI and 3 each covered SHE and planetary health, respectively.

Multiple-choice questions addressed the definition of sustainable high-value care⁴  and identification of health consequences of climate change. Four open-ended questions assessing residents’ knowledge of QI-based preventative medicine practices and their effects on climate change were included. Prompts addressed objectives reflecting the patient care and systems foci of QI endorsed by the ACGME for different residency levels.

For the 2023-2024 academic year, 61 internal medicine residents submitted completed assessments. In defining sustainable value care, 46 of 61 residents (75.4%) answered correctly. For prompts addressing sustainable health care, 50 responses (Table) included discussion of resource utilization, waste, plastic, and carbon footprint. To address cobenefits of preventative care on the environment, responses were received with suggestions such as “systems changes/nonpreventative care,” lifestyle medicine, screening, and vaccines.

Residents were asked to select whether health consequences would be experienced from climate change in infectious diseases, malnutritional diseases, illnesses from extreme weather, mental health conditions, and neurological disorders. Forty residents correctly selected all 5 conditions.

Despite the prompt, 25 residents (43.1%) advised medication-only management for wildfire-triggered asthma at the individual patient counseling level. Exposure prevention, trigger education, environmental history, and relocation were mentioned. For community-level interventions, residents recommended natural disaster prevention, patient/community education, advocacy for policy change, air quality control, and population health assessment. There was no significant difference between scores based on postgraduate year for SHE or planetary health. The assessment was repeated in June 2024 with nonsignificant increase in defining sustainable value care (50 of 62 residents, 81%) and only one resident recommended medication management at the individual counseling level for flooding-mold triggered asthma.

The major barrier we encountered in implementing this curriculum was the brevity of our workshops. Given the popularity of the hands-on QI curriculum format in midyear review, we plan to increase the number of workshop sessions and expand discussion of planetary and community health through QI for coming years.

The authors would like to thank Dr Constance Fiocco for her support of the quality improvement (QI) curriculum and for pilot testing of the assessment used here as QI chief, the residents for their enthusiasm about this topic, and the program directors for their support.