A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education

Int J Qual Health Care. 2016 Apr;28(2):227-32. doi: 10.1093/intqhc/mzw008. Epub 2016 Feb 7.


Objective: Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum.

Design: Randomized, controlled trial.

Setting: Tertiary-care medical center residency training programs.

Participants: Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222).

Intervention: Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants.

Main outcome measures: Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework.

Results: Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001).

Conclusions: Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

Keywords: graduate medical education; quality improvement; randomized controlled trial; spaced education.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Competitive Behavior
  • Education, Medical, Continuing / methods*
  • Education, Medical, Continuing / organization & administration
  • Female
  • Humans
  • Internship and Residency
  • Male
  • Patient Care Team / organization & administration
  • Patient Care Team / standards
  • Quality Improvement* / organization & administration
  • Quality Improvement* / standards