Perspective: Transformative learning: a framework using critical reflection to link the improvement competencies in graduate medical education.

Quality improvement (QI) in health care involves activities ranging from enhancing personal practice to reforming the larger health care system. The Accreditation Council for Graduate Medical Education recognizes this broad definition of QI in its requirement that physicians-in-training demonstrate competence in practice-based learning and improvement (PBLI) and systems-based practice (SBP). Creative metaphors have been used to teach the PBLI and SBP competencies, but conceptual frameworks describing the relationship between these competencies are needed. Transformative learning is an adult education theory that states individuals must critically reflect on life events in order to change their beliefs or behaviors. The authors propose that critical reflection during transformative learning can conceptually link PBLI and SBP. Reflection on personal experience with suboptimal patient care leads to recognizing personal or system limitations. Addressing personal limitations improves individual practice (PBLI), whereas applying QI methodologies leads to large-scale improvements (SBP). Educators who adopt the transformative learning framework should be able to design meaningful QI curricula that encourage residents to be reflective and empower them with QI skills.