Quick Response (QR) Codes to Facilitate Formative Feedback

Background:High quality feedback is imperative to promote lifelong learning, inspire goal setting, and improve medical students’ knowledge and skills.¹ The Clinical Skills course (CS) at Wake Forest School of Medicine (WFSM) is a preclinical course consisting of longitudinal small-group instruction in communication, history taking, physical examination, clinical documentation, clinical reasoning, and oral presentation skills. The CS course is designed such that students receive verbal feedback from their coaches and peers during each class session. In order to improve the effectiveness of feedback delivered, we proposed that written documentation via Quick Response (QR) codes and compilation of feedback over time would increase opportunities for student self-reflection and longitudinal improvement. QR codes are two-dimensional barcodes corresponding to web links that have been widely integrated into healthcare settings for increasing participant engagement, just-in-time learning, and training support. Previous studies evaluating the effectiveness of QR codes in training support found that QR codes were well-received, often more so by faculty than students.^2,3

Hypothesis:The educational objective of this study was to determine if documented feedback facilitated by QR codes leads to a perceived increase in the amount of, quality of, and learner reflection on verbal feedback provided to students in the CS course. 

Methods:The CS course consists of 26, 3.5 hour class sessions across the course (18 sessions in year 1; 8 sessions in year 2). Individual QR codes were created and distributed to the 312 1^st and 2^nd year students enrolled at WFSM from July 2020 to April 2021. Both students and the 38 faculty coaches were instructed on QR code use prior to the first class session. Each QR code provides a unique link to the individual student’s feedback form in RedCap, which is pre-populated with the student’s name, multiple choice questions for core clinical skills, and a free text field for narrative comments. After submitting the form, students are emailed a copy of their feedback. The aggregated feedback for a student is stored in RedCap and accessible for faculty at the mid-year and end-of-year course meetings. We distributed a 6 question survey on the QR code feedback system to all students and faculty participating in the CS course over during the 2020-2021 academic year. In addition, we emailed the faculty with the highest rates of QR code usage to request additional insights on their perspectives of the QR code system. Outcome measures of this study include: amount of feedback, perceived benefit of written feedback, and student/faculty reflection on implementation. 

Results: The survey response rate was 18% (57/312) for students and 39% (15/38) for faculty. Quantity of feedback was reported as “rare,” with 47% of faculty using the QR codes only 1-3 times per semester. Of faculty who used the QR codes, 53% used the summary reports for mid-year and end-of-year feedback meetings with their students. The most valuable elements of the QR code system to students were the ability to quickly receive documented feedback and ease of use of the tool. Faculty most appreciated the ability to review past feedback given and the aggregate data available for review at the mid-year and end-of-year meetings. Overall, 72% of students and 53% of faculty reported that the QR codes did not change the quality of their feedback in comparison to the previous verbal feedback. 

Conclusions: The QR code feedback system provides an opportunity for specific feedback, however, it requires willingness of faculty to complete it, streamlining of the form for ease of use, and education on best practices for QR code use. The primary challenges of the QR code feedback system, identified by students and faculty, were implementation and workflow feasibility. Limitations to this study included a low survey response rate, which could be due to timing of the survey (end of year), survey burnout given number of surveys received, and limited respondent interest in the survey topic.