Medical interns share experiences running quality improvement projects in South African primary care

Medical interns in South Africa are gaining far more than clinical experience from a mandatory quality improvement project during their family medicine rotations, according to a new qualitative study that offers one of the most detailed pictures yet of how young doctors experience quality improvement training in primary healthcare settings. The research, published in BMC Medical Education, found that while the projects build teamwork, communication and data skills, inadequate preparation and relentless clinical workloads are undermining their full potential.

The study comes at a time when health systems worldwide are under pressure to deliver safer, more efficient and more equitable care, and when medical educators are increasingly convinced that the ability to improve systems must be taught as deliberately as the ability to diagnose disease. Quality improvement, often abbreviated as QI, refers to the structured, data-driven effort to make healthcare processes better, whether by reducing waiting times, improving chronic disease management or strengthening record-keeping. In South Africa, the Health Professions Council of South Africa has formalised this ambition by requiring second-year medical interns to complete a quality improvement project during their family medicine rotation, placing the work squarely in the country’s busy primary healthcare clinics.

To understand what this requirement actually feels like on the ground, researchers from the University of Pretoria and the University of the Witwatersrand conducted an exploratory qualitative study involving 18 purposively selected medical interns. The participants, who had a mean age of 28.6 years, were predominantly female, with 88.9 percent of the group being women, and the vast majority, 83.3 percent, had completed their undergraduate medical training in South Africa. Between November 2024 and August 2025, the research team carried out semi-structured interviews lasting between 30 and 45 minutes each, conducted virtually over Zoom or Microsoft Teams. The interviews were audio-recorded with consent and transcribed verbatim, and data collection continued until the team reached data sufficiency, the point at which new interviews ceased to yield substantially new insights.

The analytical backbone of the study was thematic analysis, a qualitative method in which researchers systematically code transcript data and cluster codes into broader themes that capture shared patterns of meaning across participants. The team used ATLAS.ti software, a widely used platform for managing and coding qualitative data, to organise this process. From the coded interviews, five major themes emerged. Four of them highlighted strengths of the quality improvement project experience, while the fifth addressed the challenges that complicate implementation.

The first strength was involvement in team-based collaboration. Interns described how the projects required them to work alongside nurses, clinic managers, allied health professionals and fellow doctors, breaking down some of the hierarchies that often characterise hospital practice. In primary healthcare settings, where a small team must deliver a broad range of services, the ability to coordinate across professional boundaries proved to be a formative experience. Interns reported learning to negotiate, delegate and communicate with colleagues they might otherwise have interacted with only in passing, skills that the study’s authors link directly to safer and more coherent patient care.

The second theme was enhanced patient engagement. Because quality improvement projects typically focus on real problems in the clinic, such as delays in care, gaps in chronic medication collection or deficiencies in patient education, interns found themselves talking to patients not just as diagnostic puzzles but as partners whose experiences could reveal where the system was failing. Participants described this as a shift in perspective, one that encouraged them to see the clinic through the eyes of the people it serves. In a primary healthcare context, where continuity of care and community trust are central to outcomes, this engagement was seen as one of the most valuable by-products of the project requirement.

The third strength was a supportive learning environment. Interns recounted that when supervision was constructive and colleagues were willing to help, the projects became genuinely enjoyable learning experiences rather than bureaucratic box-ticking. Mentorship from family physicians and experienced clinic staff helped interns refine their project questions, navigate practical obstacles and stay motivated. This finding matters because it suggests that the same mandatory requirement can produce very different educational outcomes depending on the local culture of the clinic, and that supportive environments amplify the learning value of the exercise.

The fourth theme was strengthened data literacy. Quality improvement projects demand the collection and interpretation of data, whether patient records, waiting time measurements or audit findings. Interns said the experience taught them to think in terms of measurable change, to define indicators, to gather baseline information and to assess whether an intervention made a difference. For doctors who will spend their careers working in systems increasingly governed by performance metrics and evidence-based management, this fluency with data represents a foundational professional skill that traditional clinical rotations rarely cultivate.

Against these strengths, the fifth theme catalogued the challenges. The most prominent were inadequate knowledge and competing clinical demands. Many interns entered the rotation with only a shaky grasp of quality improvement methodology, having received limited formal teaching on how to design a project, choose a change idea or analyse data. As a result, some felt they were learning by trial and error, which made the projects more stressful and less systematic than they should have been. At the same time, the demands of clinical service, including long hours, patient loads and the sheer intensity of intern duties, left little protected time to plan and execute a project. The tension between service delivery and education is a chronic feature of postgraduate medical training, and this study shows it operating at the level of a single mandatory assignment.

The authors conclude that participation in quality improvement projects gave interns genuine opportunities to develop teamwork, communication and data literacy skills while engaging directly with the improvement of clinical practice. But they also argue that the benefits are not automatic. Structured training, protected time, mentorship and supportive supervision, they suggest, may substantially strengthen interns’ engagement with the projects and ensure that the requirement delivers consistent educational value across different clinics and districts.

The findings carry practical implications beyond South Africa. Many countries now embed quality improvement into medical education and postgraduate training, on the premise that tomorrow’s doctors should be equipped not only to practise within health systems but to improve them. The South African experience illustrates a broader design problem: if quality improvement is added to an already packed training schedule without dedicated time and adequate preparation, trainees may complete the requirement while absorbing only a fraction of its intended lessons. Conversely, where supervisors invest in teaching the methodology and protecting time for the work, the same requirement can transform how young doctors think about systems, teams and data.

The study also speaks to the particular importance of primary healthcare in health system strengthening. Primary healthcare clinics are where most patient contacts occur in South Africa and in much of the world, and they are often the sites where inefficiencies compound quietly over years. Training interns to identify and address such inefficiencies early in their careers plants the seeds of a workforce that treats improvement as a routine professional responsibility rather than an occasional project.

Ethically, the study adhered to the Declaration of Helsinki and received approval from the Research Ethics Committee of the University of Pretoria’s Faculty of Health Sciences, with additional permission from the Ekurhuleni Health District Research Committee. Participation was voluntary, written informed consent was obtained from all participants, and data were de-identified and stored in password-protected files. The researchers note that the views expressed are those of the authors and do not necessarily reflect the positions of their affiliated institutions. The research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

As quality improvement continues its march from the margins of medical education to its core, studies like this one provide the ground-truth evidence needed to design training that actually works. The message from South Africa’s interns is clear: the projects can be transformative, but only if the system gives them the knowledge, the time and the support to succeed.