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Quality Improvement Patient Safety

Quality Improvement & Patient Safety (QIPS) Curriculum 2023-2024

Patient safety and continuous quality improvement are integral components of caring for patients. ACGME, the Clinical Learning Environment Review (CLER), and the public expect our residency training programs to reflect a commitment to safe, high quality, cost-effective care and to provide evidence that residents have a strong foundation in and longitudinal exposure to these principles of care. To meet that expectation, residents will participate in institutional online activities and formal didactics at the onset of training, followed by longitudinal engagement in ongoing educational activities.


CMH requires completion of the following IHI Open School courses* to earn a Basic Certificate in Quality & Safety, which you must provide to your Program Coordinator prior to beginning internship:

View Tables/Full PDF

Improvement Capability
Patient Safety
QI 101: Intro to Health Care Improvement
QI 102: How to Improve with the Model for Improvement
QI 103: Testing & Measuring Changes with PDSA Cycles
QI 104: Interpreting Data: Run Charts, Control Charts & Other Measurement Tools
Q1 105: Leading Quality Improvement
PS 101: Introduction to Patient Safety
PS 102: From Error to Harm
PS 103: Human Factors and Safety
PS 104: Teamwork and Communication
PS 105: Responding to a Sentinel Event
Triple Aim for Populations
Person and Family Centered Care
TA 101: Introduction to the Triple Aim for Populations
PFC 101: Introduction to Person- and Family-Centered Care
PFC 101: Introduction to Person- and Family-Centered Care
L 101: Introduction to Health Care Leadership
PFC 101: Introduction to Person- and Family-Centered Care

*Residents who transfer to CMH are strongly encouraged to complete the IHI courses if they have not done similar coursework at their prior institution.

CMH also requires completion of the following courses. You must provide copies of your certificates to your Program Coordinator prior to beginning internship:


After arriving at CMH, Interns participate in the following educational experiences:

The Patient Experience: Physician Communication, Patient Engagement, and Empathy
Infection Control – Hand Hygiene, Donning & Doffing PPE, Isolation
Introduction to Healthcare Quality and STAR reporting
ATLS and PALS as required by your specialty
SAFER - Fatigue Mitigation
Mandatory Reporting
“Boot Camp”
Disclosure of Error
Hand Off Communication – IPASS
UCLA Simulation Session
Didactic Days
Aligning Resident QI Projects with CMH Intuitional Goals
  • Cover clinical site’s systems-based challenges and techniques for designing and implementing systems changes (CLER), including those that reduce health care disparities
  • Review ongoing Sponsoring Institution research projects residents can join
Root Cause Analysis Lab and
  • RCA v. FMEA
  • RCA process
  • Fishbone diagram
  • Corrective action planning
Health Literacy

All residents must:

  • Attend regularly scheduled specialty-specific sessions arranged by Program Director (PD) to review current outcome data, patient engagement scores, and QIPS projects.
  • Complete QI project(s) as required by your specialty college and PD.
  • Participate in a mock or actual RCA. Residents are encouraged to attend any RCA related to their own patients.
  • Regularly attend M&M
  • Complete the CMH Annual Culture of Patient Safety Survey
  • Attend mock codes as required by your specialty
  • Disaster preparedness training (Orthopaedic Surgery)

In addition to the above requirements, all residents are required to log a minimum of two different QIPS activities per year and upload adequate documentation in New Innovations.

QIPS Activity+
Patient Safety Incident Report
CMH Annual Patient Safety Fair - attend or present
Root Cause Analysis - participate in a patient-related live session
Membership on one of the following committees with documented attendance at at least two meetings*:
  • Cancer Committee
  • Diversity, Equity, and Inclusion
  • Infection Control
  • Infection Prevention
  • IS Governance or subcommittee
  • Maternal Child Health – Highly Reliable Team
  • Mother Baby Substance Exposure Initiative Task Force
  • Patient Blood Management
  • Patient Engagement Council or workgroup
  • Patient and Family Advisory Council
  • Performance Improvement
  • Pharmacy & Therapeutics (includes Antibiotic Stewardship)
  • Policies & Procedures
  • Quality Leadership Council or subcommittee
  • Radiation Safety Committee
  • Regulatory, Accreditation and Audits
  • Safety
  • Sepsis
  • Stroke
  • Total Joint Team
  • Utilization Review Committee
*Committees subject to change; list current as of time of publication Other potentially qualifying committees considered on a case-by-case basis. Residents should reach out to the chair to ensure they are invited to meetings and participate.
QIPS educational activities:
  • Attend a QIPS conference, e.g. Hospital Quality Institute, IHI
  • Present a QIPS project at a conference
  • Align QIPS project with current CMH Quality and Patient Safety Performance Improvement Priorities Create and present QIPS educational content (poster, slide show, oral presentation, or video) to others, e.g. nursing, medical staff, Board of Trustees, etc.
  • QIPS publication
Patient Safety Activities
  • Disaster preparedness training (excluding OS for whom training is required)
  • ACP High Value Care Modules or equivalent
Diversity and Inclusion Initiatives
  • Sign up with Underrepresented in Medicine (UIM) student group (e.g. LMSA, SNMA) to mentor
  • Sit on panel for diversity and inclusion recruitment event
  • Sit on regional/national committee
  • Present DEI project at any educational meeting
Other activities may be approved on a case-by-case basis as determined by PD and Director of Medical Education
+Activities may be repeated in different years of training

Logging QIPS Activities:

1. In NI go to Portfolio -> Manage Activities -> New (upper left corner of list)

2. The pop up box asks “Which Scholarly Activity would you like to log?” Select “QIPS Activity AY 2023-2024” from the drop down menu.

  • Under “For whom would you like to log this Activity?” select your name, then click “Log the Selected Activity.”

3. A form will come up where you enter the following fields:

  • Activity Date
  • QIPS Activity – this option is a drop down menu which mirrors the options in the QIPS Activity table above and notes the available points.
  • Provide details e.g. progress to date, conference you attended, etc.
  • Upload any related files as appropriate-provide relevant documentation here
  • Add contributors – select from list