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.

Interns:
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:

Improvement Capability

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

Triple Aim for Populations

TA 101: Introduction to the Triple Aim for

Leadership

L 101: Introduction to Health Care Leadership

Patient Safety

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

Person and Family Centered Care

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.

Populations

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:

Simulation

ACLS and BLS

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

Orientation

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

Simulation

UCLA Simulation Session

Didactic Days

Aligning Resident QI Projects with CMH Intuitional Goals (Archambault)

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 (90 min) 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*:

Antibiotic Stewardship
Cancer Committee
Disaster Preparedness and Patient Safety
Diversity, Equity, and Inclusion
Infection Control
Inpatient Division
Maternal Child Health – Highly Reliable Team
Medication Safety (MERP) and Pharmacy & Therapeutics
Patient Engagement
Performance Improvement
Policy & Procedures
Quality Assessment & Improvement
Radiation Safety Committee
Regulatory and Accreditation
Sepsis
Stroke
Total Joint Team
Transfusion Committee

*Committees subject to change; list current as of time of publication

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, e.g.

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