Quality Improvement Skills for Pediatric Residents: From Lecture to Implementation and Sustainability


      Quality improvement (QI) skills are relevant to efforts to improve the health care system. The Accreditation Council for Graduate Medical Education (ACGME) program requirements call for resident participation in local and institutional QI efforts, and the move to outcomes-based accreditation is resulting in greater focus on the resulting learning and clinical outcomes. Many programs have enhanced practice-based learning and improvement (PBLI) and systems based practice (SBP) curricula, although efforts to actively involve residents in QI activities appear to be lagging. Using information from the extensive experience of Cincinnati Children's Hospital Medical Center, we offer recommendations for how to create meaningful QI experiences for residents meet ACGME requirements and the expectations of the Clinical Learning Environment Review (CLER) process. Resident involvement in QI requires a multipronged approach that overcomes barriers and limitations that have frustrated earlier efforts to move this education from lectures to immersion experiences at the bedside and in the clinic. We present 5 dimensions of effective programs that facilitate active resident participation in improvement work and enhance their QI skills: 1) providing curricula and education models that ground residents in QI principles; 2) ensuring faculty development to prepare physicians for their role in teaching QI and demonstrating it in day-to-day practice; 3) ensuring all residents receive meaningful QI education and practical exposure to improvement projects; 4) overcoming time and other constraints to allow residents to apply their newly developed QI skills; and 5) assessing the effect of exposure to QI on resident competence and project outcomes.


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        • McGlynn E.A.
        • Asch S.M.
        • Adams J.
        • et al.
        The quality of health care delivered to adults in the United States.
        N Engl J Med. 2003; 348: 2635-2645
        • Mangione-Smith R.
        • DeCristofaro A.H.
        • Setodji C.M.
        • et al.
        The quality of ambulatory care delivered to children in the United States.
        N Engl J Med. 2007; 357: 1515-1523
        • Leach D.C.
        Competencies: from deconstruction to reconstruction and back again, lessons learned.
        Am J Public Health. 2008; 98: 1562-1564
        • Nasca T.J.
        • Philibert I.
        • Brigham T.
        • et al.
        The next GME accreditation system—rationale and benefits.
        N Engl J Med. 2012; 366: 1051-1056
        • Aron D.C.
        • Headrick L.A.
        Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach.
        Qual Saf Health Care. 2002; 11: 168-173
        • Tomolo A.M.
        • Lawrence R.H.
        • Watts B.
        • et al.
        Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills.
        J Grad Med Educ. 2011; 3: 49-58
        • Rosenberg A.A.
        • Kamin C.
        • Glicken A.D.
        • et al.
        Training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study.
        J Grad Med Educ. 2011; 3: 309-314
        • Windish D.M.
        • Reed D.A.
        • Boonyasai R.T.
        • et al.
        Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.
        Acad Med. 2009; 84: 1677-1692
        • Lipstein E.A.
        • Kronman M.P.
        • Richmond C.
        • et al.
        Addressing core competencies through hospital quality improvement activities: attitudes and engagement.
        J Grad Med Educ. 2011; 3: 315-319
        • Weingart S.N.
        A house officer-sponsored quality improvement initiative: leadership lessons and liabilities.
        Jt Comm J Qual Improv. 1998; 24: 371-378
        • Weiss K.B.
        • Wagner R.
        • Nasca T.J.
        Development, testing, and implementation of the ACGME Clinical Learning Environment Review (CLER) program.
        J Grad Med Educ. 2012; 4: 396-398
        • Nasca T.J.
        A comprehensive approach to ensure safe care for today and the future.
        in: Philibert I. The ACGME 2010 Duty Hour Standards: Enhancing Quality of Care, Supervision and Resident Professional Development. Accreditation Council for Graduate Medical Education, Chicago, Ill2011
      1. Accreditation Council for Graduate Medical Education. Common program requirements. Available at: Accessed April 22, 2013.

      2. Accreditation Council for Graduate Medical Education. Pediatric program requirements. Available at: Accessed February 13, 2013.

      3. Accreditation Council for Graduate Medical Education. Revision of the institutional requirements, October 2012. Available at: Accessed April 22, 2013.

        • Hicks P.J.
        • Schumacher D.J.
        • Benson B.J.
        • et al.
        The pediatrics milestones: conceptual framework, guiding principles, and approach to development.
        J Grad Med Educ. 2010; 2: 410-418
        • Britto M.T.
        • Anderson J.M.
        • Kent W.M.
        • et al.
        Cincinnati Children's Hospital Medical Center: transforming care for children and families.
        Jt Comm J Qual Patient Saf. 2006; 32: 541-548
        • Doran G.T.
        There's a S.M.A.R.T. way to write management's goals and objectives.
        Manage Rev. 1981; 70: 35-38
        • Deming W.E.
        The New Economics for Industry, Government, Education.
        Massachusetts Institute of Technology, Center for Advanced Engineering Study, Cambridge, Mass1993
        • Langley G.J.
        • Nolan K.M.
        • Nolan T.W.
        • et al.
        The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
        Jossey-Bass, San Francisco, Calif1996
        • Benneyan J.C.
        • Lloyd R.C.
        • Plsek P.E.
        Statistical process control as a tool for research and healthcare improvement.
        Qual Saf Health Care. Dec. 2003; 12: 458-464
        • Amin S.G.
        Control charts 101: a guide to health care applications.
        Qual Manag Health Care. 2001; 9: 1-27
        • Philibert I.
        Involving Residents in Quality Improvement: Contrasting Top-Down and Bottom-Up Approaches—IHI 90 Day Project.
        Accreditation Council for Graduate Medical Education, Chicago, Ill2008
        • Batalden P.B.
        • Davidoff F.
        What is “quality improvement” and how can it transform healthcare?.
        Qual Saf Health Care. 2007; 16: 2-3
      4. Institute for Healthcare Improvement (IHI). Open School. Available at: Accessed April 22, 2013.

      5. Kaminski GM, Schoettker PJ, Alessandrini EA, et-al. A comprehensive model to build improvement capability in a pediatric academic medical center. 2014;14:29–39.

        • Kaminski G.M.
        • Britto M.T.
        • Schoettker P.J.
        • et al.
        Developing capable quality improvement leaders.
        BMJ Qual Saf. 2012; 21: 903-911
        • Singleton A.F.
        • Bazargan M.
        • Ilagan B.
        • et al.
        Using resident focus groups to improve subspecialty consultations in a pediatric urgent care setting.
        J Natl Med Assoc. 2006; 98: 1478-1482
        • Mohr J.J.
        • Randolph G.D.
        • Laughon M.M.
        • et al.
        Integrating improvement competencies into residency education: a pilot project from a pediatric continuity clinic.
        Ambul Pediatr. 2003; 3: 131-136
        • Tuli S.Y.
        • Thompson L.A.
        • Ryan K.A.
        • et al.
        Improving quality and patient satisfaction in a pediatric resident continuity clinic through advanced access scheduling.
        J Grad Med Educ. 2010; 2: 215-221
        • Akins R.B.
        • Handal G.A.
        Utilizing quality improvement methods to improve patient care outcomes in a pediatric residency program.
        J Grad Med Educ. 2009; 1: 299-303
        • Wheeler D.S.
        • Giaccone M.J.
        • Hutchinson N.
        • et al.
        A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections.
        Pediatrics. 2011; 128: e995-e1004
        • Reardon C.L.
        • Ogrinc G.
        • Walaszek G.
        A didactic and experiential quality improvement curriculum for psychiatry residents.
        J Grad Med Educ. 2011; 3: 562-565
        • Lawrence R.H.
        • Tomolo A.M.
        Development and preliminary evaluation of a practice-based learning and improvement tool for assessing resident competence and guiding curriculum development.
        J Grad Med Educ. 2011; 3: 41-48
      6. Medicare Payment Advisory Commission (MedPAC). Graduate medical education financing: focusing on educational priorities. In: Report to the Congress: Medicare Payment Policy, March 2010. Available at: Accessed February 20, 2013.