Quality Improvement & Patient Safety

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Last Revised 1/23/2018

The Accreditation Council for Graduate Medical Education (ACGME) expects residents to obtain competency in systems-based practice which includes advocating for quality patient care and optimal patient care systems; working in interprofessional teams to enhance patient safety and improve patient care quality; and, participating in identifying system errors and implementing potential systems solutions.

The following are some of our current Quality and Patient Safety Initiatives for residents:

Residents' Yearly Quality Projects

  • 2013-2014: QI Documentation in MedHub Learning Portfolio
  • 2012 - 2013: Advance directive module to improve patient care and referrals
  • 2011 - 2012: 86% completion rate of housestaff survey to identify areas of focus for future quality improvement and patient safety projects in 2012-2013.
  • 2010 - 2011: Team Cards

Hospital-wide Initiatives

  • Team care interdisciplinary rounds
  • Clinical documentation improvement program
  • Use of SAFE reporting system
  • Root cause analysis meetings
  • Morbidity and mortality conferences
  • Improving hand-hygiene compliance
  • Improving sepsis recognition and management
  • Improving patient flow

Quality and Patient Safety Training

100% of residents complete the following training modules available through Healthstream:

  • Team Cards and C-I-CARE
  • Disaster Preparedness
  • Prevention of Hospital Acquired Infections
  • Duke LIFE Series
  • Emergency Codes

Patient Safety Culture Survey 2012

This survey provides valuable information and insight from staff and physicians allowing for continued improvement of patient safety.

Infection Prevention and Control Education

Infection Prevention and Control Education is provided to all new House Staff at orientation annually in June.  Education covered in orientation includes basic principles of Infection Prevention activities including hand hygiene protocols, CDC Isolation Precautions for Specific conditions, Santa Clara County TB isolation, treatment, and discharge protocols, Influenza education, safety device sharps training for syringes, phlebotomy, and  PIV catheters used at SHC.  Also included are State Law mandated measures MRSA patient screening and education, as well as CLIP documentation of line insertion and line necessity.  In addition, this year a large focus of our education will be on the SHC Clinical Effectiveness Project Getting to Zero: Reducing Central Line Associated Bloodstream Infections.  The CLIP( Central Line Insertion Process) and Maintenance Bundle videos will be shown. Supporting documentation from this training is available below:

Other Quality Improvement References