Quality Improvement Training for Residents & Fellows



Morbidity, Mortality, & Improvement Conference

The Morbidity and Mortality Conference is held monthly. This conference is an opportunity for residents to present cases from the hospital or clinic with high educational value.  Two to three cases are presented each month. Residents are encouraged to utilize the HPI SEC & SSER Patient Safety Measurement System for Healthcare, which strives to analyze events through the lens of Systems and Processes, as well as Teams and Human Factors, and to provide a framework toward quality improvement.

Quality Improvement Training for Residents and Fellows

Quality improvement is included among the ACGME Common Program requirements.

Residents and fellows are expected to “Develop skills and habits to be able to systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement.”

More specifically, the following milestones have been defined and are incorporated into our program’s training experience:

  • Demonstrates knowledge of common patient safety events
  • Demonstrates knowledge of how to report patient safety events
  • Demonstrates knowledge of basic quality improvement methodologies and metrics
  • Identifies system factors that lead to patient safety events
  • Reports patient safety events through institutional reporting systems (simulated or actual)
  • Describes local quality improvement initiatives
  • Participates in analysis of patient safety events (simulated or actual)
  • Participates in disclosure of patient safety events to patients and families (simulated or actual)
  • Participates in local quality improvement initiatives
  • Conducts analysis of patient safety events and offers error prevention strategies (simulated or actual)


  • Discloses patient safety events to patients and families (simulated or actual)
  • Demonstrates the skills required to identify, develop, implement, and analyze a quality improvement project
  • Actively engages teams and processes to modify systems to prevent patient safety events
  • Role models or mentors others in the disclosure of patient safety events
  • Creates, implements, and assesses quality improvement initiatives at the institutional or community level

The resident curriculum is led by Dr. Karthik Balakrishnan, MD, MPH, FAAP, FACS.  In addition to ongoing training to meet the milestones noted above, PGY3 residents will participate in a collective quality improvement project. The aim of the  project is to develop a plan to support a hospital or clinical performance improvement or patient safety measure by:

  • Reflecting on practice and practice analysis
  • Critically analyzing the current literature
  • Developing a plan for implementation of the proposed change
  • Developing an outcomes’ assessment (performance measure)

Its overall purpose is to foster an understanding of the complexities of health care delivery and develop the skills to address them as is described by the core competency, Systems-Based Practice. 

The program is illustrated in the image below. Working sessions will take place on weekday evening, four times a year between July and October.  Thereafter the team will meet on its own for completion of the project in the following June.