Developing a Quality Improvement Curriculum in a Community-Based Orthopaedic Surgery Residency

Abstract

Background:

In response to Accreditation Council of Graduate Medical Education (ACGME) directives, a resident-led quality improvement (QI) curriculum was implemented in our orthopaedic residency program. This study describes the evolution of this curriculum, the QI projects resulting from our program, and resident perceptions of the curriculum as an educational tool and a means to improve patient care and the residency experience.

Methods:

QI teams consisted of one resident from each post-graduate year group filling the hierarchical roles of team leader, project coordinator, team recorder, and topic researcher. QI projects proposed by residents and approved by the program director were approached using Six Sigma methodology to Define, Measure, Analyze, Improve, and Control (DMAIC) the quality issue. In 6-8 conferences during the academic year, residents studied QI concepts and applied the principles learned to their selected topics. Current residents and recent graduates were surveyed regarding their experience with the curriculum.

Results:

Since 2016, residents conducted 22 QI projects of which 6 which were published in our university medical journal. Ten studies focused on improving patient care or community health, 10 augmented professional education, and 2 enhanced resident wellness. When surveyed, most current residents and recent graduates opined that our curriculum was an effective educational tool for the QI program. Among graduates, 89% of respondents indicated they have applied QI concepts learned during residency to improve patient care in their own practice.

Conclusions:

Our curriculum, based on the DMAIC process, enabled residents to design and conduct effective QI projects thereby elevating the quality of our residency training program. The curriculum fulfilled the ACGME requirements and core competencies for orthopaedic residents in the QI domain and, more importantly, prepared graduates to champion QI initiatives for their own patients.

Introduction

In recent years, quality improvement (QI) education has been incorporated into orthopaedic residency curriculums¹, facilitating resident participation in QI initiatives in compliance with Accreditation Council of Graduate Medical Education (ACGME) directives². More specific guidance for orthopaedic resident performance in core competencies is provided in the ACGME Milestones Project³.

With respect to the healthcare systems–based practice domain³, junior residents must engage in supervised QI and/or patient safety projects, whereas senior residents must take leadership roles in these initiatives at the institutional or community level, leading to publication of project results. The ACGME also mandates that graduating residents are prepared to critically analyze patient care outcomes, demonstrating the ability to effectively critique their future independent practice and self-impose QI measures for the benefit of their future patients³.

In this context, a QI curriculum was introduced into our community-based orthopaedic residency program in academic year (AY) 2017. The purposes of this study are to describe the methodology and evolution of this curriculum, to summarize the resident-led QI projects and publications resulting from our program, to report resident perceptions of curriculum effectiveness as an educational tool, and to discuss the lessons learned from our experience.

Materials and Methods

Curriculum Goals

Our QI curriculum was modeled after an existing university program, the important elements of which were subsequently published⁴. The primary goals of our curriculum were to establish a culture of quality patient care and safety, to familiarize residents with current QI concepts, and to fulfill ACGME core competency requirements in systems-based practice and in practice-based learning and improvement. Secondary goals were to foster resident participation in specific departmental and/or interdisciplinary QI activities enhancing healthcare delivery for current patients, to develop sufficient QI expertise among senior residents to permit their mentoring of junior residents, and to instill all graduating residents with valuable QI skills to positively affect their future clinical practice.

Quality Improvement Methodology

In the inaugural year of our program, residents were introduced to healthcare QI methodology in didactic sessions conducted by the program director who had no experience in QI pedagogy. Educational materials and videos were derived from many sources including the Institute for Healthcare Improvement (IHI; ihi.org). QI techniques and tools were discussed including Ishikawa cause-and-effect diagrams, the “5 whys” approach (continually asking “why” to determine root cause), Pareto charts and analysis, and the Plan-Do-Study-Act (PDSA) sequence to address the identified problem⁵.

An Ishikawa cause-and-effect or fishbone diagram is a visual aid used to display the contributing factors to a particular problem in the pattern of a fishbone. Using both this diagram and the “5 whys” technique often exposes the underlying root cause of a problem⁶. When there are multiple contributing factors influencing a quality issue, a Pareto chart weighting each factor according to its importance focuses problem-solving efforts on the key contributing factor or factors⁷. After the problem is well defined and a corrective intervention is proposed, a 4-step PDSA cycle may be used to determine expeditiously whether the change will deliver the desired improvement⁸. If not, then the remedy is modified and evaluated through another PDSA cycle.

Six Sigma methodology, originally introduced by an engineer to reduce discrepancies in products manufactured at Motorola⁹, has been adapted for use in the healthcare sector. The 6 Sigma Define, Measure, Analyze, Improve, and Control (DMAIC) method consists of a 5-step process to systematically approach and address the quality issue. A more deliberative and robust approach to improve an existing medical process compared with PDSA cycles¹⁰, DMAIC has become the centerpiece of our QI program, summarized as follows. First, the QI project objective, scope, and time frame are clearly defined. Second, measurable contributing factor data are identified, collected, and displayed (e.g., on fishbone diagrams or Pareto charts). Third, pertinent data are analyzed to confirm the most likely cause of the quality shortcoming. Fourth, after brainstorming, a measure to improve the healthcare process is implemented. Fifth, system performance after the process change is tracked and controlled to sustain any realized improvement. If there is no measurable improvement, then an alternate solution is proposed and the process repeated.

Project Selection

QI ideas proposed by residents are reviewed and approved by the residency program director who established clear criteria for acceptable projects. All resident proposals must improve the quality of patient care, community health, resident education or wellness, or resident satisfaction with the training program. Moreover, all QI projects must be of interest to the residents conducting the study to increase the likelihood that the undertaking will come to fruition.

Projects must comply not only with department policies and procedures but also with regulations governing the participating hospitals in our community and the local center for graduate medical education. Residents are encouraged to choose manageable proposals with limited scope so that the project may be completed during a single year.

Resident Teams

QI teams consist of 5 residents, one from each postgraduate year (PGY) class, allowing the 20 residents enrolled in our program to be divided into 4 project groups. The team member at each PGY level has designated duties and responsibilities (Table I). Crucial roles are played by the PGY3 resident who serves as project coordinator and interdepartmental liaison for the study and by the chief or PGY5 resident who teaches junior residents QI principles and methods, directs the activities of all team members, and presents study findings at year-end conference.

TABLE I.

Roles and Responsibilities of Quality Improvement Resident Team Members^*

PGY1—researcher	• Conducts thorough literature review • Studies current organization policies and procedures • Compares with published best practices to determine quality gap
PGY2—recorder	• Records minutes from team meetings • Presents progress and findings to team and faculty • Collects data and assists with data analysis • Formulates and compiles information for publication
PGY3—implementer/coordinator	• Communicates with parties in study, including proposal of new organization policies or procedures • Serves as interface between QI team and other parties • Prepares deliverables (posters, presentations, manuscripts)
PGY4—no role	• No defined QI assignment or role in project • Assigned to 6-mo, off-site pediatric orthopaedic rotation
PGY5—team leader	• Teaches QI principles and methodology to team members • Responsible for project conduct and completion • Sets deadlines and keeps team on task • Interfaces with faculty mentor • Presents project findings at year-end Grand Rounds

^*QI = quality improvement, and PGY = postgraduate year.

In a new AY, the QI curriculum is repeated, and new project topics are selected. Residents advance to the next hierarchical level on the project team and an incoming PGY1 resident is added as the new researcher. In this manner, residents are given progressive responsibilities as QI team members each year and may participate in as many as 5 projects during residency. As planned, this experience is expected to comply with the ACGME core competency requirements in systems-based QI and patient safety for graduating residents.

Meeting Schedule and Format

During the AY, 6 to 8 early-morning conferences are devoted to the QI curriculum (Table II). Each meeting has the first 15 to 20 minutes earmarked for didactics, 30 minutes for QI team breakout discussions, and the last 5 to 10 minutes for verbal reports from each team to all residents and faculty mentors in attendance. Didactics are frontloaded during the AY to allow more time during later meetings to plan and execute the project, analyze collected data, draw conclusions from the study, and prepare presentations and manuscripts.

TABLE II.

Orthopaedic Resident Quality Improvement Curriculum for an Academic Year^*

Meeting	Session Goal	Session Resources	Assignment for Next Session
1	• Introduction and overview of QI curriculum • Review of DMAIC—PDSA—6 Sigma—Lean methodologies • Decide on a quality gap to study	• IHI Open School modules • Stanford Rite tutorials	• Investigate system-based quality problems that should be improved • Conduct a literature review of the identified quality problem as a team
2	• Project is approved by faculty advisor and program director • Create a fishbone flow chart of process from start to finish • Develop the AIM statement	• IHI AIM statement module • IHI SMART criteria	• Draft AIM statement • Complete IHI Open School Module 201: Root Cause and Systems Analysis
3	• AIM statement is approved by faculty advisor, program director • Discuss plan for collecting measures and data • Identify barriers to measures and data collection	• REDCap database for data compilation • IHI Quality Improvement Tool Kit: Includes downloadable templates for flow charts, run charts, and analyses	• Begin data collection • Complete IHI Open School Module 103: Testing and measuring changes with PDSA • Complete IHI Open School Module 104: Interpreting data
4	• Identify barriers to measures and data collection	• Customizable resources for projects	• Continue data collection • Draft project findings • Complete IHI Open School Module QI105: Leading QI • Complete PS101: Patient Safety
5	• Revise presentation, edit manuscript • Discuss target conference(s) for abstract submission • Discuss target journal for publication	• Determine national or regional conference abstract submission guidelines • Review target journal publishing guidelines	• Complete poster presentation • Complete podium presentation • Finalize manuscript for publication
6	• Present findings at final conference	• Podium presentation slides	• Consider projects for next AY

^*AIM = goal of QI project, AY = academic year, DMAIC = Define, Measure, Analyze, Improve, and Control, IHI = Institute for Healthcare Improvement, PDSA = Plan, Do, Study, Act, QI = quality improvement, REDCap = Research Electronic Data Capture, and SMART = Specific, Measurable, Achievable, Relevant, and Timely.

The QI didactics are designed as a flipped classroom model. Thus, residents are expected to be familiar with the session goals and to have reviewed the session resources before each meeting (Table II). Chief residents highlight IHI teaching modules, reviewing QI concepts and principles. Then, the QI teams meet in breakout sessions to discuss the status of their projects, to identify problem solutions, and to assign new tasks to accomplish before the next meeting. Last, during the team report, project updates are provided, thereby holding each team accountable for interim progress and avoiding redundant efforts by teams with overlapping topics.

Surveys of Recent Graduates and Current Residents

In August 2024, all residents who had experience with our QI curriculum were surveyed to assess their perceptions of the course. All residency graduates from 2018 to 2023 comprised the graduate cohort (n = 24), whereas all those currently enrolled in our residency program and the 2024 graduates engaged in fellowship training comprised the current resident cohort (n = 24). Questionnaires administered to both cohorts asked how effectively our curriculum conveyed QI concepts and principles, improved patient care or community health, and enhanced resident education or wellness.

In addition, graduates were asked to describe how they used QI methodology from our curriculum to improve their current practice, while current residents were asked how likely they would be to apply QI concepts and principles in their future practice. An open comment section invited all survey respondents to critique the curriculum. Survey responses were collected anonymously.

Data Management and Reporting

Questionnaire data from each resident QI project were compiled in the Research Electronic Data Capture (REDCap) system^11,12. Some surveys, including those in this study, were administered through REDCap. In these cases, potential participants were sent an email invitation containing a REDCap web link to the pertinent questionnaire. Collected data were analyzed by the resident investigators in consultation with a research statistician using standard descriptive statistics and nonparametric statistical tests selected for each study.

Residents were encouraged to disseminate study results through poster and podium presentations at local or regional conferences and through publications in our university medical journal. All QI manuscripts adhered to Standards for Quality Improvement Reporting Excellence guidelines¹³.

Results

Resident Quality Improvement Projects

Twenty-two resident-led projects have been completed since the QI curriculum was introduced (Table III). The inaugural study to create a bone health improvement plan for patients with fragility fractures was conducted at the same time the curriculum was being developed. Some of the early QI projects accomplished from 2017 to 2020 were carried over to a second or third AY, as residents learned how to plan and execute their studies efficiently. Since AY 2020, all projects have been 1 year in duration.

TABLE III.

Orthopaedic Resident Quality Improvement Projects, 2016-2024^*

AY	Project Title	Type
2016	Developing a bone health improvement protocol for fragility fracture patients	PC
2017	Enhancing splinting competency and confidence through inter-residency education	RE
2017, 2018, 2019	Improving inpatient nursing education on skeletal traction set-up and maintenance	NE
2018, 2019	Standardizing preoperative clearance for total joint arthroplasty patients	PC
	Standardizing DVT prophylaxis for lower extremity trauma patients	PC
	Implementing PROMIS for total joint arthroplasty postoperative follow-up	PC
2020	Improving patient handoffs among residents through the Listrunner application	PC
	Improving orthopaedic intern knowledge base using a reference pocketbook	RE
	Improving resident preparedness using a clinical rotation electronic handbook	RW
	Implementing PROMIS in an orthopaedic private practice setting	PC
2021	Increasing tranexamic acid use in hip fracture patients	PC
	Improving time to antibiotic administration in patients with open fractures	PC
	Improving orthopaedic resident mentorship of medical students	SE
	Implementing an osteoporosis protocol for fragility fracture patients	PC
2022	Increasing financial literacy and business acumen among orthopaedic residents	RE
	Creating an operative microscope lab to improve resident familiarity and skills	RE
	Evaluating resident wellness and increasing resident social events	RW
	Identifying barriers to faculty participation in Mortality & Morbidity conference	RE
2023	Using virtual reality for resident education on direct anterior total hip arthroplasty	RE
	Improving the inpatient discharge process for patients and residents	PC
	Increasing visiting subintern interest in our orthopaedic residency program	SE
	Increasing resident after-hours utilization of the orthopaedic skills lab	RE

^*AY = academic year, DVT = deep vein thrombophlebitis, NE = nursing education project, PC = patient care project, PROMIS = Patient-Reported Outcomes Measurement Information System, RE = resident education project, RW = resident wellness project, and SE = medical student education project.

All studies were consistent with the topic selection guidelines specified by the program director. Initiatives included 10 studies to improve patient care, 10 to augment professional education, and 2 to enhance resident wellness. Of the education studies, 7 were focused on residents, 2 on medical students, and 1 on orthopaedic nurses. How the 6 Sigma methodology was applied in 3 resident QI projects is presented in Table IV.

TABLE IV.

Define, Measure, Analyze, Improve, and Control (DMAIC) Process in Resident Quality Improvement Projects^*

Brief Title	Define (D)	Measure (M)	Analyze (A)	Improve (I)	Control (C)
Fracture Splinting Workshop14	Numerous splints were improperly applied in the primary care setting, some resulting in skin complications or loss of fracture reduction	Surveys revealed that local family medicine residents lacked experience and confidence applying and molding splints used for common fractures	While all family medicine residents completed a required orthopaedic rotation, they had no formal training in splint application	Orthopaedic surgery residents conducted a hands-on splinting workshop for family medicine residents to improve their skills applying and molding common splints	Postworkshop surveys documented improved confidence in splint application, permitting senior family medicine residents to conduct similar splinting workshops for their new junior residents
Enhancing Business Acumen	There is no formal business education in the residency curriculum to fulfill ACGME core competencies in practice management and personal finance	Survey revealed deficient resident knowledge base in private practice models, contracts, revenue generating options, and other business aspects	Lack of expertise in practice management well documented in the literature was also found among most local faculty leading to deficiency in our present curriculum	Local faculty with business expertise conducted 1-hr seminars to improve financial literacy and business acumen among orthopaedic residents	Postseminar resident surveys showed improved comfort with financial and business topics including practice models, contracts, and revenue opportunities
Operative Microscope Utilization	Residents reported lacking experience using the operating microscope, leading to an inability to participate in microsurgical cases	Surveys confirmed deficient resident knowledge of and comfort with using the operating microscope and with microsurgical techniques	Many nerve repairs are done with loupe magnification due to attending surgeon choice, microscope availability, and time or cost associated w/microscope use	Trained faculty conducted 90-min labs to improve microsurgical skills, supervising residents suturing latex gloves using microscopic instruments	Postlaboratory surveys showed improved resident comfort with, knowledge of, and interest in microsurgical techniques which may be added to our curriculum

^*ACGME = Accreditation Council of Graduate Medical Education.

Six of the 22 QI projects were reported in our university medical journal (Table V). Three of the 6 published studies were devoted to improving the musculoskeletal education of healthcare providers by orthopaedic residents. For example, in a 90-minute splinting workshop offered to family medicine residents¹⁴, proper application of 3 commonly used plaster splints (sugar tong forearm, long-arm posterior, and short-leg posterior with reinforcing stirrup) were demonstrated for the learners who then practiced their splint application and molding skills under the supervision of their orthopaedic counterparts. Emphasis was placed on using the appropriate materials and splinting techniques. Knowledge of splint construction and confidence in splint application significantly improved among study participants whose feedback on the practicum was uniformly positive.

TABLE V.

Summary of Published Quality Improvement Projects

Brief Title	Purpose	Conclusions
Fragility Fracture Protocol15	To develop a protocol to diagnose and treat fragility fracture patients for osteoporosis and prevent secondary fragility fractures	Diagnostics include vitamin D level, thyroid panel, and bone densitometry. Treatments include calcium and high-dose vitamin D supplementation. At home fall risk assessment is indicated
Fracture Splinting Workshop14	To conduct an educational splinting workshop for family medicine residents to improve their performance and confidence in applying 3 common plaster splints	Knowledge of and confidence in proper splinting techniques significantly improved among 32 family medicine residents who participated in a 90-min educational and practical workshop conducted by orthopaedic residents
Skeletal Traction Workshop16	To implement a hospital-approved skeletal traction policy and educate orthopaedic nurses by demonstrating traction system assembly and management methods	Knowledge of and comfort with skeletal traction techniques significantly improved among 29 nurses who participated in a 45-min education session and practical workshop on traction systems provided by orthopaedic residents
Electronic Patient Handoff17	To improve change-of-shift communication among orthopaedic trauma team members, a secure telephone app for patient handoffs was used for 3 mo on a trial basis	Although most of the 23 trauma team trial users agreed that the secure telephone app was easy to use, increased clinical efficiency, and improved patient care and safety, our team resumed using the secure email sign-out system after the trial due to cost concerns
Clinical Rotation Handbook18	To enhance resident preparedness and minimize stress by using an electronic handbook to share key rotation-specific data during clinical rotation transition periods	Most of the 20 residents perceived enhanced wellness with significantly less stress, greater preparedness, and more confidence starting a new clinical service after using the resident-authored rotation handbook than before this resource was available
Medical Student Mentorship19	To improve medical student awareness of orthopaedic surgery as a career option by four 1-hr mentoring sessions designed and delivered by orthopaedic residents	There were statistically significant improvements in interest in and knowledge of orthopaedics among the 18 participating medical students. This mentorship program may be a useful alternative to orthopaedic clerkships when the latter are limited or not available

In response to a deficiency in nursing education regarding management of patients in skeletal traction, a resident QI team proposed and helped implement a new skeletal traction policy at a Level I trauma teaching hospital¹⁶. To facilitate orientation of orthopaedic nurses, residents conducted a 45-minute didactic demonstrating proper assembly of a hospital bed overhead traction frame and pulley system. The 29 nurse participants in this study showed significant improvement in knowledge of and comfort with various aspects of skeletal traction care including frame assembly, traction weight application, and skeletal pin tract care. This QI initiative was carried over 3 AYs, allowing sufficient time for approval of the skeletal traction policy by the hospital executive committee and for education and training of the orthopaedic nurses.

The third QI education project focused on orthopaedic resident mentorship of medical students in the aftermath of travel restrictions and limited clerkship opportunities imposed by the COVID-19 pandemic¹⁹. Residents presented four 1-hour forums (orthopaedic as a career, fracture recognition and treatment, splinting workshop, and residency application process) to interested medical students. Before-surveys and after-surveys of 18 forum participants revealed significant increases in knowledge of and interest in orthopaedic surgery. This type of resident mentoring may be a useful alternative for medical students when formal clinical clerkships are limited or unavailable.

Survey Results

Surveys were completed by all 24 members of the current resident cohort and by 19 of 24 in the graduate cohort. Twenty-one of 24 (88%) in the current resident group and 17 of 19 graduates (89%) believed the curriculum was effective or very effective conveying QI concepts and principles. Eighty-three percent of current residents and 84% of graduates considered the curriculum was effective or very effective enhancing patient care or community health. In addition, 88% of residents in-training and 79% of graduates indicated that the QI program was effective or very effective improving resident education or wellness. Therefore, the 2 groups had similar positive impressions regarding the effectiveness of the curriculum.

Open-ended comments about the QI program solicited in the questionnaires were generally favorable, although a few respondents preferred longer-duration projects or collaborations with other specialties (Table VI). Notably, the surveys also revealed that 88% of the current residents were likely or very likely to use QI concepts and principles in their future practice, while 89% of graduates have actually done so.

TABLE VI.

Representative Comments Derived From Resident Graduate and Current Resident Surveys

Give a specific example of how you applied the quality improvement (QI) concepts and principles you learned during residency to improve some aspect of your current practice  • “Root cause analysis concepts have been used to analyze identified problems.”  • “Used data gathering to improve patient throughput in clinic.”  • “Track(ed) PROMs and update(ed) practice guidelines based on (patient) feedback.”  • “Established a multidisciplinary … excellence committee at my institution to identify and address areas for improvement. For example, we have improved our process for timely and appropriate preoperative antibiotics administration, streamlined our discharge instructions … and expanded (the) no. of rooms to recover outpatient joint patients.”

Do you have any comments (positive or negative) regarding your QI experience during residency?  • “Excellent program that teaches the fundamentals. The program gives residents an avenue to impart change in their residency experience, work, patient care, hospital system, education, and even wellness. Very effective and productive program.”  • “The QI program has provided a basis for understanding practice evaluation and improvement that is likely to affect my practice in the future.”  • “… the QI residency projects were beneficial in developing skills and experiences in this type of research. However, the scope of the projects was often limited …”  • “The curriculum is very detailed and not completely geared towards orthopaedics so it can be challenging to maintain interest in the didactics …”

How would you improve our QI curriculum?  • “Collaboration with other specialties and with hospital administration in order to have more robust resources for carrying out effective and relevant projects.”  • “(The curriculum) improves every year with small changes.”  • “Maybe one project every 2 yrs rather than every year. Or maybe more (residents) per team.”  • “Longer-duration (primary QI project for each resident class giving) the opportunity to make mistakes, find problems, make adjustments, and (complete a) meaningful project.”

Discussion

This retrospective review of our QI curriculum demonstrates that the program goals established 8 years ago have been met. Current residents and graduates were familiar with QI concepts and principles and, cumulatively, have participated in 22 QI initiatives, thereby strengthening the culture of quality patient care and safety in our residency program. Our teaching model is now self-sustaining as chief residents, drawing on their previous experience as subordinate members of the QI team, have become capable team leaders and mentors of junior residents.

Importantly, our program has satisfied ACGME requirements and core competencies for orthopaedic residents in the QI domain. For example, in the skeletal traction workshop¹⁶, QI team residents demonstrated Level 5 competence in systems-based practice for QI and patient safety by creating, implementing, and assessing their nursing education initiative at the hospital level³. Also fulfilling ACGME mandates, nearly all graduates of our program have successfully applied QI methodology to improve the care of patients in their own clinical practice, as indicated by the survey data presented in this study.

Our published articles add to the growing number of QI studies in orthopaedic surgery. Some share the common theme of improving fracture management through professional education and are similar to previous publications in the literature. For instance, the fracture splinting workshop¹⁴ designed to reduce or mitigate potential complications associated with extremity immobilization by applying well-molded splints is comparable with previous QI efforts to reduce cast saw complications by using sound cast removal techniques^20,21. In both cases, educating residents about proper immobilization techniques should lead to fewer complications and better outcomes.

In addition to formulating QI projects to improve patient care, residents have collaborated to identify and remedy perceived shortcomings in their residency program. For example, during AY 2022, resident QI teams designed and implemented a financial literacy curriculum to enhance their business acumen, enhanced resident and family well-being by increasing social events, and created a skills laboratory to improve their performance using the operative microscope (Table III). These projects have elevated the quality of our residency program and have allowed residents to experience the benefits of QI methodology firsthand.

Early in AY 2024, program leaders and residents met to discuss how the QI curriculum itself could be improved. Although suggestions to expand QI teams or extend project timetables were considered, we reaffirmed the existing guidelines for residents to select projects of interest which may be easily managed and completed in 1 year. For instance, a study to improve patient care in the resident clinic by using diagnostic and therapeutic ultrasound is currently underway. Our curriculum was, however, modified to compress the didactics into the first and second meetings, since PGY1 residents are now more knowledgeable about QI, having been exposed to the fundamentals in medical school.

Lessons Learned From Our Experience

Implementing our QI curriculum required the sustained efforts of a dedicated program director and the willingness of chief residents to serve as mentors to junior residents, but no special training or formal extracurricular QI education was necessary. Moreover, no new departmental costs were incurred as educational resources, such as IHI teaching modules, were available to residents free of charge. Our unwavering teaching priority was for residents to learn QI concepts and principles, which eventually would be applied to patients in their own practice.

Some projects were more labor intensive than others. For example, the splinting workshop¹⁴ demonstrated that multidisciplinary projects may be problematic owing to conflicting departmental priorities. Similarly, the skeletal traction workshop¹⁶ was a time-consuming endeavor because approval of a new hospital policy was necessary. Both initiatives required more than 1 year to complete.

We also learned that some project improvements were more easily sustained than others. For example, when a best-practices treatment protocol was adopted, such as standardizing deep vein thrombophlebitis prophylaxis for lower extremity trauma patients (Table III), the benefits were enduring as the standardized approach was well accepted. However, improvement realized from professional education initiatives was relatively more difficult to sustain due to personnel turnover and the need for continuing medical education of new staff members.

Conclusions

Our QI curriculum has been an effective tool to familiarize residents with QI methodology enabling them to design and conduct projects to improve patient care, community health, and even their own education or wellness, thereby elevating the quality of our residency program. Over time, our teaching model has become self-sustaining as experienced chief residents mentor their junior counterparts. Moreover, our program fulfills all ACGME requirements and core competencies for graduating residents in the QI domain, including the knowledge and leadership skills necessary to champion QI initiatives in their future practice.