Article Text

Download PDFPDF

Improving patient safety through mandatory quality improvement (QI) education in a family medicine residency programme
  1. Shira Goldstein1,
  2. Jude K A des Bordes1,
  3. Samuel Neher2,
  4. Nahid Rianon1
  1. 1Department of Family and Community Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
  2. 2Office of Educational Programs, The University of Texas McGovern Medical School, Houston, TX, USA
  1. Correspondence to Dr Nahid Rianon; Nahid.J.Rianon{at}


Although the American College of Graduate Medical Education (ACGME) requires that medical trainees acquire competencies in patient safety and quality improvement (QI), no standard curriculum exists. We envisaged that a sustainable QI curriculum would be a pragmatic way to improve residents’ skills and competence in patient safety. Our aim was to develop and evaluate a patient safety-oriented QI curriculum in an established family medicine residency programme. A patient safety curriculum fulfilling ACGME requirements was developed and implemented in a family residency programme. The curriculum comprised didactics, self-paced online modules, experiential learning through individual QI projects, and mortality and morbidity conferences. The programme was evaluated using a survey at the end of its first year. We assessed knowledge on patient safety and QI, confidence in discussing safety concerns with peers, and ability to recognise safety gaps and initiate corrective actions. We also assessed the perception of the programme’s relevance to the residents’ training. All 36 residents participated, 19 completed the evaluation survey. Fifteen (79%) respondents reported learning more about the causes of medical errors, 42% could report safety concerns and 26% could recognise quality gaps. In addition, 58% felt the curriculum increased their confidence in discussing patient safety concerns with peers while 74% found the curriculum very relevant to their training. Some participants described the programme as ‘very productive’. Embedding a QI curriculum into the ongoing residency training may be a realistic approach to training family medicine residents with no prior formal QI training.

  • Quality improvement
  • Medical education
  • Patient safety

Data availability statement

Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article or uploaded as supplementary information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • No standard curriculum to teach patient safety and mandatory quality improvement (QI) in family medicine residency training is available in the current literature.


  • We developed a patient safety and QI curriculum that showed the potential of improving knowledge and competencies in patient safety and QI.


  • Contributes to the development of a patient safety and QI curriculum that may be adapted for other family residency programmes.


Although the acquisition of competencies in patient safety and quality improvement (QI) has been emphasised in medical education by accreditation authorities, no standard curriculum exists for training family medicine residents.

An informal assessment of our family medicine residents during bedside teaching and discussions revealed that about one-half of the residents had no prior formal training in patient safety and QI. In addition, our residents lacked the skills to communicate safety concerns for near misses or mortality events. These were barriers to identifying safety gaps and initiating appropriate corrective QI projects by residents. The inability to communicate medical errors, near misses and other safety concerns deny residents the opportunity to learn from such events in an open and supportive environment.

There was an urgent need to develop and implement a QI curriculum within a short time to ensure that the requirements of the Accreditation Council for Graduate Medical Education (ACGME) were included and yet could be started immediately within the existing structure of the programme without extra resources or time

Our objective was to design, implement and evaluate a culture of safety curriculum aimed at addressing the identified gaps in QI education. Our QI educational initiative included didactics; skill building through developing and presenting individual QI projects; and participation in quarterly morbidity and mortality (M&M) conferences.


This project was approved as a QI project by our Research Compliance Office and was exempt from obtaining informed consent. We designed a culture of safety curriculum, implemented it and did an evaluation using anonymous online survey at the end of its first year of implementation. The QI education targeted all 36 family medicine residents. This programme took place from 1 September 2020 to 30 June 2021.

Patient and public participation

Patients and the public were not involved in the design. Conduct, reporting or dissemination of this project as the project did not involve patients or the public.

Programme design and implementation

Based on ACGME guidelines, best practices from the literature and guided by the self-efficacy theory, we developed a programme to improve the knowledge and self-efficacy of residents on issues of patient safety and QI. The self-efficacy theory posits that an individual’s self-efficacy could be improved by direct experiences in successfully performing an activity (mastery experiences), indirect experiences through observing others (vicarious experiences or modelling), being persuaded that they have the capacity to succeed (verbal persuasion) and improving individual’s psychological and emotional state such as reducing anxiety (psychological states).1

The programme was made up of three components:

  1. Standard patient safety and QI education:

    1. Didactics: we organised three lectures on QI to help residents understand the principles of QI and to distinguish it from human subjects research. The lectures emphasised the six aims for healthcare improvement as outlined by the Institute of Medicine.2

    2. Self-paced online QI modules: completion of existing self-paced QI modules through the American Academy of Family Physicians (AAFP-TIPS QI),3 was required of all residents.

  2. M&M conferences: a quarterly M&M conference was instituted during mandated resident didactic time. Potential cases of quality or safety breaches were identified by attending on the family medicine hospital service. Cases were openly discussed. This was followed by a 20-minute teaching session on the topic. System thinking and root-cause analysis were emphasised.

  3. Individual QI projects: only second year residents completed projects as they had dedicated time for a project during their second year of training.

Programme evaluation

At the end of the first year of implementation of the safety curriculum, we assessed how many participants had completed the learning modules, whether the curriculum improved knowledge in the targeted areas: medical errors, how to report patient safety concerns, confidence in discussing safety concerns with the peers, and ability to recognise safety gaps and initiate corrective action. We also assessed the residents’ perception of the relevance of the programme to their medical training.


Individual QI projects

Each resident completed an individual QI project under the mentorship of one or two faculty members. They were supported by our QI team who helped them with the design and submission of the QI charter. The QI team also assisted with the analysis of their data and preparation for presentation. Residents shared their projects and outcomes in an oral presentation during their didactic sessions. Two examples of impactful projects that had the potential to improve quality of care and patient safety were ‘Improving care through post-hospital follow-up with primary care physicians’, which ultimately sought to reduce 30-day hospital readmission and ‘Clinic Education on HPV Vaccination and Vaccination Rate Outcomes’, which aimed at improving HPV vaccination rates among patients aged 18–45 years who had not completed their HPV vaccination course

End of year one evaluation

Nineteen (19) residents completed the end of year one evaluation. More than half (58%) of them reported that the training (based on the curriculum) increased their comfort level in discussing concerns about patient safety with peers. Nearly three-fourths (74%) thought the curriculum was very relevant to their medical training. Fifteen (79%) of the respondents indicated that the programme improved their understanding of causes of medical errors, eight (42%) felt they could accurately report safety concerns and five (26%) could recognise safety gaps and initiate response. Analysis of the responses to the open-ended questions showed that the programme was generally well-received by the residents, some residents describing it as ‘very productive’, although others felt the ‘modules were too many, too boring’.

All residents completed the AAFP-TIPS QI module.

Figure 1 summarises the results of the end of year one evaluation. Box 1 is a summary of some of the notable quotes.

Figure 1

Participant’s assessment of the culture of safety curriculum at end of year one.

Box 1

Some sentiments expressed by participants on the patient safety programme at end of year one

The programme offered opportunity to improve care

The programme emphasised important concepts

It gets residents to think about systems and processes rather than individual actions

I like the online (computer) modules

It is informative and educational

I like the M&M sessions

Very productive sessions

Good for residency programme

Too many modules, too boring


We developed a culture of safety curriculum which sought to address the needs of the family medicine residents through formal learning comprising didactics and online safety modules, M&M sessions and experiential learning with individual QI projects emphasising the six aims of high quality healthcare as described by the Institute of Medicine report.2

The evaluation showed that the participants reported improvement in their QI knowledge, confidence in discussing patient safety concerns and identifying safety gaps that helped in developing individual QI projects.

Residents liked the online modules which mainly discussed medical errors, reporting of errors and the overall culture of safety. While the residents reported knowing the major causes of medical errors and how to report errors, the end of year evaluation confirmed that their confidence on these knowledge and practice had also been positively impacted by the QI education. Ratings on how to report safety concerns and initiation of response to safety gaps were low on evaluation. These skills may be acquired through experiential learning. Since not many of the residents had had the chance to present at the M&M sessions, they probably felt inadequate. However, they were all able to identify safety gaps for their individual QI projects.

The programme was designed to provide residents with both the requisite knowledge and experiential exposure to build their self-efficacy. Studies have amply demonstrated that providing knowledge alone may not change behaviour thus our reliance on the self-efficacy theory as a guide in the design of our curriculum.1 This theory guides the development of self-efficacy through mastery experiences, vicarious experiences, social persuasion and emotional states, all of which were components of our culture of safety curriculum. Our M&M conferences offered a conducive environment without fear of retribution that provided the necessary psychological and emotional conditioning for learning, facilitating case discussions and experiential learning with an emphasis on patient safety principles. The M&M conferences helped the adult learners learn from real-life situations.4 We used M&M sessions as one of the components of the curriculum because it afforded the opportunity to the residents to learn from near misses and occurrence of medical errors. In one study, medical students and residents felt they learnt better from errors.5 Our online modules provided evidence-based learning material from the AAFP.3 The individual projects offered experiential training for the mastery of QI.

Recognising and reporting safety breaches was a concern for our residents. This was in agreement with the findings in a study by Fisher et al in which residents indicated their role confusion regarding initiating discussion after errors occur.5 Learners in the study by Fisher et al wanted more open discussion on medical errors.5 Residents reported improvements in their confidence in openly discussing patient safety breaches and their ability to recognise safety gaps followed by initiating a response. This could be a direct impact of their participation in the M&M conferences where co-residents and faculty spoke openly about patient safety breaches and used those events as teachable moments.

Our curriculum used evidence-based learning modules from the AAFP and fulfilled the ACGME competencies. Capitalising on the adult learner’s interest, our programme allowed residents to learn through their own choices of projects, learn at their own pace within a defined time line and under the guidance of a structured programme. Medical errors contribute significantly to patient M&M every year in the USA, and errors are highest when clinicians are inexperienced.6 Identifying gaps in safety measures, reporting any variance in care and communicating with the care team about near misses or medical errors are steps to improve patient safety by promoting culture of safety.

The programme was incorporated into our existing didactic schedule and thus made no extra demand on time or other resources. The online modules were self-paced and required about an hour to complete.

Limitations included the use of subjective, self-reported measures for assessing the impact. Due to lack of objective assessments, our results are mainly subjective resident-reported outcomes and may not be comparable with findings from other studies. Our study was also limited in scope to observe behavioural changes due to short period of post-curricular observation time. Any observed behavioural change could be affected by Hawthorne effect.


Overall, the curriculum promoted a culture of safety where residents were comfortable discussing safety gaps and medical errors with a goal to improve quality of care and patient safety. Our programme of QI education may help formalise a curriculum for similar academic residency programmes. Using objective measures as well as more elaborate qualitative assessment in future evaluations will be helpful in better assessing the impact of the programme. An individualised and pragmatic approach seems to be a reasonable method for developing a curriculum that meets ACGME criteria about QI and patient safety.

Data availability statement

Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication



  • Contributors SG, JKAdB, SN and NR contributed to conceptualisation and design of study. SG and NR contributed to acquisition of data. JKAdB, NR and SN contributed to analysis of data. SG, JKAdB, SN and NR contributed to drafting of work and critical revisions. SG, JKAdB, SN and NR contributed to approval of final version. SG, JKAdB, SN and NR agreed to be accountable for accuracy and integrity. NR serves as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.