A Structured Longitudinal Curriculum to Promote Resident Engagement in Quality Improvement

Since 1999, the ACGME has emphasized systems-based practice and practice-based learning, including quality improvement and patient safety (QIPS). However, the Clinical Learning Environment Review (CLER) program demonstrates limited experiential quality improvement (QI) opportunities. Our program implemented a graduated longitudinal curriculum over four years to prepare residents for a career with meaningful participation in quality improvement, with special attention to individualized project development and execution.

1. The learner will demonstrate understanding of QIPS concepts through completion of the asynchronous modules and optional readings/activities. 2. The learner will design a quality improvement project by applying concepts of QIPS in the Plan-Do-Study-Act (PDSA) cycle. 3. The learner will summarize findings in a final abstract presentation. 4. The learner will use a quality improvement lens to reflect on their own documentation and decision-making during patient care among a group of peers.

A revised longitudinal QIPS curriculum was implemented in September 2021 with three components: foundational knowledge via Institute for Healthcare Improvement modules in post-graduate year (PGY)-1/2; practice review through Morbidity and Mortality conference and five facilitated chart review sessions in PGY-3/4; and experiential learning via a resident-driven QI project beginning in PGY-3. Beginning in 2022, PGY-3 residents submitted structured proposals with iterative feedback and check-ins, culminating in a final PGY-4 abstract.

Beginning in 2022, PGY-3 project proposals were evaluated with an adapted 18-point Multi-Domain Assessment of Quality Improvement Projects (MAQIP) tool. From 2022–2026, 48 unique projects were proposed by 60 residents, with a mean score of 16 (range 14–18). Project topics included operations, EMS, procedural safety, sustainability, artificial intelligence, pharmacology, medical education, wellness, and social EM. Of the graduating classes of 2024–2025 (n=30), 24 (80%) presented their work at national conferences or the institutional QI symposium.

Our longitudinal curriculum provides a feasible approach to delivering foundational QI knowledge while supporting experiential learning with the goal of scholarly dissemination. We found the Institute for Healthcare Improvement (IHI) modules were the most effective way to deliver core content, and awarding asynchronous conference credit facilitated completion. To address knowledge gaps and reinforce key concepts before proposal submission, two targeted didactic sessions were added at the end of PGY-2 and start of PGY-3, led by the Associate Program Director (APD) overseeing the curriculum. A PDSA-based project proposal framework was developed and refined to include required faculty or staff mentorship, structured guiding questions, and a fishbone diagram to identify contributing factors. Allowing residents to pursue projects aligned with their individual interests, rather than assigning topics, resulted in a broad range of innovative and meaningful projects. We also encouraged collaboration across residency classes and the institutional Resident Safety Council. Quarterly check-ins with the APD promoted steady progress and addressed logistical barriers. Additionally, the APD reviewed project progress quarterly with the Director of Quality and other clinical leaders for feedback and operational alignment. All residents completed an abstract summarizing their final project, with encouragement to submit for presentation at the institutional QI symposium or a national conference. Early outcomes demonstrate successful scholarly dissemination among initial graduating cohorts. Key challenges included identifying projects that were both feasible and methodologically rigorous within a 1.5-year timeframe and obtaining meaningful outcome data. Clear expectations, consistent oversight, accessible mentorship, and data access were key elements of program implementation. The new proposed ACGME program requirements include a two-week rotation in quality improvement for all residents. With this dedicated time it will become more important for residents not just to learn about QI, but to engage longitudinally in rigorous QI programs that maximize educational and scholarly impact.