Re-thinking How We Teach Quality Improvement: Adding Meaning to an ACGME Requirement

  • Katlyn BaxterEmail author
  • Chelsey Petz
  • Jennifer L. Middleton
  • Miriam Chan



Many residency programs have struggled to meaningfully meet the ACGME quality improvement (QI) requirements. Similarly, our residents were receiving limited QI education, and their longitudinal projects were ineffective.


Create an integrated didactic and experiential learning environment that equips residents to become leaders of QI.

Setting and Participants

Internal medicine (IM) residency program of 45 residents in a large community hospital.

Program Description

This curriculum included eight content areas. Games, real-life application, and project celebrations cultivated engagement. Sessions occurred during residents’ 2-week outpatient rotations. Project development was standardized.

Program Evaluation

The QI Knowledge Application Tool-Revised (QIKAT-R) and separate surveys were used before and after the curriculum’s implementation to evaluate resident QI knowledge and confidence, respectively. We also tracked QI scholarship and faculty engagement. Mean QIKAT-R scores improved significantly from 7.0 (SD 2.9) at baseline to 16.6 (SD 4.7) post-curriculum (n = 37 pairs, p = 0.043). Residents’ adverse event reporting increased from 44% (19/43) at baseline to 90% (28/31) post-curriculum. Seven presentations were accepted for local, regional, and national conferences, compared with one presentation the preceding year.


A QI curriculum can be successfully integrated in a “4 + 2” program.


quality improvement resident education X + Y curriculum assessment QIKAT faculty engagement adverse event reporting 



We would like to acknowledge the assistance and support of our IM program director, Thomas Boes, MD. This project would not have been possible without his support and the generous curricula time he allotted us. Additionally, we acknowledge John Elliot, PhD, for his assistance with biostatistics.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5059_MOESM1_ESM.docx (22 kb)
ESM 1 (DOCX 22 kb)


  1. 1.
    Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med 2012;366(11):1051–1056.CrossRefGoogle Scholar
  2. 2.
    Weiss KB, Wagner R, Bagian JP, Newton RC, Patow CA, Nasca TJ. Advances in the ACGME Clinical Learning Environment Review (CLER) Program. J Grad Med Educ. 2013;5(4):718–721CrossRefGoogle Scholar
  3. 3.
    Weiss KB, Bagian JP, Wagner R. CLER pathways to excellence: expectations for an optimal clinical learning environment (executive summary). J Grad Med Educ. 2014;6(3):610–611.CrossRefGoogle Scholar
  4. 4.
    Wong BM, Levinson W, Shojania KG. Quality improvement in medical education: current state and future directions. Med Educ 2012;46(1):107–119.CrossRefGoogle Scholar
  5. 5.
    Patow CA, Karpovich K, Riesenberg LA, et al. Residents’ engagement in quality improvement: a systematic review of the literature. Acad Med 2009;84(12):1757–64CrossRefGoogle Scholar
  6. 6.
    Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med 2010;85(9):1425–39.CrossRefGoogle Scholar
  7. 7.
    Morrison GR, Ross SM, Kemp JE, Kalman H Designing effective instruction. Hoboken, NJ: Wiley. 2010: ISBN: 978-0-470-57408-9.Google Scholar
  8. 8.
    Singh MK, Ogrinc G, Cox KR, et al. The quality improvement knowledge application tool revised (QIKAT-R). Academic Medicine 2014;89(10):1386–91. Scholar
  9. 9.
    Williams DM. Mr. Potato Head Plan, Do, Study, Act (PDSA) Exercise. Austin, TX: TrueSimple, LLC. 2014. Available at Accessed 11 January 2019.Google Scholar
  10. 10.
  11. 11.
    Shark Tank. The ABC television network. Available at: Accessed 11 January 2019.
  12. 12.
    Institute for Healthcare Improvement. Open School. Available at: Accessed 11 Jan 2019.
  13. 13.
    Byszewski A, Hendelman W, McGuinty C, Moineau G. Wanted: role models – medical students’ perceptions of professionalism. BMC Medical Education 2012 12:115. CrossRefGoogle Scholar
  14. 14.
    Ogrinc G, Headrick LA, Morrison LJ, Foster T. Teaching and assessing resident competence in practice-based learning and improvement. J Gen Intern Med 2004;19(5 Pt 2):496–500.CrossRefGoogle Scholar
  15. 15.
    Tudiver F, Click IA, Ward P, Basden IA. Evaluation of a quality improvement curriculum for family medicine residents. Fam Med 2013;45(1):19–25.Google Scholar
  16. 16.
    Sepulveda D, Varaklis K. Implementing a multifaceted quality-improvement curriculum in an obstetrics-gynecology resident continuity-clinic setting: a 4-year experience. J Grad Med Educ. 2012;4(2):237–41.CrossRefGoogle Scholar
  17. 17.
    Fok M, Wong R. Impact of a competency based curriculum on quality improvement among internal medicine residents. BMC Medical Education 2014; 14:252.
  18. 18.
    Glissmeyer EW, Ziniel SI, Moses J. Use of the Quality Improvement (QI) Knowledge Application Tool in Assessing Pediatric Resident QI Education. Journal of Graduate Medical Education 2014;6(2):284–91. Scholar
  19. 19.
    Vinci LM, Oyler J, Johnson JK, Arora VM. Effect of a quality improvement curriculum on resident knowledge and skills in improvement. Quality & Safety in Health Care 2010;19(4):351–4. Epub 2010 May 31.CrossRefGoogle Scholar
  20. 20.
    Johnson KM, Fiordellisi W, Kuperman E, Wickersham A, Kuehn C, Kamath A, Szot J, Suneja M. X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block. Journal of Graduate Medical Education 2018;10(3):316–324. Scholar
  21. 21.
    Ogrinc G, Cohen ES, van Aalst R, Harwood B, Ercolano E, Baum KD, Pattison AJ, Jones AC, Davies L, West A. Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents. J Grad Med Educ. 2016;8(4):563–568.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Katlyn Baxter
    • 1
    Email author
  • Chelsey Petz
    • 1
  • Jennifer L. Middleton
    • 2
  • Miriam Chan
    • 2
  1. 1.Department of Internal MedicineOhioHealth Riverside Methodist HospitalColumbusUSA
  2. 2.Department of Family MedicineOhioHealth Riverside Methodist HospitalColumbusUSA

Personalised recommendations