Improving patient safety through mandatory quality improvement (QI) education in a family medicine residency programme
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). The programme was made up of three components: Standard patient safety and QI education: 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. Self-paced online QI modules: completion of existing self-paced QI modules through the American Academy of Family Physicians (AAFP-TIPS QI), was required of all residents. 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. 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. 

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. 

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). The programme was made up of three components: Standard patient safety and QI education: 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. Self-paced online QI modules: completion of existing self-paced QI modules through the American Academy of Family Physicians (AAFP-TIPS QI), was required of all residents. 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. Individual QI projects: only second year residents completed projects as they had dedicated time for a project during their second year of training. 

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

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 

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. summarises the results of the end of year one evaluation. is a summary of some of the notable quotes. 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. 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. 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. 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. Our online modules provided evidence-based learning material from the AAFP. 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. Learners in the study by Fisher et al wanted more open discussion on medical errors. 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. 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. 

