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Bridging the Gap

A Framework and Strategies for Integrating the Quality and Safety Mission of Teaching Hospitals and Graduate Medical Education

Tess, Anjala MD; Vidyarthi, Arpana MD; Yang, Julius MD, PhD; Myers, Jennifer S. MD

Author Information
doi: 10.1097/ACM.0000000000000777


In 2012, the Accreditation Council for Graduate Medical Education (ACGME) unveiled a new approach to the oversight of the quality of graduate medical education (GME) in the United States. As part of this Next Accreditation System, the ACGME defined explicit characteristics of the ideal institutional clinical learning environment and promoted these characteristics collectively as a core component of the accreditation process.1 As a result, the assessment of our training programs now includes a Clinical Learning Environment Review (CLER) site visit and focuses on the ability of the GME program and its sponsoring institution to educate and integrate residents and fellows into the areas of health care quality and patient safety, while also providing a learning environment that supports the related areas of care transitions, professionalism, supervision, and duty hours/fatigue management and mitigation.2,3 CLER Pathways were created as expectations within each of these six focus areas to assist institutions in prioritizing their work.4

Major challenges face teaching hospitals and their GME leaders as they strive to achieve these goals. Traditionally, the work and priorities of GME leaders have been separate from those of hospital quality leaders. Indeed, some GME programs and educators have not valued the education and engagement of their residents and fellows in quality and safety. Similarly, many teaching hospitals have not recognized the value of involving residents and fellows in the quality and safety activities of their institution. Over the last four years, we have explored this concept of integrating the quality and safety mission of teaching hospitals and GME, gaining input from hospital quality and safety leaders and GME educators through national conference workshops, informal surveys, and discussions with peers. On the basis of this input and our combined experiences in GME and hospital administration at three academic medical centers, we provide a framework to guide leaders in GME and their teaching hospitals as they strive to integrate and enhance their quality and education missions.

A Conceptual Framework for Integrating Quality and Safety and GME

Given that our framework addresses GME, we defined “trainees” to include both residents and fellows. Although we focus on the relationship between teaching hospitals and GME, our framework also could include an entire health system and any related ambulatory practices.

We designed our framework around two core principles. The first is that trainee quality and safety education requires contextual hands-on experience with real patient safety cases and quality improvement (QI) data that reflect clinical practice. To empower and engage trainees at this formative stage in their careers, we must structure experiential learning such that trainees draw and build on their prior experiences. The second principle is that the clinical learning environment should reinforce the quality and safety practices being taught in the formal curriculum. Instead, a parallel “hidden” curriculum often exists, which comes from the unspoken cultural attitudes and norms of the environment.5 Trainees may be supervised by faculty who do not value quality or safety, and these negative messages will undermine any formal attempts to educate and engage them. To transform the clinical learning environment into one that models and supports quality and safety, we need to train faculty and include interprofessional teaching and learning models that mirror ideal health care delivery processes.6

We identified six institutional elements that we believe are foundational for integrating trainees in the quality and safety activities of their teaching hospitals (see Figure 1). For each element, we defined an ideal state and the organizational characteristics required to achieve it (see Table 1). Though ideals and aspirational goals are useful in setting a direction, true progress requires executing concrete strategies. Therefore, we also offer strategies for each element that are meant to stimulate conversation and the future innovations that we anticipate from the GME and health care quality community. Many of these examples are currently being implemented at our institutions.

Table 1:
Essential Elements and Potential Strategies for Integrating the Quality and Safety Mission of Teaching Hospitals and Graduate Medical Education
Figure 1:
Overview of a framework for integrating the quality and safety mission of a teaching hospital and graduate medical education (GME). The framework’s six key elements are organizational culture, teaching hospital–GME alignment, infrastructure, curricular resources, faculty development, and interprofessional collaboration.

Element 1: Organizational culture

Having a culture that prioritizes quality and safety and that values the role of the trainee in the continuous improvement process is essential for an institution to learn from its frontline experts. One strategy to develop this culture is for leaders to establish transparent analysis and discussion of errors as standard practices. Reviews of preventable adverse events and near-miss safety events should use the principles of human error and root cause analysis tools. Reviews of individuals’ roles in the event should use the “just culture” framework that incorporates an individual’s responsibility to practice safely.7 Case-based, patient safety educational conferences, such as the Morbidity and Mortality Conference, should strive to be balanced and include both cognitive and systems errors. They should be conducted in a nonpunitive manner, be focused on uncovering system factors and identifying possible solutions, and encourage both faculty and trainees to engage in open and respectful discussion. Residents and fellows, in their roles as learners and frontline experts, should be encouraged to participate in hospital or department root cause analyses. Trainees who report events should receive feedback on the findings of the review and any action plan, and those who are involved in adverse events should be emotionally supported by leadership and their peers and trained in error disclosure. Over time, by exposing residents and fellows to constructive discussions of adverse events and the improvements in patient care that result, these strategies will build a culture of safety in the learning environment.

Promoting a culture that supports trainee engagement in QI is equally challenging. Again, both health care quality and safety and GME leaders need to enable and empower residents and fellows to participate in meaningful ways. Leaders from both sides need to listen to trainee concerns about quality in ad hoc and formal ways and be willing to share data and provide support to residents and fellows as they work on system changes. Because participation in QI efforts is now mandated, encouraging trainees to choose projects that align with institutional needs is critical for successful implementation and sustained results. Importantly, such trainee-led initiatives demonstrate to the hospital quality and safety leaders that learners can be effective leaders and change agents. We have found at all of our institutions that over time what is learned from these projects develops into the core organizational belief that trainees are an asset to the quality and safety mission.

Element 2: Teaching hospital–GME alignment

Alignment between the teaching hospital and GME programs is challenging because the leaders of each are often positioned both organizationally and physically in different spaces. Without alignment and collaboration, initiatives at best may not achieve their full potential, and at worst they can end up at odds. Our strategies focus on creating shared structures that guide collaboration.

One strategy is to create positions on quality and safety committees for GME leaders so that the committee considers the role of trainees in their discussions. Similarly, hospital quality and safety leaders can attend GME committee meetings to translate the institution’s quality priorities into educational strategies. GME and quality and safety leaders also can consider establishing a joint committee with representatives from both sides to strategically plan together, establish metrics to assess progress, and hold both sides responsible for outcomes. Metrics of success could include educational outcomes such as the number of residents trained, or measures of engagement such as the number of trainees who file a safety event report, complete the institutions’ safety culture survey, or participate in a QI project.

Formal relationships between trainees and quality and safety leaders can support further alignment. Several institutions have established GME-wide housestaff quality councils to achieve this goal.8 These councils both advise the teaching hospital on quality and safety issues and engage residents in QI work by encouraging them to lead specific projects. By taking on leadership roles, trainees can help align QI projects with institutional priorities, especially if the GME councils report to the quality and safety leaders. In addition, some institutions have created GME incentive programs or surveys to encourage trainee engagement.9,10 Finally, two of our institutions have established GME-wide health care quality leadership training pathways as another engagement strategy.11,12

Element 3: Infrastructure

Even if the culture of an institution values trainees, and the intention to align the quality and safety mission and GME exists, integrating these areas of work needs a supporting infrastructure to succeed. The ideal infrastructure requires systems, processes, and roles that support the goal of integration.

For example, a centralized reporting system for errors and near-miss safety events can be available to all staff, including residents and fellows. Although most institutions have this mechanism in place, residents and fellows need to be trained on what and how to report incidents and on what happens after they submit their reports.

Another example is creating systems that allow GME leaders to review quality and safety data. The ACGME requires institutions to provide trainees with data to show their personal or team-based clinical effectiveness, as part of their educational experience; however, trainees cannot wait months for baseline data to begin a QI project, and project leaders need data to monitor the project’s progress.12 Each institution needs to identify a mechanism that allows educators to access data quickly and, where necessary, to designate an individual to handle data requests. Reports should be trainee-specific or at least at the level of the training program with both process and outcome measures included. Another related infrastructure component is a streamlined process for the review of selected QI projects, in which the project leader is uncertain whether the project qualifies as human subjects research, within the Institutional Review Board (IRB). Some institutions, including ours, have or are in the process of creating a pathway within their IRB for the rapid review of QI projects using specific criteria.

In addition, institutions should establish systems to support educational program development. To avoid repeatedly reinventing the same educational content, the GME office should sponsor a centralized repository to house and share educational materials, tools, and best practices across the institution (see the Curricular resources section below).

Finally, the creation of new roles is a critical component of the infrastructure needed. We recommend assigning one core faculty member from each training program to be responsible for quality and safety education. As a bridge between these two worlds, this individual can assist the program directors in delivering curricula and the hospital quality and safety leaders in connecting with trainees. For larger institutions or health systems, the GME office can create a similar role for an individual who is responsible for this work at the institution level. Two of us hold this role currently (A.T., J.S.M). Many institutions also are participating in the Chief Residents in Quality and Patient Safety program sponsored by the U.S. Department of Veterans Affairs.13

Element 4: Curricular resources

Teaching residents and fellows about quality and safety requires a new curriculum. In response to earlier ACGME accreditation requirements,14 some programs put relevant curricular resources in place, and these resources have been summarized in two systematic reviews.15,16 The ideal curricular programming spans the institution and delivers content that is specific to the quality and safety infrastructure of the organization. However, the efficiency of a centralized curriculum needs to be balanced with training-program-specific customization. For example, a centralized curriculum that uses a wrong-site surgery error to illustrate the patient safety concept of systems theory may feel irrelevant to neurology or psychiatry residents and could result in their disengagement.

In practical terms, institutions should consider two strategies when creating curricular resources. If an institution is large with diverse programs that have well-developed curricula, a new core mandated curriculum may be met with resistance. In these instances, we recommend establishing core curricular standards that allow for individual training program customization. For example, all curricula should require a didactic on core principles, opportunity for hands-on work, and an assessment of the learner. At smaller institutions, or at those where few programs have developed curricula, implementing a core curriculum would likely be welcomed. Most institutions are somewhere in between and may choose to create a core curriculum for those programs that need it and allow others to customize or use existing curricula that meet core standards.

Element 5: Faculty development

To integrate and engage trainees in quality and safety, faculty must be prepared to teach these topics and to reinforce a culture of safety and continuous QI in the clinical learning environment. However, many faculty lack adequate QI and patient safety training.17 The Association of American Medical Colleges’ Teach for Quality program makes the distinction between a “critical mass” of expert educators who will create, implement, and evaluate education, and frontline faculty who will become proficient in quality and safety competencies.18 Whereas the former group is essential for curriculum development, the latter group is essential because it includes a greater number of the faculty who teach, supervise, and model behavior in the clinical learning environment. Indeed, without understanding and a commitment from this group, institutions may end up with a hidden curriculum that does not value quality and safety, or one that actively discourages these activities. Thus, we propose that the ideal faculty development plan should target both types of faculty.

Faculty development strategies depend on the institution’s structure, preference, and resources. If the institution is large and curricular resources are decentralized to departments, a “train the trainer” model may be most efficient to develop core quality and safety educators. If the institution is smaller, using a centralized training approach for a smaller number of core faculty who teach in all departments may be preferred. In either model, we recommend that “expert educators” faculty development include training in curriculum development and CLER expectations, along with quality and safety content, to meet the needs of both the training programs and the institution. The quality and safety content for the frontline faculty can be similar to the introductory resident content because most faculty are at the same level as residents and fellows in this regard. Faculty development strategies that include faculty as co-learners with trainees and other health care professionals can also be considered.

Element 6: Interprofessional collaboration

Quality and safety work is by its very nature interprofessional, yet much of the training in this field occurs in professional silos. Advancing interprofessional, team-based education is an imperative for medical education in the 21st century, and core competencies for interprofessional collaborative practice were published recently.19 The ACGME CLER expectations present an opportunity for us to capitalize on this need and to move the work forward. Nurses and other allied health professionals play a large role in the learning environment. Although some excellent examples of successful programs in interprofessional quality and safety education exist, they are not yet the standard.20,21 We believe that failing to use the CLER expectations as an opportunity to advance interprofessional education in GME is a missed opportunity.

One strategy to achieve this goal is to engage residents and fellows in the quality and safety work that is currently being done by nursing and other health care professionals and vice versa. For example, all health care professionals should be included in case reviews of safety events, QI project work, and related curricula in which they have a role. These interprofessional experiences may prepare all health care professionals to provide collaborative, team-based care.

Institutions that have training programs in nursing and allied health, particularly at the graduate level, are already primed for co-teaching and co-learning. Additionally, many teaching hospitals employ advanced practitioners (physician assistants and/or nurse practitioners), and trainees work closely with them. GME leaders should identify partners among the leaders of these other health professions and plan joint quality and safety educational sessions.

Practical Considerations for Applying the Framework

To meet the new expectations of the ACGME and to align with the 2014 Institute of Medicine report’s focus on workforce needs,22 a paradigm shift is needed in which trainee education in quality and safety shifts from the individual responsibility of the program director to the shared responsibility of the GME office, frontline faculty, and hospital quality leaders (see Figure 2).

Figure 2:
Overview of a new paradigm for educating trainees in quality and safety. The responsibility for doing so is shared by the hospital quality and safety leaders, the graduate medical education (GME) office, frontline faculty, and teaching program directors and core faculty.

We envision that institutions could use our framework and its six elements in a variety of ways. One approach is to perform a self-assessment with leaders from both GME and quality and safety by using our framework to review local strengths and opportunities. Another approach is to use the framework to perform a targeted needs assessment in a specific context for strategic planning. For example, if an institution is grappling with how to increase resident engagement in error reporting or how to review quality data, leaders could construct a plan that incorporates many or all of the elements (see Appendix 1 and Supplemental Digital Appendix 1 at Lastly, many of the strategies in our framework will help institutions achieve the goals outlined in the CLER Pathways to Excellence document.4 To illustrate this connection, we have mapped the strategies to the CLER Pathways in the examples we provided in the two appendices.

Despite the desire and need to integrate the quality and safety mission and GME, many barriers exist. Lack of time on the part of the residents, fellows, and faculty is an important issue and will require a shift in priorities on the part of educational and clinical leaders. Faculty development programs, infrastructure changes such as a centralized error reporting system, and new GME roles all come with a cost and require resource investment. Institutions have competing priorities and may not be able to invest time and resources in training residents and fellows who are traditionally viewed as a transient workforce. All institutions are required to focus on quality measures for regulatory purposes, and these specific measures may not always align with what is relevant or interesting to trainees. Many institutions do not have the data infrastructure to support measurement for improvement, which will shift the burden of measurement to trainees. In addition, measurement has less educational value for trainees than hands-on improvement work. Finally, although we hope it is becoming less frequent, a lack of support by both trainees and faculty for learning quality and safety skills may still be a barrier at some institutions. We expect to see institutions developing innovative strategies to help overcome these issues in the future.


Integrating a teaching hospital’s quality and safety efforts and GME programs in the context of the new ACGME CLER program will not occur quickly or easily. It will take considerable time, coordinated effort, and a commitment on the part of both GME and hospital leaders to integrate and engage trainees in the quality and safety activities that occur in the clinical learning environment around them. We offer this framework as a starting point for hospital and GME leaders as they begin to prepare their organizations for the Next Accreditation System. We hope that with the input and engagement of both quality and safety and GME leaders who support this new work, the culture of our teaching hospitals will shift. Resident engagement in quality and safety will no longer be just an accreditation requirement; it will be seen as a marker of a successful training institution.

Acknowledgments: The authors would like to acknowledge Dave Davis, MD, David Longnecker, MD, Meaghan Quinn, and the Association of American Medical College’s Integrating Quality Committee for their early thoughts and feedback on this framework. The authors also acknowledge the support of their institutions’ health care quality leaders and designated institutional officials, without whom the early strategies could not have been implemented: Kenneth Sands, MD, and Carrie Tibbles, MD (Beth Israel Deaconess Medical Center); Adreinne Green, MD, and Robert Baron, MD (University of California, San Francisco); P.J. Brennan, MD, Patricia Sullivan, PhD, and Jeffrey S. Berns, MD (University of Pennsylvania).


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Examples of Practical Health Care Quality Challenges Facing Teaching Hospitals, Using the Conceptual Framework for Integrating the Quality and Safety Mission of Teaching Hospitals and Graduate Medical Education

Scenario: A GME office would like residents in each of its 25 training programs to receive some type of quality data specific to the resident or department to promote understanding of quality metrics and to meet the goals set forth by the Accreditation Council for Graduate Medical Education practice-based learning and quality improvement milestones.

No title available.

Supplemental Digital Content

© 2015 by the Association of American Medical Colleges