Patient safety and quality improvement (QI) dominate hospital-wide initiatives, seeking to reduce errors, create safety-vigilant cultures, and minimize patient harm. Institutional efforts, such as Comprehensive Unit-based Safety Programs (CUSP), highlight the value of multidisciplinary teams that include medical trainees (residents and clinical fellows) to target areas of improvement and build capacity for change. The role of medical trainees in the QI and patient safety realm is variable across institutions and health systems. This article examines the current QI educational landscape for medical trainees, building capacity for change through structured QI education, and the added value of trainee involvement in QI initiatives. As medical trainees become the future physician workforce, they will be tasked with meeting the needs of a dynamic health care environment and ensuring the highest level of clinical care with a focus on quality and patient safety.
CURRENT LANDSCAPE OF MEDICAL TRAINEE EDUCATION
The Accreditation Council for Graduate Medical Education (ACGME) mandates that all medical trainees-defined as residents and clinical fellows-be equipped with the skills to advance patient safety and quality of care. The mission of the ACGME is to improve health care and population health by assessing and advancing the quality of trainee education, and providing US teaching hospitals, medical centers, health systems, and other clinical settings with feedback that addresses patient safety and health care quality.1 "Residents and fellows must receive training and experience in QI processes, including an understanding of healthcare disparities."2 Per the ACGME, part of this training includes involvement in interdisciplinary QI work.2 However, successful completion of the ACGME requirements is at the discretion of program-specific leadership. Individual training programs must deliver QI education to trainees, yet there is no standardized educational program or curriculum to follow. Thus, formal QI education programs for medical trainees vary dramatically among institutions and training programs, ranging from lecture series and online modules to mentored projects. In a survey of graduating pediatric trainees, one-third of respondents thought that the QI curricula in their programs needed improvement and one-quarter reported they lacked self-efficacy in conducting future QI activities.3 Strong educational opportunities and mentored projects directly link to trainee sentiments of self-efficacy with QI implementation.3
BUILDING CAPACITY FOR QI
Trainee involvement in QI initiatives depends on institutional infrastructure and stakeholder buy-in. For successful integration in the quality arena, trainees must receive adequate education about key improvement concepts, have faculty mentors willing to guide trainee-initiated projects, and have institutional support for hospital-wide or unit-level initiatives. The difficulty most trainees face is lack of consistent time off to commit to QI projects. Implementation of a formal, structured QI curriculum for trainees has increased trainee involvement in quality and safety projects and institution-based programs.4 Trainees across US health systems are often encouraged to join their respective hospital-based CUSP or QI teams to serve as "diverse local opinion leaders."5
The Armstrong Institute for Patient Safety and Quality is a Johns Hopkins Medicine resource that offers education to an expanding group of learners, both within and outside of the Hopkins system. The Armstrong Institute has aligned its mission with the ACGME by offering free courses and engaging the trainee community. The breadth and availability of resources and curricula ensures all levels of trainees have access to patient safety and QI education. Trainees can complete 13 e-learning modules, at their own pace, to gain certification in Patient Safety and Quality. Guided in-person (or virtual) coursework is also available for trainees wanting mentorship with a cohort of colleagues within the institution. The ultimate educational opportunity for trainees is a 9-month Leadership Academy-a cohort of patient safety and quality advocates mentored to create individual projects to improve patient safety. The program includes a series of didactic sessions led by national experts on such topics as Equity in Patient Safety, Leadership for Change, Human Factors, and Implementation Science. Trainees are offered modified clinical schedules and a substantial financial scholarship to embark on this mentored journey of QI. The Armstrong Institute is well positioned to train the next generation of quality-conscious physicians to enter the health care environment as physician leaders.
ADDED VALUE TO HEALTH SYSTEMS
Although studies have yet to correlate patient outcomes with trainee QI initiatives,5 interdisciplinary teams-including those with medical trainees-offer a multifaceted perspective on operational and clinical changes to optimize patient safety and minimize harm. Effective teams are crucial to improvement efforts and infrastructural change. Trainees offer a unique point of view as patient care providers; they work long hours, are exposed to systems-based challenges, and frequently recognize opportunities for improvement (eg, recognizing the obstacles to antibiotic administration for presumed sepsis). As a consequence of the trainee automated match process, trainee populations are transplanted to medical communities thereby adding variety in personal experience and clinical acumen, often diversifying the racial, ethnic, and sociodemographic composition of the QI team. Medical trainees exposed to QI education and practice recognize the value of these initiatives and become leaders in the patient safety arena. Maximizing patient safety has been described as an interdisciplinary effort, one that should involve trainees.
THE FUTURE
Trainees offer added value in the diversity of their clinical experiences, as well as innovative solutions to common health care safety concerns. They are future leaders of an evolving infrastructure of health care safety. Medical trainee programs should optimize QI educational curricula, ensure mentorship and project oversight, and encourage trainee involvement in institutional groups that focus on QI. Regardless of a trainee's aspirations-becoming a physician leader (ie, Chief Quality Officer) or champion for patient quality and safety in their health care setting-their involvement in patient safety and quality is paramount.
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