Quality improvement (QI) and patient safety are essential to the practice of medicine. Specific training in these fields has become a requirement in graduate medical education, although there is great variation in how residency programs choose to approach trainee education in QI and patient safety. Residents have a unique vantage point into the operations of a health care system and can guide the development of system improvement initiatives. In this report, we (1) describe the context that led to the creation of a pediatric resident safety council (PRSC) in its current structure, (2) identify the organizational features implemented to best meet the objectives of this council, and (3) describe the local and institutional impact of the PRSC. A PRSC is a useful model to build resident engagement in safe and high-quality patient care within a residency program and health care system. A PRSC encourages the professional development of future pediatric safety leaders and facilitates experiential training in patient safety and QI science.

Quality improvement (QI) and patient safety broadly impact the practice of medicine. In 2014 the Accreditation Council for Graduate Medical Education introduced the Clinical Learning Environment Review,1  which emphasized the need to increase exposure to and participation in QI and patient safety initiatives during residency training.2  Training programs are emphasizing resident education in QI and patient safety and are integrating residents into the mission set forth by Clinical Learning Environment Review guidelines.35 

Resident involvement in QI and patient safety curricula improves understanding of QI processes and methodology and contributes to improvements in clinical processes.6,7  Moreover, active resident engagement in patient safety and QI increases resident investment in safety culture and safety event reporting.810  Pediatric residents spend a considerable portion of their training on hospital-based rotations, and short-term outcomes of resident investment serve to improve a health care system; therefore, it is particularly important that residency programs champion opportunities for resident-driven QI in this setting. Looking forward, residents represent the newest cohort of physicians and quality leaders. Their training and investment in QI and patient safety impact long-term care delivery.

A pediatric resident safety council (PRSC) was developed to support resident involvement in hospital safety efforts. In contrast to previous reports of QI and patient safety education and existing councils,1117  we describe in this report a model for pediatric resident engagement in QI and patient safety in a freestanding children’s hospital. In this novel report, we describe a PRSC structure, highlight the local and institutional outcomes of the council, and demonstrate the success of this model to develop a new cohort of quality and safety leaders.

Our institution is a freestanding academic children’s hospital where 120 pediatric residents are the primary health care providers for the majority of hospitalized patients. In response to an increase in resident and institutional safety event reporting,18  residents expressed enthusiasm for the creation of a council in which resident-specific concerns could be heard, prioritized, and transformed into actionable projects. Hospital leadership was eager to include frontline providers in developing safety culture. Thus, a PRSC was created with the following aims:

  1. to build a resident-led forum for resident concerns in clinical practice areas and/or from resident morbidity and mortality conferences;

  2. to lead and collaborate with an interdisciplinary team to develop, design, and implement QI initiatives and monitor outcomes;

  3. to demonstrate leadership that enhances teamwork, raises situational awareness,19  and promotes safety and quality care; and

  4. to develop members to be future leaders in QI.

The PRSC was initially open to all residents to engage with safety initiatives led by the residency program. However, a lack of continuity and large group scheduling difficulties affected productivity. Through iterative improvement, the PRSC now includes a selection process. New members are recruited primarily from the intern class. Candidates submit applications early in the academic year, which are reviewed by current council members. Residents who do not apply to join the PRSC as interns or who develop interest in patient safety and QI later in training have alternative avenues for QI and safety work with our performance improvement and patient safety teams and within hospital divisions.

The PRSC’s current structure includes up to 3 residents from each class who serve on the PRSC throughout their training. One of the residency program’s 4 chief residents is also a council member, typically designated through previous PRSC involvement or personal interest in patient safety and QI. Additional support for the council is provided through a faculty mentor experienced in patient safety and QI research and through members of the institution’s patient safety and performance improvement teams who attend all meetings. The roles and responsibilities of all council members are detailed in Table 1.

The council aims to initiate and complete 1 to 2 group projects per academic year, typically led by 2 to 3 residents. Smaller-scale initiatives are opportunities for council members to contribute to hospital safety culture and PRSC presence in the residency. Members are encouraged to participate in at least 1 apparent cause analysis (ACA) annually to learn about institutional approaches to reduce patient harm20  and are invited to attend patient safety committee meetings as clinical schedules allow. Residents’ time commitment to the PRSC is, on average, 1 to 2 hours per week.

The PRSC’s success has been optimized through the design of its meeting structure. During resident-led PRSC huddles, members gather for 15 to 30 minutes twice monthly after resident education lectures. Regular small group meetings are an ideal venue to discuss safety concerns facing frontline providers in real time. Regular huddles minimize group scheduling challenges, allow residents to stay up to date with active projects and safety concerns, and facilitate frequent feedback on the progress of council projects. Updates on the outcomes of previously escalated concerns are relayed back to the group during meetings by the chief resident or patient safety team members, thus reinforcing the power of resident voices in hospital safety culture and the institutional commitment to the PRSC.

The PRSC has led multiple initiatives that have emerged as direct responses to resident safety concerns. The process by which residents identified a safety problem and led a multidisciplinary team to address the issue and are now studying the impact of their intervention on patient care is exemplified in Figure 1. A summary of major PRSC works in progress are detailed in Table 2. As an example of shorter-term projects, members created a personal protective equipment and infection prevention safety video for health care providers at the start of the coronavirus disease 2019 (COVID-19) pandemic, which was shared with the pediatric residency and at an institutional patient safety committee meeting.

The PRSC has also facilitated a stronger resident presence in institutional safety infrastructure. Members have championed robust use of the safety event reporting system. Among >195 submitting departments, the pediatric residency is now consistently among the top 10 reporting groups organization wide. In the spirit of providing safe, high-quality care, several residents have been recognized as recipients of our institution’s Reducing Harm Hero Award. PRSC members who have participated in ACAs have presented the results of this work at quarterly safety grand rounds. The PRSC presents updates to our work at patient safety committee meetings, which are attended by hospital safety, medical unit, and nursing leadership, and members are openly invited to attend meetings. Updates about ongoing PRSC initiatives and active resident safety concerns are a recurring item on the meeting agenda, a valuable seat at the table for resident voices.

Outcomes of PRSC projects are shared throughout the residency by several means. E-mails from chief residents, the primary means of daily communication among the entire program, often feature updates from PRSC projects. The council also produces a safety newsletter to highlight resident “good catches” and to share exemplary event reporting. The PRSC has submitted abstracts for institutional, regional, and national conferences to share the results of the group’s work.

Resident training in QI and safety impacts long-term care delivery for a generation of physicians, and the PRSC has been an effective means to develop trainees into quality and safety leaders. After completion of residency training, PRSC members have gone on to join quality and safety councils and academies at institutions where they pursue advanced subspecialty training, including in pediatric hospital medicine. They have been awarded grants in clinical and operational effectiveness and patient safety, they have attended academies for emerging leaders in patient safety, and they are pursuing master’s degrees in patient safety and health care quality.

Moving forward, the PRSC intends to present scholarly works in progress at local and national meetings and to publish the results of resident-driven interventions in peer-reviewed journals. The group additionally hopes to support residents’ professional development through sponsored attendance at educational conferences specific to patient safety and QI; securing financial support will be necessary to successfully meet this aim.

Balancing the PRSC’s ambitious aims with the demands of clinical schedules has been the primary challenge for the council. The rigor of resident schedules prohibits complete member attendance at any given meeting during regular work hours. However, including faculty and patient safety team members is crucial to maximizing council productivity. In balance, summaries and action items disseminated by the chief resident have effectively kept members up to date. Moving forward, influenced by the COVID-19 pandemic, the PRSC will also host all meetings via video conferencing to facilitate participation from off-site residents.

Clinical schedules have challenged residents’ opportunities for more robust involvement in institutional safety initiatives. The chief residents make efforts to give advance notice of these meetings, and residents may take “education days” on outpatient rotations to facilitate attendance. Additionally, many residents on the council have participated in QI electives for dedicated work on projects and to gain exposure to other QI initiatives throughout the hospital.

Although the chief resident is an effective group leader, they do not necessarily have the requisite knowledge of the QI research process to help the group in achieving this goal. Other councils have discussed the benefit of faculty mentors.13  We have introduced a faculty mentor with experience in QI design and publication who has subsequently improved the group’s scholarly productivity. This faculty mentor is also able to provide leadership continuity from year to year and assists the rising chief resident with transitioning into their role within the PRSC.

Residents are at the forefront of patient care in academic institutions. Resident investment in patient safety is crucial for best outcomes. The creation of a PRSC has fostered resident engagement in patient safety both within the residency program and health care system. Although the clinical responsibilities of resident members have posed challenges to the group, frequent small group huddles, consistent chief resident and faculty mentor leadership, and involvement of an interdisciplinary team has facilitated group productivity. A resident safety council encourages the professional development of future pediatric safety leaders and facilitates experiential training in patient safety and QI science.

We thank Dr Amina Khan, whose leadership and mentorship in the early development of the PRSC was so valuable. We acknowledge the contributions of Dr Nathan Dean and Ms Jacqueline Newton to the development and execution of PRSC initiatives. Finally, we appreciate the support of the patient safety and performance improvement teams at Children’s National Hospital for their collaboration; specifically, we acknowledge Evan Hochberg, Emanuel Ghebremariam, Yoshino Sakamoto, and Katy Merkeley.

Dr Rickey conceptualized this report and drafted and edited the manuscript; Dr Aldrich conceptualized this report; Dr Parikh conceptualized this report and provided mentorship, oversight, and critical review of the manuscript; and all authors contributed to the manuscript and its revisions, reviewed the manuscript, and approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.