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.3–5
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.8–10 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,11–17 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.
Methods
Context for the Development of a PRSC
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:
to build a resident-led forum for resident concerns in clinical practice areas and/or from resident morbidity and mortality conferences;
to lead and collaborate with an interdisciplinary team to develop, design, and implement QI initiatives and monitor outcomes;
to demonstrate leadership that enhances teamwork, raises situational awareness,19 and promotes safety and quality care; and
to develop members to be future leaders in QI.
Current Council Structure and Recruitment
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.
Council Structure and Member Responsibilities
| Responsibilities | |
|---|---|
| Resident members | Elicit and report resident concerns about active safety issues and opportunities for local and system improvements |
| Design and lead QI projects and safety initiatives and report project updates at PRSC huddles | |
| Participate in hospital-wide safety initiatives (eg, event reviews and ACA) | |
| Share updates of PRSC projects and concerns at institutional patient safety meetings | |
| Participate in QI electives with hospital leadership | |
| Serve as a patient safety champion among all pediatric residents | |
| Chief resident | Attend PRSC huddles to facilitate continuity among resident members and distribute a summary after each huddle with specific actionable items |
| Communicate relevant safety and PRSC project updates among all pediatric residents | |
| Represent residents and PRSC at hospital-wide committee meetings to leverage institutional resources, including data collection and analysis support, access to nursing leadership, and project coordination with division leaders | |
| Share opportunities for engagement with QI and safety projects with PRSC members | |
| Patient safety and performance improvement members | Attend PRSC huddles and report resident concerns to institutional patient safety team |
| Facilitate sharing data relative to PRSC projects | |
| Provide institutional support for PRSC initiatives | |
| Communicate local and national opportunities to share PRSC work | |
| Faculty mentor | Guide the group in QI design, implementation science, and research and provides critical oversight of PRSC projects |
| Provide institutional context and updates to the council |
| Responsibilities | |
|---|---|
| Resident members | Elicit and report resident concerns about active safety issues and opportunities for local and system improvements |
| Design and lead QI projects and safety initiatives and report project updates at PRSC huddles | |
| Participate in hospital-wide safety initiatives (eg, event reviews and ACA) | |
| Share updates of PRSC projects and concerns at institutional patient safety meetings | |
| Participate in QI electives with hospital leadership | |
| Serve as a patient safety champion among all pediatric residents | |
| Chief resident | Attend PRSC huddles to facilitate continuity among resident members and distribute a summary after each huddle with specific actionable items |
| Communicate relevant safety and PRSC project updates among all pediatric residents | |
| Represent residents and PRSC at hospital-wide committee meetings to leverage institutional resources, including data collection and analysis support, access to nursing leadership, and project coordination with division leaders | |
| Share opportunities for engagement with QI and safety projects with PRSC members | |
| Patient safety and performance improvement members | Attend PRSC huddles and report resident concerns to institutional patient safety team |
| Facilitate sharing data relative to PRSC projects | |
| Provide institutional support for PRSC initiatives | |
| Communicate local and national opportunities to share PRSC work | |
| Faculty mentor | Guide the group in QI design, implementation science, and research and provides critical oversight of PRSC projects |
| Provide institutional context and updates to the council |
Membership Expectations
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.
Fostering Member Engagement and Productivity Through Group Huddles
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.
PRSC Outcomes
Initiatives and Project Progress to Date
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.
Examples of PRSC Initiatives
| Project Title | Project Team Members | Description | Safety Concerns Addressed | Progress to Date |
|---|---|---|---|---|
| Acute care scope of practice guideline | Pediatric residents | Clinical guideline document delineating admission criteria for the acute care floor versus ICU; accessible to all clinical care providers | Lack of shared understanding regarding clinical criterial appropriate for acute care versus ICU disposition | Document finalized and uploaded to clinical reference library; accessible through hospital intranet |
| Inappropriate acute care admissions requiring unplanned transfers to ICUs | Included in resident onboarding documents for hospitalist rotations | |||
| Anticipate formal distribution to fellows and faculty | ||||
| Designing postimplementation knowledge assessment survey and outcomes study | ||||
| Nighttime safety huddles | Pediatric chief residents, pediatric residents, nursing leadership | In-person huddles involving overnight senior pediatric resident and nursing staff to discuss patients at risk for clinical decompensation on acute care floors | Delayed escalation of care overnight resulting in high frequency of early-morning ICU transfers | Piloted on inpatient medical unit with planned expansion to include surgical and COVID 19 units |
| Suboptimal interdisciplinary shared mental model about patients at risk for clinical decompensation | Developing metrics and gathering data for outcome measures | |||
| Hospital-wide safety dashboard | Pediatric residents, pediatric chief residents, late rescue collaborative, performance improvement team | Patient list accessible via inpatient electronic health record to identify patients at risk for escalation of care on the basis of both clinical and subjective criteria | Absence of an easily accessible, centralized list of patients at risk for requiring escalation of care | Dashboard is active and being reviewed at nighttime safety huddles |
| Suboptimal interdisciplinary shared mental model about patients at risk for clinical decompensation | Obtaining feedback from invested stakeholders for dashboard modifications | |||
| Lack of existing substrate for clinicians to reference to facilitate structured safety huddles |
| Project Title | Project Team Members | Description | Safety Concerns Addressed | Progress to Date |
|---|---|---|---|---|
| Acute care scope of practice guideline | Pediatric residents | Clinical guideline document delineating admission criteria for the acute care floor versus ICU; accessible to all clinical care providers | Lack of shared understanding regarding clinical criterial appropriate for acute care versus ICU disposition | Document finalized and uploaded to clinical reference library; accessible through hospital intranet |
| Inappropriate acute care admissions requiring unplanned transfers to ICUs | Included in resident onboarding documents for hospitalist rotations | |||
| Anticipate formal distribution to fellows and faculty | ||||
| Designing postimplementation knowledge assessment survey and outcomes study | ||||
| Nighttime safety huddles | Pediatric chief residents, pediatric residents, nursing leadership | In-person huddles involving overnight senior pediatric resident and nursing staff to discuss patients at risk for clinical decompensation on acute care floors | Delayed escalation of care overnight resulting in high frequency of early-morning ICU transfers | Piloted on inpatient medical unit with planned expansion to include surgical and COVID 19 units |
| Suboptimal interdisciplinary shared mental model about patients at risk for clinical decompensation | Developing metrics and gathering data for outcome measures | |||
| Hospital-wide safety dashboard | Pediatric residents, pediatric chief residents, late rescue collaborative, performance improvement team | Patient list accessible via inpatient electronic health record to identify patients at risk for escalation of care on the basis of both clinical and subjective criteria | Absence of an easily accessible, centralized list of patients at risk for requiring escalation of care | Dashboard is active and being reviewed at nighttime safety huddles |
| Suboptimal interdisciplinary shared mental model about patients at risk for clinical decompensation | Obtaining feedback from invested stakeholders for dashboard modifications | |||
| Lack of existing substrate for clinicians to reference to facilitate structured safety huddles |
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.
Scholarly and Leadership Outcomes
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.
Future Directions
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.
Challenges and Lessons Learned
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.
Conclusions
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.
Acknowledgement
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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