What Every Graduating Resident Needs to Know About Quality Improvement and Patient Safety: A Content Analysis of 26 Sets of ACGME Milestones

Abstract

Purpose: Quality improvement (QI) and patient safety (PS) are broadly relevant to the practice of medicine, but specialty-specific milestones demonstrate variable expectations for trainee competency in QI/PS. The purpose of this study was to develop a unifying portrait of QI/PS expectations for graduating residents irrespective of specialty.

Method: Milestones from 26 residency programs representing the 24 member boards of the American Board of Medical Specialties were downloaded from the Accreditation Council for Graduate Medical Education (ACGME) Web site in 2015. A codebook was generated by in-depth reading of all milestone sets by two authors. Using a content analytic approach, milestones were then coded by a single author, with a 25% sample double coded by another author. Descriptive statistics were used to characterize frequency counts.

Results: Of 612 total milestones, 249 (40.7%) made mention of QI/PS. A median 10 milestones per specialty (interquartile range, 5.25-11.75) mentioned QI/PS. There were 446 individual references to QI, 423 references to PS, and another 1,065 references to QI/PS-related concepts, including patient-centered care, cost-effective practice, documentation, equity, handoffs and care transitions, and teamwork. QI/PS references reflected expectations about both individual-level practice (531/869; 61.1%) and practice within a health care system (338/869; 38.9%). QI and PS references were linked to all six ACGME core competencies.

Conclusions: Although there is variability in the emphasis placed on QI/PS across specialties, overall, QI/PS is reflected in more than 40% of residency milestones. Graduating residents in all specialties are expected to demonstrate competence in QI, PS, and multiple related concepts.