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requirements, to encourage self-assessment and self-directed learning, and to facili-
tate better feedback from the program and faculty [ 34 ]. This is a departure from the
traditional training method that revolves around the diagnosis and management of
disease. The current generation of physicians must be able to objectively evaluate
their performance while providing comprehensive care, optimizing communication,
defining the goals of the medical care organization, and demonstrating a high level
of professionalism. While medical care organizations are adjusting to the shifting
healthcare landscape by implementing continuous QI, the role of residents in this
process is not well defined. There is a growing body of research regarding different
implementation strategies in residency programs across specialties, but these are
largely limited to isolated case reports. The remainder of this chapter will focus on
different implementation strategies, barriers to implementation, and future direction
of quality improvement in graduate medical education.

Quality Improvement

Physician Avedis Donabedian is considered by many to be the father of modern
healthcare quality assurance. In his 1966 article “Evaluating the quality of medical
care” published in the Milbank Memorial Fund Quarterly [ 22 ], he divided health-
care quality measures into structure, process, and outcome. In his publication, he
described the seven pillars of quality: efficacy, efficiency, optimality, acceptability,
legitimacy, equity, and cost [ 23 – 25 ]. Donabedian’s influence on healthcare system
awareness and design remains an important framework for healthcare quality
improvement (QI) to this day.
Key to any QI initiative is the systematic measurement of significant metrics.
Performance should be measured over time by using a control and identifying
events that deviate from the average range or control limits. The upper and lower
control limits define the acceptable range for which a process is assumed to be in
control (see Fig. 11.1). Events that fall outside the control limits should be assessed
for factors that led to a change in processes.

Performance over time

Time

Upper control limit

Average

Lower control limit

Va

riab

le

Fig. 11.1 Performance measured over time

11 The Role of Educators in Quality Improvement