325time wastes in patient care [ 11 ]. Examples of activities within the lean model for
continuous quality improvement include rapid improvement event (RIE) workshops
and value stream mapping, which attempt to quickly and efficiently reinforce valu-
able measures and eliminate wasteful measures. Residency programs can use the
lean model to identify ways to improve patient care (improve admission time, OR
turnover, clinic waiting time, etc.).
Another example of a model for quality improvement that may be applied to
healthcare is the Six Sigma management strategy that, like lean, has origins in busi-
ness. Six Sigma relies on statistical methods to systematically eliminate defects and
reduce variability in processes and may be used in a variety of quality improvement
initiatives [ 12 ]. For example, Six Sigma principles may be applied when streamlin-
ing a process for preventing bloodstream infections [ 13 ]. A downside of this system
is the need for advanced proficiency training and certification, which may result in
requiring an outside organization to perform data analysis. Although effective, this
makes trainee involvement less feasible.
Johnson Faherty et al. (2016) identified models for engagement in resident train-
ing programs based on short-, medium-, and long-term quality improvement initia-
tives. Short-term projects (typically 1–2 weeks) typically build upon and improve
prior efforts instead of completely overhauling system. This may involve improve-
ments to workflow within a specific team that can flexibly alter daily routines with-
out negatively impacting patient care. Medium-term projects (up to 6 months) are
typically unit or clinic-based and are thought to be focused on attending physicians,
nurse managers, and other staff members who remain in a particular area long term.
Long-term projects (months to years) focus issues that impact hospital-wide quality
measures or issues that affect the healthcare system as a whole [ 14 ].
Table 19.1 Template for continuous quality improvement projects that may be used by trainees
for quality improvement or patient safety-related projects
Template for continuous quality improvement
Identify a problem What is the problem?
Why should it be improved?
Background Have there been other attempts for improvement?
Is there information about the problem (literature review, discussions
with stakeholders, etc.)?
Establish a goal What is the focus or aim of the project?
Project logistics How can we track progress? Can data points be generated?
Does the data generated support the goal of the project?
Is the project feasible (taking cost, time, resources into account)?
What is a reasonable timeline?
Analyze interventions Are changes actually improvements? How do we know?
Will the results be valid or reliable?
PLAN (who? what? where? when?)
DO (setting the plan into motion)
STUDY (analyze project results)
ACT (build on project results to make further improvements and identify new problems)
End results of plan-do-study-act cycle should identify problems leading to additional projects,
hence continuous quality improvement [ 8 , 9 ]
19 Quality Improvement and Patient Safety