Patient Safety and Quality Improvement (GME)

POLICY #: 8240.31


1. To provide guidelines for residency program, faculty, and resident involvement in Patient Safety and Quality Improvement in accordance with ACGME requirements.

2. All physicians share responsibility for promoting patient safety and enhancing quality of patient care. Graduate medical education must prepare residents to provide the highest level of clinical care with continuous focus on the safety, individual needs, and humanity of their patients. It is the right of each patient to be cared for by residents who are appropriately supervised; possess the requisite knowledge, skills, and abilities; understand the limits of their knowledge and experience; and seek assistance as required to provide optimal patient care.

3. Residents must demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes. Graduating residents will apply these skills to critique their future unsupervised practice and effect quality improvement measures.

4. It is necessary for residents and faculty members to consistently work in a well-coordinated manner with other health care professionals to achieve organizational patient safety goals.


1. Patient Safety

A) Culture of Safety

i. In partnership with Santa Barbara Cottage Hospital, each residency program and their faculty must actively participate in patient safety systems and contribute to a culture of safety.

ii. The Program must have a structure that promotes safe, interprofessional, team-based care.

B) Education on Patient Safety

i. Programs must provide formal educational activities that promote patient safety-related goals, tools, and techniques.

C) Patient Safety Events

i. Residents, fellows, faculty members, and other clinical staff members must:

1. Know their responsibilities in reporting patient safety events at the clinical site;

2. Know how to report patient safety events, including near misses, at the clinical site; and,

3. Be provided with summary information of their institution’s patient safety reports

ii. Residents must participate as team members in real and/or simulated interprofessional clinical patient safety activities, such as root cause analyses, as well as formulation and implementation of actions.

D) Resident Education and Experience in Disclosure of Adverse Events

i. All residents must receive training in how to disclose adverse events to patients and families.

ii. Residents should have the opportunity to participate in the disclosure of patient safety events, real or simulated.

2. Quality Improvement

A) Education in Quality Improvement

i. Residents must receive training and experience in quality improvement processes, including an understanding of health care disparities.

B) Quality Metrics

i. Residents and faculty members must receive data on quality metrics and benchmarks related to their patient populations.

C) Engagement in Quality Improvement Activities

i. Residents must have the opportunity to participate in interprofessional quality improvement activities.

1. This should include activities aimed at reducing health care disparities.


APPROVED BY: E. Wroblewski, M.D. (CMO) DATE: 1/18, 1/21
DATE REVIEWED: 1/18, 1/21