HomeProfessionalsCareer DevelopmentFellowsInnovations in Fellowship Education2017 ▶ Teaching Skills of Quality Improvement in a Pulmonary & Critical Care Fellowship: A Team Project in the Ambulatory Setting
Teaching Skills of Quality Improvement in a Pulmonary & Critical Care Fellowship: A Team Project in the Ambulatory Setting

Mount Sinai St. Luke’s-West-ICAHN School of Medicine

New York, NY

Abstract Authors: Edwardine Mirna Mohanraj, MD; Steven Chakupurakal, MD; and Janet Shapiro, MD

Program Director: Edwardine Mirna Mohanraj, MD

Type of Program: Pulmonary/Critical Care



Improvement in patient outcomes and reduction in medical errors are the focus of healthcare institutions. Fellows entering subspecialty fields are charged with ‘improving the quality and safety of healthcare at both the individual and systems levels’. Few resources exist to aid in the design of feasible and sustainable curricula in quality and safety. We developed a novel, longitudinal curriculum in quality improvement for subspecialty fellows centered on an annual team project in the ambulatory setting. The aims were to teach principles of quality improvement and safety, promote trainee monitoring of practice improvement, implement process improvements, and foster teamwork and leadership skills. The team project provided a framework for fellows to achieve competence in practice-based learning and improvement and systems-based practice.


The longitudinal QI curriculum consists of 4 distinct elements: completion of the Institute for Healthcare Improvement Basic Certificate in Quality and Safety (year 1), participation in departmental and divisional QI committees and initiatives (years 2-3), development and leadership of individual QI projects (years 2-3) and participation in an annual group QI project (all years). 9 Pulmonary & Critical Care fellows worked jointly on this project under faculty supervision. The fellows identified a practice gap: patients with high-risk indeterminate pulmonary nodules had inconsistent surveillance imaging. Fellows elected to improve the process for timely radiographic monitoring. The project began with instruction on tools of quality improvement. Senior fellows led three subgroups: mission statement, process map, and data collection strategy. Progress was presented at bimonthly project meetings.


The ‘mission statement’ subgroup reviewed the pulmonary nodule literature and articulated the goal that 100% of patients with indeterminate nodules should undergo timely chest CT surveillance. The ‘process map’ subgroup elucidated the process for CT scan scheduling and identified multiple patient-based and systems-based roadblocks. All fellows reviewed their patient panels: 660 clinic visits over a three-month period. Baseline data revealed that only 80% (21/26) of ordered CT scans were actually scheduled. A process of stream-lining the appointment and authorization process was accomplished with interdisciplinary involvement of fellows, clinic staff and Radiology leadership. After implementation, 94% of ordered CT scans were scheduled (29/31); 68% of CT scans were actually completed. Faculty provided competency-based feedback to fellows in areas of safety, quality, and interprofessional teamwork. Feedback was utilized by the Clinical Competency Committee to inform milestones: SBP1, SBP2, SBP3, PBLI1, PBLI2, PROF2.


This fellow-directed team project was successful in teaching principles of quality work, leadership and teamwork. Fellows reflected on their practice, implemented system improvements and gained valuable skills applicable to future annual team projects and individual quality improvement endeavors. Evaluation of fellow participation provided meaningful data for ACGME-designated milestones. The team project – as part of a robust, longitudinal quality improvement curriculum – is readily reproducible in any medical training environment.