Quality Improvement and Patient Safety


Department of Neurological Surgery – Residency Program Policy

Policy: Quality Improvement and Patient Safety

Program Chair: Michael Rosner, MD

Last Revision: March 11, 2020


To ensure that residents and fellows of The George Washington University School of Medicine and Health Sciences participate in Quality Improvement/Patient Safety activities as part of their educational program. 


In accordance with ACMGE Common Program Requirements, residents must “systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement.”  As such, “the program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.”

  • Quality Improvement/Patient Safety activities include but are not limited to the following:
  • Quality Improvement/Patient Safety Conferences
  • Participation in institutional Quality Improvement/Patient Safety and related committees
  • Institute for Healthcare Improvement (IHI) Patient Safety Course
  • Grand Rounds
  • Patient Satisfaction Surveys
  • Core Measures
  • Utilization Management
  • Scholarly activity resulting in implementation of initiatives to improve patient quality and safety of care
  • Health Policy Fellowship
  • SCOPE:

This policy applies to all residents in the Program in Neurological Surgery.


  1. Residents must demonstrate attendance, and complete the associated IHI Online Modules, for each Quality Improvement/Patient Safety Core GME session once every two years (or a total of three times during the course of the 7 year residency).
  2. PGY-1 and PGY-2 residents must attend the Core GME session on reporting of patient safety events held at the beginning of each academic year.
  3. Residents must complete one independent activity in Quality Improvement/Patient Safety by the end of their PGY-5 year in order to achieve a Level 4 Milestone in Quality Improvement and eligibility to complete the training program.
  4. At any given time one neurosurgery resident will represent the department on the following committees:
  • Housestaff Council 
  • Hospital IT Committee
  • Hospital Neuro ICU Committee
  1. At any given time one neurosurgery resident will be appointed to assist the attending representative to the following committees:
  • Hospital NSQIP Committee 
  • Hospital Multidisciplinary Trauma Process Improvement & Peer Review Committee


The program director will provide, in the GME annual program report or upon request, information to GME regarding resident participation in Quality Improvement and Patient Safety Initiatives.

Approved by GMEC: 4/20/2020