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Quality Improvement

Quality Improvement and Patient Safety

  • We have a robust and expanding Quality Improvement and Patient Safety program in the Department of Medicine
  • Currently, numerous resident‐initiated and resident‐run QI initiatives are ongoing on both the inpatient and outpatient services
  • QI efforts among housestaff are supported by a dedicated PGY‐4 Chief Resident for Quality position, an Associate Vice‐Chair for Quality and Vice‐Chair for Quality in the department.

Mission Statement

The Department of Medicine healthcare team is committed to delivering high quality, safe, efficient, and patient‐centered care to our patients and our community.


  • Excellence in patient care
  • Teamwork and collaboration
  • Respect and collegiality
  • Patient and family‐centered care

Morbidity and Mortality Conference

  • Biweekly conference at the Department of Medicine’s Power Rounds
  • Presented by team of two PGY‐2 residents
  • Systems‐based conference model with focus on dual goals of clinical education as well as addressing patient safety issues and reducing preventable errors

Resident Quality Council

  • Monthly, informal meeting involving residents, faculty and other services including nursing, pharmacy.
  • Review of interesting cases from a quality perspective, raising of important quality and system issues to be addressed
  • Opportunity to present results or progress of ongoing and completed quality projects
  • Opportunity for residents to partner with students and other disciplines/services for QI projects and

QI Curriculum –Workshop series




  • Novel, “flipped”, longitudinal curriculum initiated this academic year
  • Based on the Institute for Healthcare Improvement(IHI) Open School’s Basic Certificate in Quality and Patient Safety
  • Focus on active learning and trainee‐engagement
  • Monthly workshop during ambulatory week
  • Small‐group exercises to help anchor quality improvement and patient safety concepts to day‐to‐day clinical work

 Distinction in Quality and Safety Program

  • Certificate awarded to recognize resident involvement in quality and patient safety as evidenced by participation in quality projects within the department of medicine, the review and presentation of morbidity and mortality events and regular participation in the resident quality council. 

Quality Updates Meeting

  • Monthly inter‐disciplinary department‐wide meeting
  • Review of data/quality metrics for the department of Medicine
  • Discussion of initiatives for improvement
  • Regular updates from other teams – Clinical Documentation Improvement(CDI), Patient Experience (PX), Infection Control, Resuscitation, CHF Nurse Coordinators
  • Opportunity for resident/faculty education


  • Creation of departmental multidisciplinary quality and patient safety conferences
  • Creation of a physician code team leader for the hospital code/rapid response team
  • Creation of a physician signout tool that is imbedded in the hospital EMR
  • Creation of admission, progress note, and discharge note templates for internal medicine residents that optimize accurate documentation
  • Creation of multidisciplinary rounds with case management, physical therapy, nutrition, nursing, and physicians to facilitate patient‐centered care and hospital throughput
  • Creation and implementation for hospital discharge work‐flow process to ensure patient safety, improve accuracy of medication reconciliation, and ensure a safe transition to outpatient care.


  • Khorasani‐zadeh A, Krowl LE, Chowdhry AK, Hantzidiamantis P, Hantzidiamantis K, Siciliano R, Grover MA, Dhamoon AS. Usefulness of a metronome to improve quality of chest compressions during cardiopulmonary resuscitation. Baylor University Medical Center Proceedings 2020 Aug 24 (pp. 1‐2). Taylor & Francis.
  • Kudaravalli P, Doobay R, Carvounis C, Toomey C, Dhamoon A. Initiatives to reduce the inappropriate use of proton pump inhibitors in an outpatient primary care clinic. Ann Pharm Fr. 2020 May 30:S0003‐
    4509(20)30069‐9. doi: 10.1016/j.pharma.2020.05.002.
  • Custer A, Rein L, Nguyen D, Wentworth K, Dhamoon A. Development of a real‐time physician–patient
    communication data collection tool. BMJ Open Quality 2019 Nov 2;8(4):e000599. doi:10.1136/ bmjoq‐2018‐ 000599.
  • Krowl L, Gudlavalleti A, Patel A, Panebianco L, Kosters M, Dhamoon AS. A pilot study to standardize and peer‐review shift handoffs in an academic internal medicine residency program: The DOCFISH method. Medicine (Baltimore). 2018 Oct;97(41):e12798.
  • Masood U, Sharma A, Bhatti Z, Carroll J, Bhardwaj A, Sivalingam D, Dhamoon AS. A Successful Pharmacist‐ Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit. Inquiry. 2018 Jan‐Dec; 55: 46958018759116.
  • Lau C, Dhamoon AS. The impact of a multidisciplinary care coordination protocol on patient‐centered
    outcomes at an academic medical center. Journal of Clinical Pathways. 2017; 3[4]: 37‐46.