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Quality Improvement

The Department of Medicine’s Quality Improvement and Patient Safety (QI/PS) Program aims to continuously improve the quality of care we provide to our patients. The Program addresses important dimensions of care outlined by the Institute of Medicine, including safety, effectiveness, and efficiency.

Medical Peer Review Committee

One of the key functions of the QI/PS Program is the Medical Peer Review Committee. This committee reviews  adverse events and “near misses” to identify possible root causes, areas for improvement, and recommendations. Cases reviewed include incident reports, unexpected deaths,  procedure-related complications, gaps in transitions of care and reports from physicians, nurses, and family members. The committee is made up of attending physicians, residents, nursing leadership and pharmacists across the Department of Medicine.

The Medical Patient Care Committee

The Medical Patient Care Committee sets the clinical priorities for the Department’s QI/PS Program. The committee includes leading clinicians and educators in the Department as well as nursing leaders. Each committee meeting focuses on both quality and operational priorities.  Coordination  and communication are key to  the analysis, design, and implementation of clinical interventions. 

Multidisciplinary Working Groups

Our Multidisciplinary Working Groups represent collaborations to improve the quality of care, coordination, and/or patient experience across divisions within the Department of Medicine and/or between the Department of Medicine and other departments at BIDMC . The working groups aim to improve the quality of patient care across multiple disciplines and specialties. Examples include a diabetes working group, a heart failure committee, and an anticoagulation working group.

Division-Based Dashboards and Quality Improvement Activities

The clinical divisions in the Department of Medicine have developed performance dashboards, which focus on quality indicators relevant to their specialty. The data presented in the dashboards come from several sources, including electronic medical records, billing systems, patient surveys, and pharmacy and laboratory databases. The data collected and analyzed in the dashboards allow each division to evaluate its performance over time, perform comparative analyses, and identify best practices and areas for improvement. Additionally, clinical divisions develop, implement and study quality and process improvements

Education Programs

The QI/PS education programs aim to ensure that all Medicine physicians and trainees understand the rationale behind continuous quality improvement and have the skills to systematically improve the care they provide.

Goals include:

Development of continuous self-directed learning with respect to quality of care

  • Satisfaction of the Accreditation Council on Graduate Medical Education (ACGME) core competencies in systems based practice, practice-based learning and improvement

  • Demonstration of being able to conduct a root cause analysis and stress the importance of provider reporting of medical errors and “near misses”

  • Increased participation in QI/PS initiatives in the Department of Medicine

We’re particularly proud of our QI/PS training for residents, which is part of an Educational Innovation Project awarded by the Residency Review Committee of the ACGME. This training includes: 

  • Medical Procedure Service

  • Re-organization of ward residents into unit-based

  • Geographically-integrated teams

  • Stoneman QI/PS Rotation

Contact Information

Scot B. Sternberg, MS
Administrative Director, Quality
Department of Medicine
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215