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2021 QIPS Project and Annual QIPS Day Process

quality fileIn order to meet the Institutional Requirements and maintain a focus on quality and patient safety, the UT College of Medicine, Chattanooga adopted a policy in 2019 requiring that every resident in all training programs has “significantly participated” in a Quality Improvement and Patient Safety Project prior to graduation. Each Fellowship training program has the discretion to determine if their fellows will be required to complete a project.  

The Program Director must document that each Resident has been significantly involved in at least one Quality Improvement/Patient Safety (QIPS) Project at any time during their training in Chattanooga in order to meet graduation requirements. Discretion is granted to Fellowship Program Directors regarding whether or not this will be required for fellows who may have completed a project in their core residency program.”

 “Significant involvement” is defined by the Program Director in consultation with the Departmental Chair, the Quality Champion, the project mentor, the CCC* and other faculty as appropriate. “Significant involvement” should include that the resident/fellow is able to demonstrate an understanding of the project, articulates what quality improvement components were employed in their QIPS project and describe their personal role. Each graduating resident/fellow shall consist of a copy of the project’s aim statement, goals, and PDSA cycles and shall be submitted to the Program Director for their approval..

Each department fellowship program is granted the discretion to decide:

  1. If the fellowship program will require significant participation by the fellow in a QIPS project.
  2. If the fellowship program will approve a previously completed QIPS project (i.e., during residency) to meet this requirement. 
The Department Chair in consultation with the Program Director, Quality Champion, Program Research Director and other faculty as appropriate, and with consideration of the resident’s/fellow’s scholarly activities will have the final decision as to whether or not the resident met the QIPS requirement.
 In completing the already required Resident/Fellow Reappointment/Promotion or Termination Form the PD will certify the resident’s/fellow’s significant participation in the a QIPS project. This form shall be received by the Dean’s Office, DIO by March 1st of the graduation year.

In the event that the Program Director, in consultation with the Chair, believes that the resident/fellow did not participate to a significant degree in the QIPS project or does not submit the necessary documentation of such participation, the PD should present such evidence to the Quality Improvement/Clinical Competency Committee for review and recommendations on remedial steps and decision on graduation. After the CCC recommendation, the resident/fellow may utilize the UTCOM, Chattanooga GME Institutional Policy #720 Academic Appeals and Due Processfor final adjudication.  

 *The UTCOM, Chattanooga encourages that each departmental CCC include a review of the QIPS project in the periodic CCC resident/fellow review.

In order to assist the residents, fellows and training programs, the following is a recommended timeline:

Resident/Fellow Quality Projects:

Lists of Projects: The project can take many different forms from an individual project to a team project to an existing EHS QIPS project. A list of current EHS projects is available under the QIPS 2021 tab on this webpage.

Initial Discussion on Project: In September 2020 (or before) Residents/Fellows should meet with their mentor, Quality Champion, Program Director or other faculty member to discuss options and decide on Project.

Coaching Request Form with Project Plan or Idea submitted by October 2, 2020: All residents/fellows working on QIPS projects that will be considered for presentation at QIPS Day in May and any projects that will meet the graduation requirement of June 2021 should have a Project idea or tentative idea picked out by the first week in October. Residents should begin to formulate their project plans in September, select their mentor and consider what coaching they will require.  Departments vary in their ability to provide Quality Improvement coaching, so residents/fellows need to discuss with their Department leaders. Coaching Request Form by October 2, 2020.

QI Coaching—October 2020 through May 2021: All projects should have coaching from either the resident’s own department faculty (Departmental QIPS Team), the UTCOM/EHS QIPS Resident Advisory Committee or by the EHS Process Improvement Department.  The EHS Process Improvement Department and the Quality Project Advisory Committee have volunteered to provide coaching and feedback for all projects. After the coaching form is received, you will be notified of the times and availability of coaching sessions. It is expected that the entire team (all residents, faculty mentor and any other team members) will attend the coaching session.

 IRB submission:(Before you start gathering data.) In accordance with IRB policy from UTHSC (adopted by our IRB) you need to submit the IRB form before data is collected. 

  •  The new policy requires that before you can gather data, if the Project meets any of the following criteria, you must submit your QI projects to the IRB:
    • The intent is to use the data to contribute to generalizable knowledge.
    • Participants are randomized to compare outcomes.
    • The activities are not normally done as part of standard operating procedures,
    • Results will be used to apply knowledge to other programs outside the institution,
    • The project is subject to peer review (designed to be used outside of the institution),
    • Anonymity of participants cannot be assured,
    • The activities involve more than minimal risk to participants.
  • Numbers 1-3 are within the definition of research.  Numbers 4, 5 refer to knowledge sharing outside the institution, through presentations or publications.  Number 6, 7 concern human subjects research and HIPAA.
  • There will be projects that may not meet any of these criteria and could bypass IRB.  However, those will be few and the majority, if not all will need to be reviewed by IRB.
  • After deciding on your project,  you will want to contact Stacey Hendricks to determine what IRB materials need to be submitted and when your IRB review will occur, whether your project is expedited or excused from review.  

 The IHI Open School Project template has been sent out to all PD and can be used for organizing, implementing and presenting the project. (IHI Open School Project Template enclosed.)  

  •  The IHI open school modules are available on the IHI site and are free for all residents and faculty. The modules will walk a resident and faculty members through the QI project process. All residency directors can track how many modules have been completed by each resident. Some Departments require residents to complete a set number of IHI modules. While the UTCOM strongly encourages residents to complete some or all of the modules, UTCOM does not require the completion of a defined number of modules. The Guide for participants in IHI modules and reporting guides will be emailed to you and will be available under QIPS Day 2021 tab on this.webpage. 
  • Verification of completion of QIPS Project and approval for graduation. The Program Director approval statement (Resident/Fellow Reappointment/Promotion or Termination Form) shall be received by the DIO by March 1st of the graduation year

QIPS Annual Quality Day Participation:

Every project will be eligible to be reviewed for participation in QIPS Day. Forms for Annual QIPS Day must be submitted to your Department Chair or Program Director for approval by Friday, April 9, 2021).

  • The submission form utilizes the IHI Model for Improvement (e.g. AIM Statement, PDSA Cycles, IHI Charter Template, etc.). Any other quality project format needs approval from the department and from the QIPS Review Team.
  • The QI Proposal Submission Form with a completed IHI Charter Template must be emailed from your Chair or Program Director (with his/her approval denoted) to Dr. Kohrt by Friday, April 16, 2021.
  • The QIPS Advisory Committee will review and make selections by Friday, April 30, 2021 for presentation at the 2021 Annual QIPS Day.
  • Residents/Fellows selected for presentation will be notified by the end of the day on April 30.
  • QIPS Day presentations will be given on Friday, May 14, 2021. Tentatively presentations will be conducted via Zoom on May 14. Specifics will be emailed to all presenters, residents, fellows, faculty, staff, and judges by May 3, 2021.

Last Published: Oct 5, 2020