INTERNAL MEDICINE
POLICIES & PROCEDURES

Internal Medicine Policy for Resident Involvement in
Quality Assurance Activities

 Policy Number : 15
Date Issued : 11/2002
Prior Revision Date :
  Date Revised :
PURPOSE To educate residents about the science of quality improvement. To teach them to apply the science to their patient care. To teach them to participate in the quality improvement activities of the hospital through membership on the hospital committees.
SCOPE Applies to all interns and residents (hereafter all will be referred to as trainees) in the Internal Medicine training program on the Presbyterian Hospital of Dallas campus.
PROVISIONS

Residents will be elected on a yearly basis to serve on the following PHD committees:

  • Graduate Medical Education Committee/ Medical Education Committee
  • Ethics Committee
  • Process Improvement Committee for Internal Medicine
  • Institutional Research Board

As members of these committees, the resident will observe the organization and function of the committee. The resident will be an active, participating, voting member. The resident will be asked to research issues and report their findings back to the committee. The resident will be responsible for reporting the activities of the committee to his/her peers at the monthly resident meeting. The resident will be responsible for taking feedback from his/her peers back to the committee for consideration.

One resident from each year will be appointed to a resident’s council for improvement of the educational opportunities and patient care activities provided by the Internal Medicine Department of PHD.

As a member of the council, the resident will work with the Chairman of the Department of Internal Medicine and the Associate Program Director to improve:

  • Process of patient care – inpatient and outpatient
  • Teaching Conferences
  • Attending Rounds
  • Subspecialty Rotations
  • Quality of residents life

Residents are required to choose a process improvement project in the Internal Medicine Clinic. They will be required to:

  • Validate- identify issue
  • Analyze- the processes for improvement
  • List- opportunities for improvement
  • Use- use them
  • Evaluate- whether the process implemented resulted in improvement
 
  MARK FELDMAN, M.D.
Chairman, Internal Medicine
Program Director, Internal Medicine 		BRUCE BOUGENO Vice President, Medical Staff Affairs