For Joel Bradley, MD, director of graduate medical education quality and safety education and an adult and pediatric hospitalist at Dartmouth Health in Hannover, N.H., quality improvement (QI) by hospitalists is inextricably linked to the safety of hospitalized patients and to improving the quality and safety of the care they receive. However, he said, this link isn’t always emphasized as it should be for frontline clinicians.
Dr. Bradley
“We know from recent research that adverse events are common in hospitals and may be happening in as many as a quarter of cases.”1 That is often enough that almost every hospitalist is likely to encounter some patient harm every day they come to work. “Our option is to tolerate or not tolerate harm to patients, with the option to intervene as advocates for our patients and their safety,” he said.
Dr. Bradley suggested that quality and safety work for most hospitalists and trainees is best viewed as incremental and small-scale, not requiring complex, multi-site, longitudinal studies or research funding. “I think an incremental framework for improving individual practice and the systems we work in is the crux of modern clinical practice. It also provides an answer to the statement that many clinicians tend to make that they don’t have time for quality.” Instead, he said, small acts of improvement can be integrated into most hospitalists’ daily work.
“Like reporting patient safety events and trusting that the system will feed back to you what happened, and what was improved, because that is the job of the QI architecture of a health system,” Dr. Bradley said. “It doesn’t matter whether you work in a community setting or an academic setting. There should be a patient safety and quality program that can act on things that frontline physicians report and believe are important to patient care.”
Those who work in quality improvement are writing more and more about patient and family involvement, such as through their advisory councils, Dr. Bradley said. “Ultimately, the purpose of quality work is to serve patients and the communities of our health systems. How are we going to do that unless the data are transparent both to providers and to patients and families?” he said. “The case I would make is that the more we involve patients and families in discussing quality gaps and harm, the more we will feel obligated ethically—as individuals and as clinical teams—to keep improving the system.”
“We’re entering a new phase where provider-patient partnership goes from being an idea in QI to, potentially, a reality,” Dr. Bradley added, thanks to AI-generated tools that can more swiftly aggregate patient feedback about care. That will invite more hospitalists and other front-line clinicians to the table because there will be unit-level, real, actionable, point-of-care data to work with. “At the end of the day, as a hospitalist, unit medical director, or section chief, you’ll be able to know how you did today.”
What Is Quality?
Quality and QI in hospital medicine start with improving outcomes through evidence-based practices to reduce variability. For Nicholas Meo, MD, associate chief medical officer for quality and safety and a hospitalist at Harborview Medical Center in Seattle, “there are ways to measure how effective we are at healthcare delivery. And that can be viewed through a lot of different lenses.” The umbrella term for this is quality. And of the commonly accepted characteristics of quality, safety is a critical one.
“Safe care is a dimension of quality. If we identify situations in which care is unsafe or if we make care safer, that care becomes higher quality. Along the same lines, if we deliver care that is more patient-centered, then we’re delivering higher quality.” Other examples, Dr. Meo said, include greater efficiency, timeliness, and appropriateness, or delivering care that is evidence-based or in line with the patient’s values.
“Improvement is the set of methods, tactics, and approaches that we employ to achieve better quality,” Dr. Meo said. There are some common tools that can be used that will help identify a quality problem, be specific about what you’re trying to accomplish to solve that problem, and then employ strategies to iteratively tackle or address it. “So quality improvement is putting those things together, focusing on some aspect of quality, and using a set of tools or approaches to try to close the gap. In our milieu, PDSA [Plan-Do-Study-Act] is a common tool for this,” Dr. Meo said.
“I think engaging in quality is central to the hospitalist physician’s identity. We’re not only experts in how to deliver hospital-based care, but we also understand how to navigate complex systems. And we see where our systems don’t best serve patients. Just going to work, you’re going to learn what quality is and where we may be falling short.”
Dr. Meo oversees all of the patient safety activities at Harborview Medical Center. “So when harm reaches a patient, we can commit to investigating, learning as much as we can about that event, and putting in place a plan to prevent something like that from happening again. We then work with patients and families after they’ve been harmed to try to reach some measure of resolution with them.”
If a hospitalist is involved in reporting a case to the safety department, he said, they may be asked for their perspectives on that case. “You may be asked for your ideas about how we can do it better. And depending on the case, depending on the hospital and its process, you may be asked to participate in communicating back to the patient and family after we have conducted the review,” he said.
“At Harborview, we’re constantly thinking about this and how we can do better by patients in this regard,” Dr. Meo said. “Adverse events will happen. Sometimes they’re not preventable, but sometimes we identify an adverse event that was preventable in some way. And I think that we all have, no matter where we work, a responsibility to be as transparent as possible with patients and families after these events occur.”
Dr. Meo recommended sticking to the facts of the case when informing patients, not speculating, but trying to honestly and authentically share what is known about an event. “And that’s what we’re trying to put in place here—the structures that will allow that to happen.”
He also urged individual hospitalists to engage with the structures that already exist where they work. “Talk to the risk manager, or the patient safety chief, or the patient safety officer in your hospital. Ask them what they expect from a hospitalist in terms of how to talk to families. They probably have either experts or other resources to help you along the way.”
Making It Explicit
Dr. Juthani
“I think quality is such an implicit part of health care that it sometimes takes an effort to make it explicit,” said Prerak Vipul Juthani, MD, MBA, clinical assistant professor of medicine at Stanford Medicine in Stanford, Calif. “I also think quality is the heartbeat of a hospital, because it keeps the hospital going. And if you don’t have a strong culture of quality, chances are that the next pandemic, or anything else that’s unexpected, will be tougher to manage because you don’t have rigorous quality improvement foundations. QI initiatives teach us to adapt quickly and to learn quickly.”
Dr. Juthani said he got a bit of QI training in medical school, but not enough. “In residency, the only reason I got into it was that I was lucky enough to get involved in QI committees,” he said. Today, he works on a variety of safety projects and task forces at Stanford, including reviews of all sorts of safety events and near misses, as well as more systemic issues.
“We create fishbone diagrams for whenever something occurs. We use A3s [lean problem-solving methodology], which is just an entire template for approaching a qualitative improvement project. And we also create Pareto diagrams. These are all things that are foundational to QI. The good part is that medical schools are picking up on this, with a curriculum behind it. But it’s never too late, even if you didn’t get a formal education in it, because once you start practicing, in whatever capacity, these groups will orient you,” he said.
How do we teach working hospitalists to rise to this level of basic QI? “I think it has to involve leadership taking a grassroots approach if that sort of culture isn’t already present in a hospital,” Dr. Juthani said.
What Is SHM Doing?
SHM teaches QI to hospitalists through its comprehensive Center for Quality Improvement, which offers projects addressing 16 specific clinical topics. SHM also has the Hospital Quality & Patient Safety (HQPS) Online Academy of internet-based modules to provide training not included in traditional medical education, and eQUIPS (electronic quality improvement programs) for web-based, collaborative, and topic-specific projects. Other avenues include a special interest group in quality improvement, coaching and mentoring, and a variety of educational offerings at the annual SHM Converge.
The Quality and Safety Educators Academy (QSEA), offered by SHM since 2012, most recently in September of 2025, is an intensive, three-day experience for hospitalists who are engaged—or want to be—in teaching QI principles to learners, including medical students, residents, advanced practice providers, and even other hospitalists. The next QSEA offering has not been scheduled yet.
Dr. Myers
In her keynote address at last year’s QSEA, Jennifer Myers, MD, FACP, MHM, executive director of the Center for Healthcare Improvement and Patient Safety at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, and a founding co-director of QSEA, emphasized the team approach across professions. “As physicians, you know, most of our training is done uni-professionally—physicians teaching physicians—but the practice of medicine is a team-based approach.” That includes nurses, social workers, patient navigators, physical therapists, and more.
“So I spoke about why collaborating with nurses and other healthcare professionals and making that standard practice and a foundation for quality improvement is so important,” Dr. Myers said. “That’s what drew me to QI early in my career. I liked the interprofessional nature of bringing different brains and eyes together. As you are designing educational experiences, having them co-designed by a nurse and a physician can really result in some innovative things.”
QSEA is the only national faculty development academy designed for the teachers of quality, Dr. Myers said. It was specifically designed for hospitalists who were being tapped on the shoulder or who were raising their hands to lead quality and safety teaching in their institution.
What has the training of QI educators taught her about how to share this knowledge with working hospitalists? “I would say the way to get involved in QI is to volunteer for QI projects early in your career. You know, if there is a problem in care delivery, volunteer to try to understand it and work to solve it.” But it’s also important to understand the evolving healthcare system and the emergence of value-based models to understand the metrics related to hospital reimbursement, and what’s going to be important to the healthcare system, she said.
“I also think that to learn the work, you need to experience it. You need to be exposed to it. Like handling safety event reports, being part of a QI effort. You need the experience of doing, which is really how we learn anything.”
Dr. Bradley said he believes quality is easier to learn once the individual has started working in the context of their job, after completing their education. “It becomes a lot more interesting when I have a junior hospitalist come to me a year or two into practice, saying: ‘Hey, I experienced this thing with my patient. What do I do now?’ That’s a powerful invitation for real teaching, where quality and safety come home to roost,” he said.
High-Value Care
Dr. Puri
Isha Puri, MD, MPH, FHM, is director of quality improvement and scholarly activity for the internal medicine residency program at Texas Health Harris Methodist Hospital in Fort Worth, Texas, and a hospitalist. She has been involved in QI for close to 10 years. “The way it began for me was working on independent projects. The American College of Physicians has an advanced course in QI, which I took and then built my QI project,” she said.
In a previous position at Peninsula Regional Medical Center in Salisbury, Md., the director of hospital medicine encouraged her to focus on high-value care because of her interest in quality. “QI for antibiotic stewardship was an opportunity to do that. Later, I served as director of quality improvement for the hospitalist program at Lahey Medical Center in Burlington, Mass.” In that role, Dr. Puri focused on projects aimed at bringing improvement to the program and its patient care.
“Currently, I’m working with the graduate medical education program for internal medicine residents. I am the QI lead for them. I built their curriculum for QI and patient safety. And we try to keep it exciting because it’s for the residents and medical students.”
The program follows a structured curriculum of patient safety and quality improvement, based on the Institute for Healthcare Improvement. All residents complete the basic certificate in patient safety and quality improvement. The curriculum also includes interactive workshops, which incorporate small group discussions and mock interactive sessions, she said. One of the simulation sessions focuses on root cause analysis conducted as a small group workshop in which residents role-play simulated near-miss cases.
Dr. Puri’s quality program at Harris also partners with other specialties, for example, the surgical department, which proposed a project on feeding tube complications. “We were able to roll it out, after both the surgery and medicine residents jumped in to develop an algorithm on how to prevent feeding tube complications. We took that to unit-based council meetings for nursing staff and taught them how to prevent these complications,” she said.
“Along similar lines, we’ve had quite a few quality initiatives with oncology, working with the National Comprehensive Cancer Society Guidelines.” Some of these reports have been submitted as QI abstracts for medical meetings, she said. “The last one we did was a pancreatic cancer project, for which the resident actually won the best poster award for a Texas ACP [American College of Physicians] meeting.”
And recently, Dr. Puri spoke to a pulmonologist, who suggested looking at prone bronchoscopies. “They wanted us to do it as a quality project and see how our numbers compare with other community hospitals. So I feel like we’re helping them and they’re helping us,” she said.
“As a hospitalist, I think it’s important to keep that enthusiasm going. When you feel more connected to your patients, you feel better connected to the nursing staff, and it gives you improved HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores because of that engagement.”
Attestation of Quality
For Dr. Bradley, the recent adoption of the Patient Safety Structural Measure (PSSM) and protocol by the federal Centers for Medicare and Medicaid Services in August of 2024 illustrates an opportunity for hospitalists to move the daily practice of quality and safety toward more advanced, public-facing reporting structures.
PSSM is an attestation-based measure requiring hospitals to affirm that they have a structure, culture, and leadership commitment prioritizing patient safety across five major domains. Those are: leadership commitment to eliminating preventable harm; strategic planning and organizational policy; culture of safety and learning health system; accountability and transparency; and patient and family engagement. Each domain contains five attestation statements for hospitals to evaluate and determine whether they can affirmatively attest “yes” to each statement.
Reporting is mandatory, and hospitals’ attestations to their specific evidence-based practices will be reported along with public reporting of performance on Care Compare starting in the fall of 2026. At this point, Dr. Bradley said, PSSM is more of a box-checking exercise without real teeth. However, it formally incentivizes a practice of prompt, transparent disclosure of medical errors, which is both an obligation for clinicians and a matter of public trust between the hospital, clinical teams, and communities.
“If we treat PSSM as a kind of ethical summons for hospitalists, we can say we now have permission and encouragement from the federal government to do this—including public posting of patient-facing information about our safety and quality (on the hospital floors). This can help hospitalists and clinical teams enter into real conversations with the patients and families about how to make care better.”
In a recent article in the Journal of Hospital Medicine, Dr. Bradley and Dr. Andrew White of the University of Washington highlight the opportunities for PSSM and for the Communication and Resolution Program (CRP) model, in which hospitals disclose adverse events to patients, investigate, explain what happened, and apologize, coordinating early event detection and reporting, open communication with patients, and efforts to reconcile emotional, physical and financial harms for injured patients.2
“Despite research that this proactive approach improves outcomes without increasing malpractice claims and costs, hospitals have been slow to adopt CRPs, prompting policymakers to intervene,” they note.3 For hospitalists, the professional development of communication skills for explaining harm to patients should be a priority. “Hospitalists at organizations with effective CRPs will also experience the satisfaction of contributing to system improvement and the ethical treatment of injured patients.”
Larry Beresford is an Oakland, Calif.-based freelance medical journalist.
References
- Bates DW, et al. The safety of inpatient health care. N Engl J Med. 2023;388(2):142-153. doi:10.1056/NEJMsa2206117.
- Bradley JM, White AA. Next steps-policy in clinical practice: The patient safety structural measure. J Hosp Med. 2026;21(3):308-310. doi:10.1002/jhm.70238.
- Mello MM, et al. Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. Health Aff (Millwood). 2017;36(10):1795-1803. doi:10.1377/hlthaff.2017.0320.