To help fellows in maternal-fetal medicine gain a well-rounded education in patient safety and quality, we present a curriculum outline that addresses the requirements of the Accreditation Council for Graduate Medical Education and the American Board of Obstetrics and Gynecology. For each month of fellowship, the outline suggests brief video clips, readings, and activities. Emphasis is placed on helping fellows develop and complete a quality improvement project. If desired, the curriculum can be modified to fit program-specific needs and can be adapted for use with residents in obstetrics and gynecology.
Key words
Introduction
Education in patient safety and quality is an essential component of fellowship training in maternal-fetal medicine (MFM). The Accreditation Council for Graduate Medical Education (ACGME) guidebook, Program Requirements for Graduate Medical Education in Maternal-Fetal Medicine,
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devotes a 14-page section to patient safety, quality improvement, supervision, and accountability, nearly one-third of the entire guidebook. Although the ACGME guidebook outlines the topics to be covered, it gives no guidance on how to accomplish the required education. Moreover, the all-encompassing scope of the comprehensive requirements is likely to be intimidating to fellows and program directors alike. Therefore, dismantling the requirements into smaller, more “digestible” pieces is likely to improve accessibility and usability for learners.This document aims to outline a curriculum to help MFM fellowship program directors and MFM fellows attain the required knowledge in safety and quality topics and to guide fellows on the completion of a quality improvement project during fellowship. We have divided the ACGME requirements into several small modules, most of which a fellow should be able to complete within 1 to 2 hours of focused attention during a given month. The full curriculum has 3 components (Box): the curriculum outline (this document); a Primer on Patient Safety and Quality for Maternal-Fetal Medicine Fellows
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; and a Toolkit for Quality Improvement Projects for Maternal-Fetal Medicine Fellows.Society for Maternal-Fetal MedicinePatient Safety and Quality CommitteeFellowship Committee
Primer on patient safety and healthcare quality for maternal-fetal medicine fellows. 2023.
Primer on patient safety and healthcare quality for maternal-fetal medicine fellows. 2023.
https://s3.amazonaws.com/cdn.smfm.org/media/3767/Primer_for_Curriculum_2023_01_18.pdf
Date accessed: January 24, 2023
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The latter 2 documents are publicly available on the SMFM website and will be updated as needed to reflect changes in the ACGME requirements.Society for Maternal-Fetal Medicine
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
https://s3.amazonaws.com/cdn.smfm.org/media/3768/Fellow_QI_Toolkit_-_2022_09_28.pdf
Date accessed: January 24, 2023
BoxThree components of the full curriculum on patient safety and quality for maternal-fetal medicine fellows
| Curriculum outline (this document) |
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| Primer on patient safety and quality for maternal-fetal medicine fellows 2 Society for Maternal-Fetal MedicinePatient Safety and Quality CommitteeFellowship Committee Primer on patient safety and healthcare quality for maternal-fetal medicine fellows. 2023. https://s3.amazonaws.com/cdn.smfm.org/media/3767/Primer_for_Curriculum_2023_01_18.pdf Date accessed: January 24, 2023 |
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| Toolkit for quality improvement projects for maternal-fetal medicine fellows 3 Society for Maternal-Fetal Medicine Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023. https://s3.amazonaws.com/cdn.smfm.org/media/3768/Fellow_QI_Toolkit_-_2022_09_28.pdf Date accessed: January 24, 2023 |
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QI, quality improvement, SMFM, Society for Maternal-Fetal Medicine.
Society for Maternal-Fetal Medicine. Maternal-fetal medicine fellowship curriculum outline. Am J Obstet Gynecol 2023.
The curriculum outline is presented in Table 1. Topics are presented with a suggested timeline coinciding with the month and year of the 3-year fellowship cycle, with quality improvement (QI) project milestones superimposed to help pace fellows concurrently working on a project. Each module includes suggested video clips, readings, and activities. Each item is presented with a checkbox for fellows to record completion and to easily see which “to-do” items remain. For the readings, we have given preference to open-access material where possible. Some suggested readings are from published literature, and some are from our Primer
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or Toolkit.Society for Maternal-Fetal MedicinePatient Safety and Quality CommitteeFellowship Committee
Primer on patient safety and healthcare quality for maternal-fetal medicine fellows. 2023.
Primer on patient safety and healthcare quality for maternal-fetal medicine fellows. 2023.
https://s3.amazonaws.com/cdn.smfm.org/media/3767/Primer_for_Curriculum_2023_01_18.pdf
Date accessed: January 24, 2023
3
Society for Maternal-Fetal Medicine
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
https://s3.amazonaws.com/cdn.smfm.org/media/3768/Fellow_QI_Toolkit_-_2022_09_28.pdf
Date accessed: January 24, 2023
Table 1Curriculum outline and suggested timetable
| Timeline and topic | Suggested activities | ACGME requirements 1 |
|---|---|---|
| Year 1, July Supervision, communication, professionalism | Read this article:
| VI.A.2: The program must demonstrate that the appropriate level of supervision in place for all fellows is based on each fellow’s level of training and ability and patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation. The program must define when physical presence of a supervising physician is required. To promote appropriate fellow supervision while providing for graded authority and responsibility, the program must use the following classification of supervision:
The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members. The program director must evaluate each fellow’s abilities based on specific criteria, guided by the milestones. Faculty members functioning as supervising physicians must delegate portions of care to fellows based on the needs of the patient and the skills of each fellow. Fellows should serve in a supervisory role to junior fellows and residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow. Programs must set guidelines for circumstances and events in which fellows must communicate with the supervising faculty members. Each fellow must know the limits of their scope of authority and the circumstances under which the fellow is permitted to act with conditional independence. Faculty supervision assignments must be of sufficient duration to assess the knowledge and skills of each fellow and to delegate to the fellow the appropriate level of patient care authority and responsibility. VI.B.4.e: Fellows and faculty members must demonstrate an understanding of their personal role in the monitoring of their patient care performance improvement indicators. |
| Year 1, August Culture of safety | Watch these videos:
| VI.A.1.a.1: A culture of safety requires continuous identification of vulnerabilities and a willingness to transparently deal with them. An effective organization has formal mechanisms to assess the knowledge, skills, and attitudes of its personnel toward safety to identify areas for improvement.
|
| Year 1, September Care transitions, structured handoffs, teamwork | Watch this video:
| VI.E.3: Programs must design clinical assignments to optimize transitions in patient care, including their safety, frequency, and structure. Programs, in partnership with their sponsoring institutions, must ensure and monitor effective, structured handover processes to facilitate both continuity of care and patient safety. Programs must ensure that fellows are competent in communicating with team members in the handover process. |
| Year 1, October Patient safety event reporting | Watch these videos:
| VI.A.1.a.2: Reporting, investigation, and follow-up of adverse events, near misses, and unsafe conditions are pivotal mechanisms for improving patient safety and are essential for the success of any patient safety program. Feedback and experiential learning are essential to developing true competence in the ability to identify causes and institute sustainable systems-based changes to ameliorate patient safety vulnerabilities. Residents, fellows, faculty members, and other clinical staff members must:
|
| Year 1, November Quality improvement processes | Watch this video:
| VI.A.1.a.2.b: Fellows must participate as team members in real and/or simulated interprofessional clinical patient safety and quality improvement activities, such as root cause analyses or other activities that include analysis, as well as formulation and implementation of actions. |
| Year 1, December Quality metrics | Watch these videos:
| VI.A.1.a.3: Access to data is essential to prioritizing activities for care improvement and evaluating success of improvement efforts. Fellows and faculty members must receive data on quality metrics and benchmarks related to their patient populations. |
| Year 1, January Addressing disparities in quality improvement | Watch these videos:
| II.A.4.a.2: Programs must understand the structural and social determinants of health of the populations they serve and incorporate them in the design and implementation of the program curriculum, with the ultimate goal of addressing these needs and eliminating health disparities. |
| Year 1, February Participation in quality improvement activities | Watch these videos:
| VI.A.1.a.2.b: Fellows must participate as team members in real and/or simulated interprofessional clinical patient safety and quality improvement activities, such as root cause analyses or other activities that include analysis, as well as formulation and implementation of actions |
| Year 1, March Disclosure of adverse events | Watch these videos:
| |
| Year 1, April Levels of supervision and progressive increase in authority | Read these articles:
| VI.A.2.d: The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members.
VI.B.4: Fellows and faculty members must demonstrate an understanding of their personal role in the monitoring of their patient care performance improvement indicators. |
| Year 1, May Physician well-being | Read these articles:
| VI.D: Programs must educate all fellows and faculty members in recognition of the signs of fatigue and sleep deprivation, alertness management, and fatigue mitigation processes (two paragraphs of detail follow). The program, in partnership with its Sponsoring Institution, must ensure adequate sleep facilities and safe transportation options for fellows who may be too fatigued to safely return home. VI.F.1: Maximum hours of clinical and educational work per week. Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a 4-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting (several paragraphs of detail follow). |
| Year 1, June Physician burnout | Watch these videos:
| VI.C: Psychological, emotional, and physical well-being are crucial in the development of the competent, caring, and resilient physician and require proactive attention to life inside and outside of medicine.
The responsibility of the program, in partnership with the sponsoring institution, to address well-being must include the following:
Fellows and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care. The program, in partnership with its sponsoring institution, must:
|
| Year 2, July Catch-up | Read these articles:
| |
| Year 2, August Professionalism, fitness for work | Watch this video:
| VI.B.1: Programs, in partnership with their Sponsoring Institutions, must educate fellows and faculty members concerning the professional and ethical responsibilities of physicians, including but not limited to their obligation to be appropriately rested and fit to provide the care required by their patients.
|
| Year 2, September Unprofessional behavior | Watch these videos:
| VI.B.6: Programs, in partnership with their sponsoring institutions, should have a process for education of fellows and faculty regarding unprofessional behavior and a confidential process for reporting, investigating, and addressing such concerns. |
| Year 2, October Equity, freedom from discrimination | Watch these videos:
| VI.B.5: Programs, in partnership with their sponsoring institutions, must provide a professional, equitable, respectful, and civil environment that is psychologically safe and that is free from discrimination, sexual and other forms of harassment, mistreatment, abuse, or coercion of students, fellows, faculty, and staff. |
| Year 2, November Patient-centered and family-centered care | Watch this video:
| VI.B.4: Fellows and faculty members must demonstrate an understanding of their personal role in the safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and safety events. |
| Year 2, December Education on patient safety and lifelong learning | Watch these videos:
| IV.B.1.d: Practice-based learning and improvement: Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. IV.D: Scholarship: Medicine is both an art and a science. The physician is a humanistic scientist who cares for patients. This requires the ability to think critically, evaluate the literature, appropriately assimilate new knowledge, and practice lifelong learning. |
| Year 2, January Monitoring of patient care performance indicators | Try these activities:
| VI.A.2.e.1: Each fellow must know the limits of their scope of authority, and the circumstances under which the fellow is permitted to act with conditional independence. |
| Year 2, February to June Project wrap-up and completion | QI project wrap-up:
| |
| Year 3, July to December Project analysis and write-up | Try these activities:
| |
| Year 3, January to June Project presentation and publication | Try these activities:
|
The activities listed are suggestions, not mandates. Individual fellowship programs are free to modify the suggested activities to fit local circumstances. Some of the videos in this table are preceded by advertisements, which can be skipped after a few seconds. The Society for Maternal-Fetal Medicine makes no statement of endorsement regarding the products or services advertised.
ACGME, Accreditation Council for Graduate Medical Education; AHRQ, Agency for Healthcare Research and Quality; MFM, maternal-fetal medicine; PDSA, Plan-Do-Study-Act; QI, quality improvement; RCA, root cause analysis; SDOH, social determinants of health.
Society for Maternal-Fetal Medicine. Maternal-fetal medicine fellowship curriculum outline. Am J Obstet Gynecol 2023.
The timetable and contents are suggestions only and not mandatory. Fellowship program directors are encouraged to modify the curriculum if doing so better fits the unique attributes of their program. If the curriculum is modified, we recommend developing a revised timetable of expected completion dates. Timetables may help to motivate fellows, especially those whose workflow is driven by deadlines.
We have designed this as a self-study curriculum under the assumption that some programs will not have dedicated faculty to teach all aspects of safety and quality. If a program has appropriate faculty and resources, live activities, such as didactic lectures or small group seminars, can supplement or replace parts of the curriculum. Because fellows may have different optimal learning methods, they will likely benefit if materials are made available in various formats, including readings, seminars, lectures, and videos.
In addition to providing suggested educational resources, the curriculum emphasizes the requisite steps for fellows to design and complete their QI projects. The ACGME requirements allow fellows to simply “tag along” on existing projects within the facility, and it may be valuable to observe or participate in large-scale QI projects. However, we believe that most people learn best by doing and, therefore, recommend that each fellow conduct an individual small-scale QI project. We encourage the fellow to start noticing gaps in quality and safety early in their first year and begin thinking about ways to close them. By the end of the first year, the fellow should identify their QI project; assemble a project team, including a faculty mentor and other key stakeholders; and design the intervention to be tested. In the second year, the fellow should implement the intervention and test its effectiveness. In the third year, the fellow should finalize the project, present the results locally, and submit the project for publication. Resources to help fellows design and implement a project are presented in the Toolkit.
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Society for Maternal-Fetal Medicine
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
Patient Safety and Quality Committee, Fellowship Committee. Fellow’s QI toolkit: Practical guide for QI projects. 2023.
https://s3.amazonaws.com/cdn.smfm.org/media/3768/Fellow_QI_Toolkit_-_2022_09_28.pdf
Date accessed: January 24, 2023
If program directors and MFM fellows systematically pursue the activities outlined, they should gain a well-rounded foundation in patient safety and quality improvement. Doing so will satisfy both the ACGME requirements and the requirements outlined in the American Board of Obstetrics and Gynecology Bulletin for Subspecialty Certification in Maternal-Fetal Medicine (Table 2).
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American Board of Obstetrics and Gynecology. 2023 bulletin for subspecialty certification in maternal-fetal medicine.
https://www.abog.org/docs/default-source/bulletins/2023/mfm-2023-bulletin-12.12.2022.pdf?sfvrsn=4ee2a312_3
Date accessed: February 18, 2023
Table 2American Board of Obstetrics and Gynecology requirements related to patient safety and quality for maternal-fetal medicine
| Topic | Requirements |
|---|---|
| Ethics and professionalism | Systematically engage in practice review to identify health disparities When engaged in shared clinical decision-making, incorporate patient, family, and cultural considerations in making treatment recommendations When providing care for patients, consider psychological, sexual, and social implication of various treatment options |
| Patient safety | Systematically analyze the practice for safety improvements (eg, root cause analysis) Systematically engage in practice reviews for safety improvements (eg, root cause analysis) Incorporate the standard use of procedural briefings, “time-outs,” and debriefings in clinical practice Participate in the review of sentinel events, reportable events, and near misses Implement universal protocols (eg, bundles or checklists) to help ensure patient safety |
| Interpersonal and communication skills | Communicate to patient and family regarding adverse outcomes and medical errors Demonstrate sensitivity and responsiveness when communicating with a diverse patient population, including, but not limited to, diversity in gender, age, culture, race, religion, disabilities, and sexual orientation Provide comprehensive information when referring patients to other professionals |
| Systems-based practice | Incorporate considerations of cost awareness and risk-benefit analysis in patient care Provide care with multidisciplinary teams to promote patient safety and optimize patient outcomes |
| Practice-based learning and improvement | Design or participate in practice or hospital quality improvement activities |
| Evidence-based medicine | Incorporate evidence-based practices and national guidelines to improve practice patterns and outcomes Implement evidence-based protocols to enhance recovery after surgery |
Excerpted from the American Board of Obstetrics and Gynecology.
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American Board of Obstetrics and Gynecology. 2023 bulletin for subspecialty certification in maternal-fetal medicine.
https://www.abog.org/docs/default-source/bulletins/2023/mfm-2023-bulletin-12.12.2022.pdf?sfvrsn=4ee2a312_3
Date accessed: February 18, 2023
Society for Maternal-Fetal Medicine. Maternal-fetal medicine fellowship curriculum outline. Am J Obstet Gynecol 2023.
Residency program directors may wish to adapt the curriculum for residents in obstetrics and gynecology. In doing so, it may be advisable to modify the timeline to fit individual clinical rotation schedules.
Contributors
- •Curriculum Outline: R. Nicholas Burns, MD; C. Andrew Combs, MD, PhD; Natasha Kumar, MD; and Jamie Morgan, MD
- •Primer: Janet Andrews, MD; C. Andrew Combs, MD, PhD; Christina Davidson, MD; Rebecca Feldman-Hamm, MD; Dena Goffman, MD; Afshan Hameed, MD; Andrew Healy, MD; Iffath Hoskins, MD; and Dotun Ogunyemi, MD
- •Project Toolkit: R. Nicholas Burns, MD, and Jamie Morgan, MD
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Article info
Publication history
Published online: February 02, 2023
Publication stage
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All authors and committee members have filed a disclosure of interests delineating personal, professional, business, or other relevant financial or nonfinancial interests in relation to this publication. Any substantial conflicts of interest have been addressed through a process approved by the Society for Maternal-Fetal Medicine (SMFM) Board of Directors. The SMFM has neither solicited nor accepted any commercial involvement in the specific content development of this publication.
This document has undergone an internal peer review through a multilevel committee process within the SMFM. This review involves critique and feedback from the SMFM Patient Safety and Quality and Document Review Committees and final approval by the SMFM Executive Committee. The SMFM accepts sole responsibility for the document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. The SMFM Patient Safety and Quality Committee reviews publications every 36 to 48 months and issues updates as needed. Further details regarding SMFM publications can be found at www.smfm.org/publications.
The SMFM recognizes that obstetrical patients have diverse gender identities and is striving to use gender-inclusive language in all of its publications. The SMFM will be using the terms “pregnant person” and “pregnant individual” instead of “pregnant woman” and will use the singular pronoun “they.” When describing study populations used in research, the SMFM will use the gender terminology reported by the study investigators.
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