Quality Improvement Training for Post-graduate Clinical Education


This website contains resources for quality improvement training in postgraduate clinical education in Iceland. 

Quality improvement training is an essential pre-requisite of post-graduate education for doctors, clinical nurse specialists and clinical pharmacists in Iceland. The training programme was developed in 2018 at Landspítali based on Learning to Make a Difference curriculum by the Royal College of Physicians.

The learning objectives are:

  • To develop necessary knowledge, skills and attitudes to make focused small-scale change through a simple structured framework.
  • To provide a real means for trainees to respond to the theme of learned helplessness and not accept mediocrity in their clinical practice.

About the Training Programme

Quality improvement training is a 4-6 month programme comprising of face-to-face teaching and implementation of a small project. Trainees will be taught to use a methodology called Model for Improvement, which will enable them to achieve their learning objectives. Teaching is interactive and delivered in two half-day small group face-to-face sessions.

Trainees are expected to have a topic in mind before starting training and work through the idea during the teaching sessions. The teaching sessions are held one month apart and trainees should continue to plan their projects in-between sessions. By the time the teaching has been completed, the trainee should have a draft project plan developed and be ready to start executing their project over approximately 4 months.

Trainees are expected to work through some pre-training preparation (read articles and watch a short video), which will enable them to develop a basic understanding of the methodology to assist them in choosing a suitable topic.

Trainees are encouraged to participate in quality improvement training during their 2nd or 3rd year of post-graduate studies. To help prepare trainees for QI training, they will attend an introductory presentation at their first year induction.

Structure of QI Training

Model for Improvement

There are many quality improvement methodologies. These include Lean, Six Sigma, Total Quality Management (TQM) and clinical audit. The Model for Improvement was developed based on the work of W. Edwards Deming who is an American engineer, statistician and management consultant. It is a continuous improvement methodology where changes are tested in small cycles, which involves planning, doing, studying and acting (PDSA), before returning to planning and so on. Each cycle starts with hunches, theories and ideas and helps them evolve into knowledge that can inform action and, ultimately, produce positive outcomes.

This QI methodology is based on approaching change through four lenses, in accordance with Deming‘s „System of Profound Knowledge“:

  1. Psychology – All improvement ultimately involves the change in behaviour of people. To be successful, it is essential to understand how people think and act.
  2. Systems – The work that people do is part of a process, and each process is connected to other processes. This network of processes forms a system. Different people participate in making systems work. Changing part of one process affects another and disrupts the wider system. One needs to understand how systems work to be able to make sustainable improvements.
  3. Variation – Understanding variation in how people work within a system and reducing it as much as possible is necessary for improvement. Therefore, data for improvement needs to be informative about variation.
  4. Theory – One cannot fully learn about the psychology of people, how systems work and variation without testing changes. Testing enables the formation of theories by investigation into how people behave and complex systems are affected by changes. Forming and testing theories in cycles enables sustainable solutions to be found and is underpinned by the approach of „learning by doing“.


Resources for Trainees

Not all quality improvement project ideas may be appropriate for trainees to implement as their very first project while still developing core competencies. Some problems may be more complex and difficult to resolve than others. This checklist may be used as a guide to assess whether the topic may or may not be appropriate.


 Can the problem be assessed, immediate improvements planned and implemented with at least 2 tests of change within 4-6 months?    
 Can the project be achieved with the little spare time that is allocated for QI training? (8 hours per month in addition to teaching time).    
 Is complexity of the problem and scale proportionate to the trainee’s current QI skills and abilities?    
 Is the intervention/treatment performed frequently? High frequency usually means high impact and makes testing ideas/changes quicker and easier to  measure.
 Is the topic focused on a targeted group of people and/or area? (1 clinical area vs. multiple)    
 Is the trainee passionate about the topic?    
 Will this ultimately improve patient care?    
 Is there an indisputable need to make a change/improvement?    
 Is the topic about improving the way the trainee’s current service is delivered rather than another department’s? (e.g. if the trainee works in the emergency department, is the topic about improving the work done in the emergency department?)    


 Title: Doctors and quality improvement

 Purpose: Presents the big picture, why doctors need to develop QI skills.

 Doctors and Quality Improvement                         
 Title: Quality improvement part 1: introduction and overview

 Purpose: Describes what quality improvement is, background about the field and examples of some methodologies. 
 Quality improvement part 1: introduction and overview
 Title: How to start a quality improvement project

 Purpose: An overview of the Model for Improvement methodology.

 How to start a quality improvement project
 Title: Junior doctor-led quality improvement project to improve safety and visibility of an interspecialty referral system

 Purpose: Example of a published quality improvement project (BMJ, 2021).

 Junior doctor-led quality improvement project
 Title: Quality improvement in nursing: Administrative mandate or professional responsibility?

 Purpose: Quality improvement from a nursing perspective.

 Quality improvement in nursing_administrative mandate or professional responsibility
 Title: The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting:   explanation and elaboration

 Purpose: Guidance and standards for reporting quality improvement work.

 The SQUIRE guidlines
 Title: Learning leadership skills in practice through quality improvement

Purpose: To appreciate the broad range of skills that are developed during quality improvement training.
 Learning leadership skills in practice through quality improvement


Resources for Project Supervisors

  • It is not necessary to seek data protection approval to pull data from Landspítali‘s health records for quality improvement purposes.
  • It is permissible for junior doctors to look into patients‘ health records and to manually collect data on a separate data collection form or spreadsheet as long as they do not record kennitalas or other patient identifiable information.
  • Always ask: do you absolutely need to include kennitalas in your data collection?
  • Once kennitalas are recorded this data is no longer anonymised and may require approval from the data protection authority.
  • The health informatics team (Hagdeild) will generally not provide patient identifiable information when data is requested for and they may ask for evidence of ethics approval.
  • The HUT department may include kennitalas in their spreadsheets and may not ask for proof of data protection (or ethics) approval.
  • Rules are gradually tighening up.
  • Residents and QI project supervisors therefore have a responsibility to make a concerted effort to always protect the identity of patients when conducting QI projects.

It is not necessary for QI projects to receive ethics approval from the Bioethics Committee, however it is important for ethical issues to be considered before starting any project. The screening tool below provides a guide for trainees and supervisors to be able to carry this out in a structured way. The trainee and supervisor should complete this together and have it signed by the QI Lead for the training programme. A signed copy should then be kept by the trainee. This will then fulfill the ethics screening criteria if the trainee chooses to publish his/her work in the future.



Contact information

Quality improvement training for post-graduate clinical education is overseen by the respective post-graduate training boards for medicine, clinical pharmacy and clinical nurse specialists at Landspítali. Quality improvement training is led by appointed leads for each training programme and a project manager and improvement coach from the Landspítali Quality Department oversees development and delivery of QI curriculum under the direction of the post-graduate training boards.

Information about Name Contact
Post-graduate medical education: Margrét Dís Óskarsdóttir margdis@landspitali.is
Internal medicine: Jordan Cunningham jordan@landspitali.is
Anaesthetics: Martin Ingi Sigruðsson martin@landspitali.is
Paediatrics: Margrét Dís Óskarsdóttir margdis@landspitali.is
Gynaecology: Heiðdís Valgeirsdóttir heiddisv@landspitali.is
Psychiatry: TBC
Radiology: Bogi Brimir Árnason bogib@landspitali.is
Surgery: Jón Örn Friðriksson jonorn@landspitali.is
Heilsugæslan: Margrét Ólafía Tómasdóttir margret.olafia.tomasdottir@heilsugaeslan.is
Post-graduate clinical pharmacy training: Kristjana Kristinsdóttir kristjana@landspitali.is
Post-graduate clinical nurse specialist training: Katrín Blöndal katrinbl@landspitali.is
Project manager and improvement coach: Amelia Samuel amelia@landspitali.is