Research Programs | MedStar Health Institute for Quality and Safety | MedStar Health

Learning and research programs focused on quality and safety

The MedStar Health Institute for Quality and Safety is a leader in the science, innovation, and discovery leading to better patient quality, experience, and safety across the continuum of health care.

Along with our Patient and Family Advisors and our MedStar Health partners, we design, implement, and test innovations to improve the future of health for all Americans. One hallmark of our program is the commitment to partnering with patients, family members, and caregivers in co-producing health innovations.

Institute for Patient Safety and Quality research programs

Diagnostic safety capacity building

MedStar Health was awarded a contract to support the Agency for Healthcare Research and Quality (AHRQ) in developing capacity related to understanding and improving diagnostic safety.

The project will engage subject matter experts from across the country to help develop new approaches and resources to improve diagnostic safety. Select resources will include a TeamSTEPPS® module to enhance communication among providers related to diagnosis, a resource to engage patients and families in the diagnostic process, and programs to guide clinicians and frontline quality and safety professionals in their diagnostic improvement efforts.

Project Dates: September 2019 – September 2021
Funded by: Agency for Healthcare Research and Quality (AHRQ)
Principal Investigator: Dr. Christine Goeschel

Patient safety learning lab to improve the diagnosis and treatment of cardiovascular disease in women

Cardiovascular disease (CVD) is our nation’s costliest chronic disease. Errors in the diagnosis, treatment, and communication of CVD disproportionately impact women. Women are nearly twice as likely as men to receive the wrong initial diagnosis following a heart attack and 30% more likely to have stroke symptoms misdiagnosed in the emergency department (ED).

The MedStar Health Learning Lab will apply a systems engineering approach to understand the factors contributing to diagnostic error in women with CVD. Collaboratively with our partners, we will design and test methods to prevent or mitigate these errors.

The Lab will focus on the ambulatory care setting and involve patients, physicians, nurses, and other providers working in partnership with the research team. The overall aims are to improve the diagnosis and treatment of women with CVD, thereby improving patient outcomes and reducing costs of care.

Project Dates: September 2019 – September 2023
Funded by: Agency for Healthcare Research and Quality (AHRQ)
Principal Investigator: Dr. Christine Goeschel

Improving diagnostic accuracy for Hepatitis C with a validated teach/improve model

Chronic hepatitis C viral infection (HCV) has been dubbed the “silent killer” due to its largely asymptomatic nature until progression results in noticeable, often irreversible, impact on the patient’s health. The MedStar project seeks to improve accurate and timely diagnosis of HCV and facilitation of comprehensive treatment within the primary care setting.

The work aligns with goals contained in the Maryland Department of Health Hepatitis C Strategic Plan, which includes a 4-pronged approach that encompasses prevention and education, testing, treatment, and strengthening the disease surveillance system.

Project Dates: 2018- 2021
Funded by: Coverys Community Healthcare Foundation
Principal Investigator: Dr. Christine Goeschel and Dr. Dawn Fishbein

Sharing choices

Communication in primary care settings for patients and family members with Alzheimer’s Disease and Related Dementias (ADRD) can be challenging.

The Sharing Choices program aims to improve communication about end-of-life care within the primary care setting through the use of an agenda-setting tool at each encounter, availability of resources, facilitation of advance-care planning and advanced directive completion, and educational resources for practice staff and clinicians on the importance of advance care planning for patients with ADRD.

Project Dates: September 2018 – August 2023
Funded by: National Institutes of Health, National Institutes on Aging
Principal Investigator: Dr. Kelly Smith (MedStar Health); Dr. Jennifer Wolff and Dr. Sydney Dy from The Johns Hopkins School of Public Health.

Engaging patients as partners in a virtual tumor board

This project aims to examine the opportunities to engage patients with breast cancer and their family members in a virtual tumor board using a mobile application to foster bidirectional communication with the care team. The aim is to design, develop, and pilot test a mobile application in two to three care practice settings within MedStar Health.

The ultimate goal is to improve the accuracy and timeliness of communication with patients and their families to support adherence to care plans and optimize patient outcomes.

Project Dates: January 2019 – June 2020
Funded by: The Genentech Foundation
Principal Investigator: Dr. Maen Farha and Dr. Kelly Smith

Guide to improving patient safety in primary care settings by engaging patients and families

The team designed, developed, implemented, and tested a Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. The Guide developed four resources for primary care practices to adopt to improve patient safety by engaging patients.

Project Dates: September 2015 – November 2018
Funded By: Agency for Healthcare Research and Quality
Principal Investigator: Dr. Kelly Smith

Partnering with patients to improve diagnosis

Our Eugene Washington Engagement Award from the Patient Centered Outcomes Research Institute and in partnership with the Society for Improving Diagnosis in Medicine will build a curriculum and processes for patients to partners with researchers and mentors on research in diagnosis.

The Institute research team, led by Kelly M. Smith, PhD, is examining sustainable approaches to scaling patient-centered education on research and the diagnostic process to empower patient-partners to meaningfully engage in the continuum of research as collaborators and co-investigators.

Project Dates: November 2017-February 2019
Funded By: Patient Centered Outcomes Research Institute
Co-Principal Investigator: Dr. Kelly Smith

Detecting, addressing, and learning from patient-perceived breakdowns in care: We Want to Know

We Want to Know (WWTK) brings the patient voice to bridge the gaps in care quality, safety, and experience by a multi-modal campaign encouraging patients and family members to speak up about perceived breakdowns in care and a WWTK specialist, who will work to ensure that patients’ concerns are addressed, and that relevant safety information is captured and fed back to the system.

For more information contact our project team at or visit the project website at

Project Dates: August 2013 – October 2018
Funded by: Agency for Healthcare Research and Quality (Grant Number 1R18HS022757)
Principal Investigator: Dr. Kelly Smith (MedStar Health) and Dr. Kathleen Mazor (University of Massachusetts)

Bridging patient safety and medical liability: the seven pillars

This project aimed to improve patient safety and medical liability risk through improved communication with patients and families, rapid resolution when patients suffer preventable harm, and learning from mistakes. To determine feasibility and effectiveness of implementing the Seven Pillars process at community hospitals. The project laid the foundational work for the development of the AHRQ CANDOR Toolkit.

Project Dates: September 2013 – September 2015
Funded By: Agency for Healthcare Research and Quality
Principal Investigator: Dr. Kelly Smith (MedStar Health) and Dr. Stephen Hines (HRET)

Diabetes to go-inpatient

Diabetes to Go-Inpatient is a diabetes survival skills education program delivered on a tablet and geared toward closing a patient’s gaps in knowledge about how to care for their diabetes when they go home.

The project, funded by the National Institutes of Diabetes and Digestive and Kidney Diseases, aims to review and optimize the Diabetes to Go education and the process of delivering the education to patients, and to support how nurses deliver type II diabetes education at the bedside. We aim to demonstrate that delivering high-quality diabetes education at the bedside is possible and improves early post-hospital outcomes for our patients

Project Dates: March 2016 – March 2019
Funded by: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases
Principal Investigators: Dr. Michelle Magee and Dr. Kelly Smith

The Telluride experience

Initially funded through a large conference grant from the Agency for Healthcare Research and Quality, the Transforming Mindsets Conference (Telluride Experience) brought stakeholders in patient safety (including patients, family members, and health professional students and faculty) together to co-create a curriculum to improve patient safety knowledge, skills, and competencies for health professionals.

The curriculum then became instituted as the Annual Academy for Emerging Leaders in Patient Safety, which has trained more than 1,000 medical and nursing students and resident physicians in patient safety competencies. For more information e-mail us at

Project Dates: February 2010-September 2020
Funded by: Agency for Healthcare Research and Quality & The Doctors Company Foundation
Principal Investigator: Dr. David Mayer

Project ECHO Hub

The Institute is proud to serve as an official Project ECHO™ (Extension for Community Healthcare Outcomes) Hub. Project ECHO is a guided-practice model that reduces health disparities in under-served and remote areas of the state, nation, and world. Through innovative telementoring, the ECHO model uses a hub-and-spoke knowledge-sharing approach where expert teams lead virtual clinics, amplifying the capacity for providers to deliver best-in-practice care to the underserved in their own communities. We have led virtual telementoring and education programs on the diagnosis and treatment of Hepatitis C, Huntington’s Disease and COVID-19 quality and safety strategies for nursing homes.

For information, contact us.