This paper illustrates how participatory governance is enacted through resident involvement in quality management within postgraduate medical education programs at an Italian university. It examines how such involvement is embedded into structured Quality Management Systems (QMS), how it varies according to organizational characteristics – such as program size, disciplinary field and training network complexity – and how it relates to performance outcomes, including resident satisfaction and audit results.
The study employs a mixed-methods design combining qualitative feedback from institutional leaders and QMS auditors with statistical analysis of data from 47 postgraduate programs. It examines the relationship between resident involvement in ISO 9001-certified QMS, organizational characteristics and performance indicators such as audit outcomes and resident satisfaction.
Qualitative evidence highlights improvements in communication, stakeholder engagement and overall quality management. Resident involvement contributes to coordination and operational efficiency across programs. Quantitative results confirm that involvement has become progressively more structured and widespread, particularly in programs with larger enrolment and complex training networks, and is positively associated with improved audit outcomes and, to a lesser extent, resident satisfaction.
As a single-institution study, generalizability is limited; further research should examine how leadership and organizational culture shape involvement across contexts.
Structured involvement strengthens performance and can guide inclusive governance strategies in higher education.
This paper presents a mixed-methods analysis of resident involvement in postgraduate education. It highlights key drivers and impacts of participatory governance, offering insights for academic leaders and higher education institutions.
Introduction
Participatory governance has become a strategic approach to managing complex systems such as healthcare and higher education. By promoting shared responsibility and stakeholder participation, it enhances accountability, responsiveness and continuous improvement.
Within this broader perspective, postgraduate medical education, which represents the focus of this study, provides a particularly relevant context in which participatory governance principles can be operationalized. Bridging academic training and clinical practice, it demands strong governance, performance monitoring and quality assurance to address evolving needs (Frenk et al., 2010). At the same time, beyond its managerial dimension, this educational stage plays a crucial role in developing the clinical competencies and professional identity of future specialists, operating at the intersection of education, healthcare policy and societal expectations (Bleakley et al., 2011). This framework aligns with European health strategies promoting the integration of education, workforce development and healthcare quality to sustain resilient health systems (European Commission, 2025).
Recent studies in public and higher education management highlight participatory governance as a framework to promote transparency, collaboration and joint innovation in complex organizations (Ansell and Torfing, 2021; Tillapaugh, 2023). This framework has been further elaborated in higher education research, which has examined participation not only as a governance structure but also as a cultural and individual process. Klemenčič (2023) conceptualized student agency as the capacity to influence and shape learning environments and Dusi and Huisman (2021) described students as “prosumers” who simultaneously co-produce and benefit from higher education processes. Together, these perspectives illustrate how participation operates across structural, cultural and individual dimensions, linking governance with engagement and shared development.
Beyond these conceptual perspectives, growing attention has focused on quality management and improvement in higher education, reflecting broader efforts to ensure accountability, transparency and continuous enhancement through management, accreditation and evaluation mechanisms.
Empirical studies indicate that the application of quality management principles in higher education is consistently associated with improved learning outcomes and institutional performance (Ab Wahid, 2019; Jasti et al., 2022; Manatos et al., 2017). However, Cardoso et al. (2016) observed that weaknesses in governance and management structures remain among the major obstacles to achieving quality in higher education, underscoring that developing a robust quality culture requires both structural coordination and active academic engagement.
Higher education institutions, viewed as quality-oriented service organizations, increasingly focus on the relationship between provider and user – the student. This relationship is commonly examined through the lens of student satisfaction and its impact on educational outcomes and institutional effectiveness (Cuthbert, 2010; Guilbault, 2016). In postgraduate settings, student satisfaction surveys are commonly used to support internal quality evaluations and external benchmarking, although research by Muijs and Bokhove (2017) shows that most variation in satisfaction occurs at the individual rather than institutional level.
Meanwhile, involvement has emerged as a central dimension of educational quality, connecting student participation not only to learning processes but also to institutional governance, accountability, and continuous improvement. In this perspective, engagement and participation are recognised as essential drivers of learning effectiveness and organisational reputation (Kuh and Hu, 2001; Pinna et al., 2018; Trowler, 2010), while at the broader policy level, including within the European higher education area, the European Students’ Union (2018) highlights the importance of student participation in governance structures.
Building on this, recent studies call for a deeper reconceptualization of student voice and agency, urging that partnership models move beyond formal representation to enable students to shape institutional practices in meaningful and transformative ways (Mercer-Mapstone et al., 2017).
Although growing interest has been devoted to both participatory approaches and quality management, limited research has examined how these dimensions interact within postgraduate medical education – specifically, how residents’ active involvement contributes to or is shaped by the functioning of Quality Management Systems (QMS).
The World Federation for Medical Education (WFME – World Federation for Medical Education, 2023) explicitly identifies the structured participation of postgraduate doctors in program management, evaluation and quality improvement as a key component of governance, linking participatory approaches with accountability and continuous enhancement.
Empirical research addressing these dimensions, however, remains limited. Da Dalt et al. (2010) reported the implementation of a QMS within a single postgraduate medical program, without addressing resident involvement. Romeu et al. (2023) examined residents’ involvement in curricular and clinical practice change and its association with satisfaction and learning environment, yet in contexts not underpinned by structured institutional QMS. Together, these contributions underscore the lack of integrated, institutionally embedded analyses of how resident involvement operates within formal quality management frameworks.
This study addresses this gap through the case of the University of Padova, where all postgraduate medical programs operate under a coordinated, ISO 9001-certified QMS – unique in Italy and, to the authors' knowledge, in Europe (Università degli Studi di Padova, n.d.). The system demonstrates how participatory governance can be embedded in structured management processes, fostering shared accountability across complex academic and healthcare settings.
Within this framework, resident involvement in QMS has been promoted as an institutional priority to strengthen shared responsibility, organizational learning and stakeholder engagement in quality governance. This study analyses the outcomes and key areas of impact of this approach. The specific objectives are to.
Identify and assess the levels and areas of resident involvement within the structured QMS of postgraduate medical programs.
Analyse the relationship between resident involvement and key organizational dimensions – including enrolment size, disciplinary area, departmental affiliation and the complexity of the training network – as potential drivers of resident contribution to QMS-related processes.
Examine how resident involvement correlates with core performance indicators, specifically resident satisfaction and results from external quality audits, to assess its potential contribution to continuous improvement and organizational effectiveness.
The analysis is based on qualitative and quantitative data systematically collected between 2021 and 2024 from 47 ISO 9001-certified postgraduate programs. Although based on a single institutional case, it offers broader insights into how structured quality systems foster resident involvement and institutionalize participatory quality governance in postgraduate medical education. Preliminary results suggest that higher resident involvement is associated with larger enrolment, more complex training networks, better audit performance and, to a lesser extent, higher satisfaction.
In this study, the terminology follows the ISO 9000 (ISO, 2015) standards: involvement refers to residents' factual participation in quality management activities, while engagement denotes their active contribution to shared objectives. The term participation is used descriptively or when citing prior studies on participatory governance or student involvement.
Materials and methods
Study design and context
This study adopts a multi-method case study design, combining quantitative and qualitative approaches to examine medical residents' involvement in quality management processes within a structured institutional framework. The University of Padova (Italy) was selected as a critical case for its comprehensive implementation of an ISO 9001-certified Quality Management System (QMS) covering all postgraduate medical programs – a distinctive institutional experience within the European context. This integrated system provides a consistent framework for managing quality processes and analysing resident involvement at scale across programs.
Postgraduate medical programs in Italy are nationally regulated and centrally assigned, with a standardized curriculum integrating formal instruction and clinical practice. Programs are embedded within both university and healthcare systems and are subject to ministerial oversight, making governance and quality assurance particularly complex. As of December 2024, the University of Padova hosts 48 active postgraduate medical programs across seven academic departments (Table 1). The School of Medicine and Palliative Care was excluded from the study because it was still completing the implementation of its QMS; the School of Health Statistics and Biometry, certified only in 2023, was not included in the analysis of 2021–2022 data.
Departments and postgraduate medical programs – University of Padova
| Department | Afferent postgraduate medical programs | N. of afferent programs |
|---|---|---|
| Medicine (DIMED) | Allergology and Clinical Immunology; Anatomic Pathology; Intensive Care and Pain Therapy; Dermatology and Venereology; Haematology; Endocrinology and Metabolic Diseases; Geriatrics; Medicine and Palliative Care; Emergency Medicine; Sports Medicine and Exercise; Internal Medicine; Nuclear Medicine; Nephrology; Radio Diagnosis; Radiotherapy; Rheumatology; Nutritional Sciences | 17 |
| Cardiac, Thoracic, Vascular Sciences and Public Health (DSCTV) | Cardiac Surgery; Thoracic Surgery; Vascular Surgery; Preventive Medicine and Hygiene; Diseases of Cardiovascular Apparatus; Diseases of Respiratory Tract; Occupational Medicine; Legal Medicine; Health Statistics and Biometry | 9 |
| Neuroscience (DNS) | Audiology and Phoniatrics; Plastic, Reconstructive and Aesthetic Surgery; Physical and Rehabilitation Medicine; Neurosurgery; Neurology; Ophthalmology; Otolaryngology; Psychiatry | 8 |
| Women's and Children's Health (DSDB) | Paediatric Surgery; Medical Genetics; Gynaecology and Obstetrics; Community Medicine and Primary Care; Child Neuropsychiatry; Paediatrics | 6 |
| Surgery, Oncology and Gastroenterology (DISCOG) | General Surgery; Digestive Diseases; Oncology; Orthopaedics and Traumatology; Urology | 5 |
| Molecular Medicine (DMM) | Infectious and Tropical Diseases; Microbiology and Virology | 2 |
| Biomedical Sciences (DSB) | Clinical Pathology and Clinical Biochemistry | 1 |
In the Italian higher education system, “Scuole di Specializzazione” are postgraduate medical training programs accredited by national ministries. Although the literal translation is “school,” they function as structured residency programs rather than academic units. Accordingly, the term postgraduate medical program is used throughout this paper for clarity and consistency. Residents are postgraduate students enrolled in accredited programs combining academic and clinical training.
Quality management framework
The implementation of the QMS within the programs was centrally coordinated and carried out in compliance with the requirements of the ISO 9001:2015 standard (ISO, 2015/2024). A structured governance model – led by the University Observatory for Postgraduate Specialist Training, the ISO-certified Postgraduate Office and the University laboratory “Quality and Environment Research Centre” (CESQA) supporting postgraduate programs – enabled institution-wide coherence and process standardization. Quality processes were mapped and classified into three main categories, based on established frameworks (APQC, 2024; Dumas et al., 2018; Porter, 1985).
Core processes, directly affecting resident training and educational outcomes.
Support processes, enabling the delivery of core services through logistics, administration and infrastructure.
Overall processes, ensuring strategic governance, continuous improvement and compliance.
These categories form the analytical backbone used to analyse resident involvement across quality domains (Figure 1).
The diagram shows a structured process framework organized into overall processes, main processes, and support processes. At the top, a wide band labeled as part of the overall processes contains two text lines reading “Directional processes: policy and objectives definition, risks and opportunities addressing, roles and responsibilities assignment, management review” and “System processes: monitoring, measurement, analysis and evaluation, audit management, nonconformity and corrective actions management”. Below this, five vertically aligned columns appear as the main processes, each marked with a downward arrow at the top and a dark blue heading. From left to right, the first column heading reads “Design of the training program”, and the support processes listed below include “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The second column heading reads “Management of clinical training and specialization training network”, with support processes listed as “Competence and awareness of staff involved in program management”, “Administrative and financial management of the program”, “Evaluation of training network units”, “Documented information management”, and “Communication management”. The third column heading reads “Management of teaching activities”, and the support processes listed are “Competence and awareness of staff involved in program management”, “Management of classrooms, equipment, and materials”, “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The fourth column heading reads “Management of research activities”, and the support processes listed below it include “Competence and awareness of staff involved in program management”, “Management of classrooms, equipment, and materials”, “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The fifth column heading reads “Evaluation of medical residents”, and the support processes listed are “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. At the bottom of the diagram, a legend explains the structure, stating that the light blue area represents “Overall processes”, the dark blue headings represent “Main processes”, and the text listed beneath each heading represents “Support processes”.Categorization of institutional processes within the QMS of postgraduate medical programs. Source: Authors’ own work
The diagram shows a structured process framework organized into overall processes, main processes, and support processes. At the top, a wide band labeled as part of the overall processes contains two text lines reading “Directional processes: policy and objectives definition, risks and opportunities addressing, roles and responsibilities assignment, management review” and “System processes: monitoring, measurement, analysis and evaluation, audit management, nonconformity and corrective actions management”. Below this, five vertically aligned columns appear as the main processes, each marked with a downward arrow at the top and a dark blue heading. From left to right, the first column heading reads “Design of the training program”, and the support processes listed below include “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The second column heading reads “Management of clinical training and specialization training network”, with support processes listed as “Competence and awareness of staff involved in program management”, “Administrative and financial management of the program”, “Evaluation of training network units”, “Documented information management”, and “Communication management”. The third column heading reads “Management of teaching activities”, and the support processes listed are “Competence and awareness of staff involved in program management”, “Management of classrooms, equipment, and materials”, “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The fourth column heading reads “Management of research activities”, and the support processes listed below it include “Competence and awareness of staff involved in program management”, “Management of classrooms, equipment, and materials”, “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. The fifth column heading reads “Evaluation of medical residents”, and the support processes listed are “Administrative and financial management of the program”, “Documented information management”, and “Communication management”. At the bottom of the diagram, a legend explains the structure, stating that the light blue area represents “Overall processes”, the dark blue headings represent “Main processes”, and the text listed beneath each heading represents “Support processes”.Categorization of institutional processes within the QMS of postgraduate medical programs. Source: Authors’ own work
Resident involvement framework
At the University of Padova, resident involvement in postgraduate medical programs occurs in two forms: formal institutional participation in governance bodies and voluntary involvement in quality management processes. The study focused primarily on the latter, as it represents an operational and non-mandated form of participation, indicative of deeper institutional integration. Voluntary participation has played a central role in the implementation of the QMS, involving residents in all operational phases, from initial training to internal audits. This approach was institutionally supported, with resident participation formally promoted as a strategic driver of quality through structured mechanisms and shared practices. Before the QMS were formally introduced, some high-enrolment programs had already engaged residents in organizational tasks, incorporated into the institutional QMS. Resident participation was further stimulated through multiple initiatives aimed at communication, training and experience sharing, combining both top-down and bottom-up approaches. Academic leadership, through the Observatory for Postgraduate Specialist Training, promoted engagement as a quality objective, while training and support activities for staff and residents enhanced QMS participation. These activities contributed to the progressive integration of resident roles into the management and continuous improvement practices of the programs.
Data and information collection and classification
The study analysed both quantitative and qualitative data to assess voluntary resident involvement in quality management across 47 postgraduate medical programs.
The qualitative component was based on the analysis of materials generated within the ISO 9001-certified QMS, including audit reports, technical notes and information from interviews conducted during internal and external audits. These sources were reviewed to identify patterns of resident engagement across QMS processes and to capture program directors' and staff members' perceptions of its impact on program management and communication. Engagement, for programs with at least one resident involved in QMS-related activities, was assessed on a four-level qualitative scale (low, medium, high, very high) and then averaged across programs.
The quantitative component drew on multiple data and information sources, organised to support both descriptive and inferential analyses, including.
Institutional data, drawn from national frameworks and University records (Dec. 2024).
Resident enrolment for 2021–2022 and 2023–2024, provided by the Postgraduate Office; 2023–2024 figures were cross-checked with data from the ministerial satisfaction survey (MUR, 2023).
Training network: accredited facilities per program based on ministerial decrees.
Resident involvement in QMS: based on data collected by CESQA staff during QMS implementation, maintenance and internal audits.
Resident satisfaction: from national surveys (2021 and 2023), further detailed below.
Third-party audits: conducted for ISO 9001 certification and subsequent surveillance (details below).
Resident involvement in each program was measured by counting residents formally assigned to QMS-related roles. Programs were classified into three levels: no (0 residents), low (1 resident) and high (2 or more residents). This classification was applied consistently for both years and chosen to ensure group balance and statistical robustness in small longitudinal samples (Altman and Bland, 1994).
Satisfaction data were drawn from national surveys conducted by the Ministry of University and Research (MUR), with 626 responses in 2021 and 1,937 in 2023. Programs with fewer than three respondents were excluded. The 2021 survey (MUR, 2021), conducted in April 2021, excluded first-year residents, while the 2023 (MUR, 2023) edition (October 2023–April 2024) covered all cohorts. The ministerial questionnaire included a general section on demographic and academic data, followed by six thematic areas: Didactic Training, Clinical Experience, Tutoring, External Experience, Research Involvement, Overall Training Experience. Responses were scored on a 0–10 scale. The 2021 survey included ∼30 questions: the 2023 version, ∼40. For this study, five items were selected as most representative of resident satisfaction across the thematic areas.
Overall satisfaction with the program (overall satisfaction)
Satisfaction with rotation experiences across facilities (rotation satisfaction)
Satisfaction with formal teaching activities (didactic satisfaction)
Satisfaction with practical activities (practical activities satisfaction)
Satisfaction with tutor supervision of practical work (mentorship satisfaction)
Audit data refer to two cycles performed by accredited conformity assessment bodies.
Initial ISO 9001 certification audits (2019–2020) by QCB Italia (later incorporated into TÜV AUSTRIA ITALIA), involving three auditors.
2023 surveillance audits by TÜV AUSTRIA ITALIA, involving four auditors (three also present in the initial phase).
A total of 229 findings were analysed (228 observations, 1 non-conformity). Due to this imbalance, all findings were treated equally. Audit performance evolution was evaluated by comparing results from initial and 2023 audits using the following categories.
High audit performance: reduction in findings >50%, or no findings in both audits.
Medium audit performance: reduction ≤50%, or one finding in both audits.
Stable audit performance: same number of findings (≥2) in both audits.
Negative audit performance: increase in findings from initial certification to 2023.
Data and information analysis
Both qualitative and quantitative analyses were conducted to explore resident involvement in QMS processes. The qualitative results, based on the documentary analysis described above, were integrated with quantitative analyses to support interpretation and cross-validation.
The three-level classification of involvement (no, low, high) was treated as an ordinal variable for descriptive and inferential comparisons.
Statistical analyses included descriptive statistics to characterize resident involvement and inferential tests (Spearman's rank correlation, ordinal logistic regression, Kruskal-Wallis, Chi-square and Somers' D) to explore associations and patterns. Analyses were exploratory and not intended to infer causality. A significance threshold of p < 0.05 was used. All analyses were conducted using Microsoft Excel, as the institutional and audit data were originally structured in this format within the QMS documentation; results were subsequently cross-checked using R software (version 4.5.1) during the revision phase to confirm their accuracy and consistency.
Results
The analysis included 47 postgraduate medical programs at the University of Padova, focusing on residents' involvement in specific processes and activities within the QMS. Table 2 presents a qualitative assessment of engagement, based on the information gathered during QMS support activities and audits. The activities listed in Table 2 refer to QMS processes (see Figure 1). The degree of engagement reflects how actively residents transformed their involvement into meaningful contributions across programs, supporting the achievement of shared objectives.
Degree of resident engagement in the quality management processes of the postgraduate medical programs
| Reference process | Activities | Degree of resident engagement |
|---|---|---|
| Management of clinical training and specialization training network | Support for the planning of shifts and rotations within the units of the training network | Very high |
| Communication management | Support for managing communication among faculty members, tutors, heads of clinical units, medical residents and program management structures | High |
| Documented information management | Support for the definition and revision of procedures and reference documentation within the QMS framework | Medium |
| Risks and opportunities addressing | Support for the identification of risks and opportunities relevant to the programs | Low |
| Monitoring, measurement, analysis and evaluation | Support for the identification of monitoring parameters – concerning both program processes and the assessment of resident satisfaction – and for data collection | Medium |
| Audit management | Participation in QMS audit activities as interviewed personnel | Very high |
| Nonconformity and corrective actions management | Support for the identification of actions to manage non-conformities and for the definition of corrective actions | Low |
In all cases where residents have been actively involved, programs – through their leadership and staff – reported notable improvements in operational efficiency and stakeholder communication, as documented in audit reports. Resident involvement is consistently recognized as a strategic asset and has received favourable feedback from external auditors during QMS assessments.
In addition to these qualitative findings, quantitative analyses were conducted to explore patterns of involvement and their relationships with program characteristics, satisfaction and audit performance.
Programs are grouped into three disciplinary areas: medical (21), surgical (12) and clinical services (14). Resident enrolment rose from 2,505 in 2021–2022 to 2,626 in 2023–2024. The medical area remained stable (1,239 to 1,236), while the surgical and clinical services areas increased from 592 to 659 and from 674 to 731, respectively. Programs are affiliated with different departments (see Table 1). DIMED had the highest enrolment, increasing from 918 to 954; DSDB remained stable at 454; DSCTV rose from 381 to 440 and DISCOG from 319 to 353.
Resident involvement in program quality management increased from 49 residents in 2021–2022 to 69 in 2023–2024 (+40.8%). According to the study's classification, in 2021–2022, 12 programs had high involvement, 22 low involvement and 12 none. By 2023–2024, highly involved programs rose to 22 (+83.3%), low involved dropped to 14 (−36.4%) and programs with no involvement decreased to 11.
Programs with higher involvement also showed larger average enrolment (around 70 residents) than those with low (≈50) or no involvement (≈40), suggesting a possible monotonic relationship (Figure 2).
The box plot chart compares the number of enrolled residents across two time periods (2021–2022 and 2023–2024) and three levels of involvement (no involvement, low involvement and high involvement). The horizontal axis shows the two periods, while the vertical axis ranges from 0 to 300 enrolled residents. For each period, three box plots are displayed side by side, one for each level of involvement. The boxes represent the interquartile range, the central line indicates the median, the cross marker indicates the mean, whiskers show the range of values, and markers indicate outliers. In both periods, both the median and the mean increase progressively from no involvement to low involvement and to high involvement, indicating higher enrolment in programs with greater resident involvement.Enrolled residents by level of involvement in program quality management for 2021–2022 and 2023–2024 periods. Source: Authors’ own work
The box plot chart compares the number of enrolled residents across two time periods (2021–2022 and 2023–2024) and three levels of involvement (no involvement, low involvement and high involvement). The horizontal axis shows the two periods, while the vertical axis ranges from 0 to 300 enrolled residents. For each period, three box plots are displayed side by side, one for each level of involvement. The boxes represent the interquartile range, the central line indicates the median, the cross marker indicates the mean, whiskers show the range of values, and markers indicate outliers. In both periods, both the median and the mean increase progressively from no involvement to low involvement and to high involvement, indicating higher enrolment in programs with greater resident involvement.Enrolled residents by level of involvement in program quality management for 2021–2022 and 2023–2024 periods. Source: Authors’ own work
To explore this relationship, Spearman's Rank Correlation (Spearman, 1904) was used to assess the association between resident involvement levels and enrolment size; this method is suited for monotonic associations between ordinal and continuous variables (Conover, 1999). A positive and statistically significant correlation was found in 2021–2022 (ρ = 0.304, p = 0.040), which strengthened in 2023–2024 (ρ = 0.364, p = 0.012). Although both coefficients fall within the “weak” range according to Evans (1996), the increasing trend suggests a growing association over time. An ordinal logistic regression (Agresti, 2010) confirmed a positive but non-significant effect of enrolment size on involvement levels.
To examine the relationship between training network complexity and resident involvement (2023–2024), the number of accredited facilities was analyzed by group. High involvement programs had an average of 9.82 facilities; low involvement programs reported a similar mean of 9.86; no involvement programs showed a lower average of 7.64. A Kruskal-Wallis test (Kruskal and Wallis, 1952) found no significant association between involvement level and network size (H = 1.32, p = 0.516).
In 2021–2022, high involvement was most frequent in the medical area (6 programs), followed by the surgical and clinical services areas (3 each). The low involvement group was evenly distributed (8 medical, 7 surgical, 7 clinical), while each area included 4 programs with no involvement. By 2023–2024, the medical area showed the greatest increase in highly involved programs (10), followed by 6 in both the surgical and clinical services areas. The number of low involvement programs decreased across all areas, whereas the no involvement group remained stable.
At the department level, DSCTV and DSDB showed a clear shift toward greater resident involvement, with an increase in high-involvement programs and a decrease in programs with no involvement.
DIMED also increased its high involvement group, while no involvement remained stable. DNS followed a similar trend. DISCOG showed the most marked progress: by 2023–2024, all its programs reached high involvement, representing a full transition to active resident participation.
Figure 3 shows the number of programs by resident involvement level across departments with ≥5 programs (2021–2022 and 2023–2024).
The stacked bar chart titled “Number of programs by level of involvement across departments” shows a vertical axis ranging from 0 to 18 in increments of 2 units and a horizontal axis listing departments labeled “DIMED”, “DSCTV”, “DNS”, “DSDB”, and “DISCOG”, with two time periods shown for each department as “2021–2022” and “2023–2024”. A legend below the chart identifies three stack categories labeled “No involvement”, “Low involvement”, and “High involvement”. The data for the bars on the chart are as follows: “DIMED”: “2021 to 2022”: No involvement: 4, Low involvement: 9, High involvement: 3. “DIMED”: “2023 to 2024”: No involvement: 4, Low involvement: 6, High involvement: 6. “DSCTV”: “2021 to 2022”: No involvement: 4, Low involvement: 3, High involvement: 1. “DSCTV”: “2023 to 2024”: No involvement: 3, Low involvement: 1, High involvement: 5. “DNS”: “2021 to 2022”: No involvement: 1, Low involvement: 6, High involvement: 1. “DNS”: “2023 to 2024”: No involvement: 2, Low involvement: 4, High involvement: 2. “DSDB”: “2021 to 2022”: No involvement: 1, Low involvement: 3, High involvement: 2. “DSDB”: “2023 to 2024”: No involvement: 0, Low involvement: 2, High involvement: 4. “DISCOG”: “2021 to 2022”: No involvement: 0, Low involvement: 1, High involvement: 4. “DISCOG”: “2023 to 2024”: No involvement: 0, Low involvement: 0, High involvement: 5.Distribution of the number of programs, grouped by level of resident involvement and department of affiliation, for the periods 2021–2022 and 2023–2024. Source: Authors’ own work
The stacked bar chart titled “Number of programs by level of involvement across departments” shows a vertical axis ranging from 0 to 18 in increments of 2 units and a horizontal axis listing departments labeled “DIMED”, “DSCTV”, “DNS”, “DSDB”, and “DISCOG”, with two time periods shown for each department as “2021–2022” and “2023–2024”. A legend below the chart identifies three stack categories labeled “No involvement”, “Low involvement”, and “High involvement”. The data for the bars on the chart are as follows: “DIMED”: “2021 to 2022”: No involvement: 4, Low involvement: 9, High involvement: 3. “DIMED”: “2023 to 2024”: No involvement: 4, Low involvement: 6, High involvement: 6. “DSCTV”: “2021 to 2022”: No involvement: 4, Low involvement: 3, High involvement: 1. “DSCTV”: “2023 to 2024”: No involvement: 3, Low involvement: 1, High involvement: 5. “DNS”: “2021 to 2022”: No involvement: 1, Low involvement: 6, High involvement: 1. “DNS”: “2023 to 2024”: No involvement: 2, Low involvement: 4, High involvement: 2. “DSDB”: “2021 to 2022”: No involvement: 1, Low involvement: 3, High involvement: 2. “DSDB”: “2023 to 2024”: No involvement: 0, Low involvement: 2, High involvement: 4. “DISCOG”: “2021 to 2022”: No involvement: 0, Low involvement: 1, High involvement: 4. “DISCOG”: “2023 to 2024”: No involvement: 0, Low involvement: 0, High involvement: 5.Distribution of the number of programs, grouped by level of resident involvement and department of affiliation, for the periods 2021–2022 and 2023–2024. Source: Authors’ own work
A Chi-square test (Pearson, 1900) was conducted to assess the relationship between involvement groups and specialization areas for 2021–2022 and 2023–2024. The 2021–2022 results (χ2 = 1.65, p = 0.80) showed no significant correlation. However, the 2023–2024 results (χ2 = 8.02, p = 0.091) suggested a potential emerging association, particularly in the medical field, where a shift towards high involvement is more evident, while the surgical and clinical services areas showed less pronounced changes.
A similar analysis evaluated the relationship between involvement groups and departments. For 2021–2022, the results (χ2 = 21.96, p = 0.038) showed a significant correlation, indicating that involvement levels were associated with specific departments. In 2023–2024, the results (χ2 = 20.65, p = 0.056) suggested a continuing trend towards significance, with a slight reduction in statistical strength.
The analysis of resident satisfaction across 2021 and 2023 highlights a general trend: programs with higher resident involvement in quality management processes tend to report higher satisfaction scores, especially in 2021. While differences were observed across all examined dimensions – particularly for overall, didactic and mentorship satisfaction – none reached statistical significance (Kruskal-Wallis, p > 0.05). Table 3 summarizes the mean satisfaction scores across the five key dimensions for both years.
Mean resident satisfaction scores (2021 and 2023) by level of involvement in program quality management
| Overall satisfaction | Rotation satisfaction | Didactic satisfaction | Practical activities satisfaction | Mentorship satisfaction | |
|---|---|---|---|---|---|
| 2021 | |||||
| No involvement | 5.80 | 6.80 | 5.68 | 6.24 | 6.03 |
| Low involvement | 6.21 | 7.53 | 5.61 | 6.56 | 6.20 |
| High involvement | 6.63 | 7.46 | 6.11 | 6.75 | 6.72 |
| 2023 | |||||
| No involvement | 6.62 | 7.76 | 6.16 | 7.04 | 7.03 |
| Low involvement | 6.94 | 7.43 | 6.49 | 7.19 | 7.19 |
| High involvement | 6.57 | 7.54 | 6.35 | 6.79 | 6.70 |
In 2021, higher levels of involvement in quality management were generally associated with greater resident satisfaction, particularly in overall, didactic, practical activities and mentorship. In 2023, this trend was less consistent, with low-involvement programs often reporting the highest scores. Although no statistically significant differences emerged, the data suggest a potential relationship between the level of resident involvement in QMS and the perceived quality of training. These patterns warrant further investigation to clarify underlying factors.
The results of third-party audits within the ISO 9001-certified QMS were analyzed in relation to resident involvement levels. Both audits from the initial certification phase (2019–2020) and those from 2023 were considered. For the School of Paediatrics, certified since 2008, the audit results refer to the 2020 audit, which coincided with a certification renewal. The School of Health Statistics and Biometry was excluded due to its 2023 certification and lack of comparable audit data. The analysis of audit findings in relation to involvement groups was performed only for the 2023 audits, for which more time-consistent and structured involvement data were available.
A significant decrease in findings was observed, dropping from 163 in the initial certification audits to 64 in the 2023 audits. In 2023, programs with no involvement had an average of 1.55 findings, while low involvement programs reported slightly fewer findings, averaging 1.14. High involvement programs had 1.45 findings on average. Although group differences were small, programs with resident participation, whether low or high, generally performed better in audits than those without involvement.
To assess performance improvement according to the predefined performance categories, results from initial certification and 2023 audits were compared across involvement groups. Most programs achieved high (58.7%, 27 programs) or medium (30.4%, 14 programs) performance. Only 4.3% (2 programs) remained stable and 6.5% (3 programs) showed a performance decline. The results varied by involvement level. Among high involvement programs, 63.6% (14) achieved high performance, 27.3% (6) medium and 9.1% (2) stable; none declined. In the low involvement group, 57.1% (8) reached high performance, 28.6% (4) medium and 14.3% (2) declined. For programs with no involvement, 50.0% (5) achieved high performance, 40.0% (4) medium and 10.0% (1) declined.
These results are summarized in Figure 4, which illustrates audit performance by level of resident involvement.
The grouped bar chart titled “Audit performance by level of involvement” shows audit performance categories listed on the horizontal axis and percentage values shown on the vertical axis. The chart presents multiple grouped bars for each performance category, with each bar representing a different level of involvement. A legend identifies the involvement levels as “No involvement”, “Low involvement”, and “High involvement”. The data for the bars on the chart are as follows: “High audit performance”: No involvement: 50.0 %, Low involvement: 57.1 %, High involvement: 63.6%. “Medium audit performance”: No involvement: 40.0 %, Low involvement: 28.6 %, High involvement: 27.3 %. “Stable audit performance”: No involvement: 0.0 %, Low involvement: 0.0 %, High involvement: 9.1 %. “Negative audit performance”: No involvement: 10.0 %, Low involvement: 14.3 %, High involvement: 0.0 %.Distribution of audit performance levels by resident involvement in program quality management. Source: Authors’ own work
The grouped bar chart titled “Audit performance by level of involvement” shows audit performance categories listed on the horizontal axis and percentage values shown on the vertical axis. The chart presents multiple grouped bars for each performance category, with each bar representing a different level of involvement. A legend identifies the involvement levels as “No involvement”, “Low involvement”, and “High involvement”. The data for the bars on the chart are as follows: “High audit performance”: No involvement: 50.0 %, Low involvement: 57.1 %, High involvement: 63.6%. “Medium audit performance”: No involvement: 40.0 %, Low involvement: 28.6 %, High involvement: 27.3 %. “Stable audit performance”: No involvement: 0.0 %, Low involvement: 0.0 %, High involvement: 9.1 %. “Negative audit performance”: No involvement: 10.0 %, Low involvement: 14.3 %, High involvement: 0.0 %.Distribution of audit performance levels by resident involvement in program quality management. Source: Authors’ own work
Audit performance improves with greater involvement, as the share of high-performing programs rises from 50.0% (no involvement) to 63.6% (high). Somers' D test (Somers, 1962) confirmed a weak but non-significant positive association (D = 0.096, p = 0.434).
Discussion
This study analysed resident involvement in the quality management of postgraduate programs at the University of Padova, highlighting its contribution to coordination and organizational improvement across programs.
The spread of involvement is closely linked to the introduction of the QMS, supported by coordinated top-down and bottom-up institutional strategies. Leadership initiatives, training sessions and experience-sharing activities strengthened communication and progressively consolidated resident engagement.
Qualitative evidence shows that residents contributed to multiple processes, especially those requiring cross-role coordination, where their participation proved most beneficial. Positive feedback consistently emerged from both program representatives and auditors regarding resident involvement over the study period. Although resident inclusion initially increased organizational demands, it soon produced measurable gains in efficiency and coordination, particularly in planning rotations and managing interprofessional activities. Overall, these findings indicate that greater complexity is offset by a more participatory and effective approach to problem-solving.
Quantitative data reinforce these findings, showing a steady growth in resident involvement across programs over time. The growing share of highly involved programs reflects a broader institutional shift toward integrating residents into organizational processes. This trend confirms that once initiated, resident participation in quality management tends to consolidate and become a core organizational practice consistent with institutional goals for participatory governance.
The relationship between enrolment size and resident involvement remained stable across both periods. Programs with larger cohorts showed higher levels of participation, supporting the view that organizational scale encourages resident contribution.
Larger programs typically manage more complex operations, which favour structured management and resident participation to improve coordination and share responsibilities. They may also have more established frameworks promoting engagement in governance and quality processes. However, causality cannot be assumed, as other organizational factors may also influence this relationship.
Similarly, programs with resident involvement often manage broader training networks, suggesting that complexity facilitates participation in management activities but does not determine it.
Resident involvement differed across specialization areas and departments. A shift toward higher engagement was observed in 2023–2024, particularly in medical programs, compared with a more balanced distribution in 2021–2022. Although not statistically significant, this pattern points to growing engagement within these areas.
Differences among departments also emerged, as some appear to have created conditions favouring stronger resident participation in quality management. In particular, DISCOG reached full inclusion of residents by 2023–2024, while DSDB expanded its high-involvement programs. These trends suggest that departmental leadership and policies play a key role in fostering participation.
Resident satisfaction tends to be higher in programs involving residents in QMS, particularly for didactic training. In 2021, high-involvement programs showed the greatest satisfaction across dimensions, while in 2023, satisfaction peaked in programs with low involvement; programs without involvement remained slightly lower in both years. Although these trends suggest a link between resident participation and enhanced perceptions of educational quality, differences were not statistically significant, confirming the exploratory nature of the analysis. The stronger association observed for didactic satisfaction likely reflects the closer managerial control over teaching components. In contrast, satisfaction with clinical rotations, practical activities and mentorship is influenced by the broader training network, which lies partly beyond the programs' managerial scope. Future studies should also consider additional factors – such as faculty engagement, workload and institutional culture – that may shape residents' perceptions of quality.
The analysis also indicates an association between resident involvement and improved audit performance. Programs with resident participation, whether low or high, performed better than those without, showing fewer findings and greater improvement between initial and 2023 audits. Although this trend suggests that involvement aligns with better outcomes, the correlation remains weak and not statistically significant, implying that factors such as institutional support, management quality and audit methodology also play a role. Further research should explore which aspects of resident participation most influence audit performance and clarify the mechanisms behind these improvements.
The evidence presented here confirms and extends previous research showing that structured resident involvement strengthens educational quality and overall program performance. Studies such as Romeu et al. (2023) found that residents engaged in curricular and clinical improvement projects reported higher satisfaction, while Da Dalt et al. (2010) described the implementation of a QMS framework focused on organizational structure within a single program rather than systematic resident involvement. Building on this evidence, the present study shows that embedding resident participation within an institutional QMS, supported by academic leadership, enhances coordination, communication and management performance. This aligns with the World Federation for Medical Education (WFME – World Federation for Medical Education, 2023) standards, which identify resident participation in management and evaluation as a key component of quality assurance.
Although grounded in postgraduate medical education, these findings demonstrate broader dynamics of participatory governance, showing how engagement can drive organizational improvement and institutional development.
Stakeholder theory (Freeman, 1984/2010) explains how organizations create value and legitimacy by identifying and balancing stakeholder expectations. This study demonstrates that, in contexts where interaction with the primary stakeholder is particularly strong – as in postgraduate programs with residents – direct involvement in decision-making and organizational processes constitutes an effective governance strategy that aligns expectations and promotes shared improvement.
Viewed through institutional theory (DiMaggio and Powell, 1983), the findings also show that the institutionalization of participatory practices can arise not only from external pressures but from internal coordination and collective learning among leadership, residents, and academic structures, as observed across the postgraduate programs of the University of Padova. Resident involvement thus emerges as a bridge between stakeholder engagement and institutional change, linking participation with legitimacy, learning, and governance renewal.
Future developments and analytical considerations
This study provides valuable insights, though several areas for future research and analysis could be further explored. One potential avenue is refining the categorization of resident involvement, which currently groups participants into three categories (no involvement = 0, low involvement = 1, high involvement = 2 or more). While this ensures comparability, it may obscure subtle differences, particularly when grouping 2–4 residents together. Future studies could explore more granular thresholds or use multilevel modelling to capture the nuances of involvement levels.
Further analyses should improve the comparability of satisfaction data, as the 2021 and 2023 surveys differed in scope, timing and questionnaire structure. Ensuring methodological consistency across future surveys would strengthen longitudinal comparisons.
The role of third-party audit data also deserves attention. Audit results may vary due to differences in certification timing, QMS maturity, or auditor expertise. Future studies should control for these factors and assess how system maturity influences audit performance.
From a methodological perspective, categorical classifications and nonparametric tests offered a solid yet simplified framework. Future work could apply post hoc analyses, effect size estimates, or multilevel models to deepen the understanding of observed relationships.
Beyond methodology, comparative studies across institutions and countries could clarify how leadership, governance and culture influence the sustainability of participatory quality management in postgraduate medical education.
Conclusions
This study demonstrates that structured resident involvement within ISO 9001-certified QMS enhances organizational performance and the overall quality of postgraduate medical training. Qualitative evidence highlights improvements in communication, coordination and operational efficiency across programs. Quantitative analyses further show a steady increase (+40.8% between 2021 and 2024) in resident involvement, stronger participation in larger and more complex programs, and a positive trend linking involvement with better audit performance and, to a lesser extent, higher satisfaction.
From a theoretical standpoint, the results clarify how participatory governance evolves through the interaction between stakeholder engagement and institutional learning. They demonstrate that resident involvement, when structured within formal QMS, acts both as a mechanism of stakeholder participation and as a driver of institutionalization. The Padova case illustrates that shared accountability mechanisms integrated into coordinated management systems legitimize inclusive governance and foster adaptive improvement across complex educational environments.
Building on these findings, several strategies can support the implementation and sustainability of structured resident involvement in QMS. Sustaining such involvement in complex institutional environments requires coordinated management processes grounded in quality standards and supported by internal and external audits. Targeted training for all key stakeholders – program directors, residents and administrative staff – on quality principles and the operation of implemented management systems is crucial to ensure shared understanding and consistent application. Systematic channels for communication and documentation reinforce transparency and facilitate the exchange of feedback across programs. Finally, institutional frameworks for the dissemination, monitoring and analysis of results and good practices, with a specific focus on outcomes related to resident involvement, strengthen collective learning and sustain engagement over time.
Overall, these findings demonstrate the effectiveness of structured resident involvement as a governance practice that links stakeholder participation with institutional quality improvement, offering a transferable model for participatory management and continuous development in postgraduate medical education.
The authors wish to express their sincere gratitude to the leadership, academic coordinators, residents, and administrative staff of the postgraduate medical schools at the University of Padova for their invaluable support during the data collection phase and for their meaningful contributions to the qualitative dimension of the study. Special thanks are extended to the institutional offices of the University of Padova, and to the Postgraduate Office, for their continued assistance and collaboration throughout the development of the research. The CESQA University research centre is also gratefully acknowledged for its support and expertise in data collection, as well as for methodological input and assistance in the interpretation of the Quality Management System–related information. Finally, TÜV AUSTRIA (certification body) is acknowledged for sharing information relevant to this research and for its cooperation during the data collection phase.
