Simulating for Quality: A Centralized Quality Improvement and Patient Safety Simulation Curriculum for Residents and Fellows.

PROBLEM: Requirements for experiential education in quality improvement and patient safety (QI/PS) in graduate medical education (GME) have recently expanded. Major challenges to meeting these requirements include a lack of faculty with the needed expertise, paucity of standardized curricular models allowing for skill demonstration, and inconsistent access to data for iterative improvement. APPROACH: In October 2017, the authors began development of a centralized QI/PS flipped-classroom simulation-based medical education (SBME) curriculum for GME trainees across multiple disciplines at Oregon Health & Science University (OHSU). The curriculum development team included OHSU and Veterans Affairs faculty with experience in QI/PS and SBME, as well as house officers. The curriculum consisted of a preassessment and prework readings and videos (sent 3 weeks before the simulation day) and an 8-hour simulation day, with introductory activities, 4 linked simulation sessions, and concluding activities. The 4 linked sessions followed the same medication error from disclosure and reporting to root cause analysis, iterative implementation of an action plan, and consolidation of lessons learned into routine operations with Lean huddles. OUTCOMES: In academic year 2018-2019, 71 residents and fellows of various postgraduate years from 23 training programs enrolled in 2 pilot sessions. Learners reacted favorably to the simulation curriculum. Learner attitudes, confidence, knowledge, and skills significantly increased across all QI/PS domains studied. NEXT STEPS: This approach focuses a small cadre of educators toward the creation of a centralized resource that, owing to its experiential SBME foundation, can accommodate many learners with data-driven practice-based learning and improvement cycles in a shorter time frame than traditional QI initiatives. Next steps include the addition of a control group, assessment of the sustainability of learner outcomes, translation of learning to behavior change and improvements in patient and health system outcomes, and adapting the materials to include learners from different professions and levels.

Sustainability of a Multifaceted Intervention to Improve Surrogate Decision Maker Documentation for Hospitalized Adults.

Documenting surrogate decision makers (SDMs) is an important step in advance care planning (ACP) for hospitalized adults. The authors performed a quality improvement study of clinical and electronic health record (EHR) workflows aiming to increase SDM documentation for hospitalized adults. The intervention included an ACP education module, audit and feedback, as well as workflow and EHR adaptations. The authors prospectively tracked SDM documentation using control charts and used chart review to assess secondary outcome, process, and balancing measures. SDM documentation significantly increased from 69.5% to 80.2% ( P < 0.001) for intervention patients, sustained over 3 years, and was unchanged for control patients (34.6% to 36.3%; P = 0.355). There were no significant differences in secondary ACP outcomes in intervention or control patients. Clinical and EHR adaptations increased SDM documentation for hospitalized adults with minimal risk, although did not affect other ACP metrics. Future studies are needed to determine the effects of such changes on goal-concordant care.

Adapting SQUIRE 2.0 to Create a Quality Improvement Evidence-Based Medicine Critical Appraisal Tool (QI-EBM-CAT) for Graduate Medical Education Trainees.

Background: Evidence-based medicine (EBM) has long been taught to physician trainees for critical appraisal of research manuscripts. There is no parallel or similar framework to guide trainees in the appraisal of quality improvement (QI) literature. Objective: To adapt existing guidelines of QI manuscript reporting into an educational QI-EBM appraisal tool to help residents distinguish research and QI manuscripts, assess QI designs and methodologies, and evaluate QI manuscripts' strengths and weaknesses. Methods: Between 2018 and 2021, we developed a QI-EBM critical appraisal tool (QI-EBM-CAT) and performed 3 plan-do-study-act cycles to refine the tool based on JAMA and SQUIRE 2.0 guidelines. We then surveyed residents regarding the usefulness of the tool and their confidence in evaluating QI manuscripts before and after completing a QI-EBM workshop using the QI appraisal tool. Results: Sixty-six of 74 internal medicine postgraduate year (PGY)-1 to PGY-3 residents (89.2%) completed the workshop and assessment surveys in 2021. The workshop was found to be moderately to very useful by 85.1% (63 of 74) of residents as a framework for QI manuscript critical analysis. The summary confidence score in QI manuscript critical appraisal improved from a 64% rating of moderately to very confident in the pre-period to 94.6% in the post-period (P<.001) with statistical improvements in all 5 confidence areas assessed (P<.001). Conclusions: The QI-EBM-CAT, designed to teach residents how to critically assess QI manuscripts using EBM principles, resulted in subjective improvements in confidence of QI manuscript analysis.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis.

Introduction: Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement. Methods: We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey. Results: The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague. Discussion: A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.

Prevalence and Characteristics of House Staff Quality and Safety Councils Within Clinical Learning Environments: Results of a National Survey.

House Staff Quality and Safety Councils (HQSCs) are relatively new multispecialty groups led by residents and fellows that focus on quality and safety activities at their training site. The authors sought to estimate the prevalence of HQSCs, describe their common characteristics and determine any perceived impacts. A national survey was conducted with Designated Institutional Officers (DIO) of graduate medical education programs in 2019. For institutions with an HQSC, a second survey was sent to program leaders to obtain additional details. Responses were obtained from 204 DIOs, 47% of whom currently have an HQSC. Forty-five percent of sites provided details about HQSC membership, leadership, funding, activities/initiatives, facilitators, and barriers. The majority reported positive program outcomes. This study found that HQSCs are common and share key characteristics, yet at the same time have many unique features tailored to their clinical learning environment. Participants report positive outcomes associated with these groups.

Faculty Development in Improvement Science: Building Capacity and Expanding Curricula Across an Academic Health Center.

BACKGROUND: The ability of health professions faculty to design, teach, evaluate, and improve relevant curricula is vital for teaching improvement science (IS) skills to trainees. OBJECTIVE: We launched a Foundational Improvement Science Curriculum (FISC) to build faculty competence in IS teaching and scholarship, and to develop, expand, and standardize IS curricula across one institution. METHODS: FISC consisted of 9 full or half-day sessions over 10 months in 2015-2016 and 2016-2017 academic years. Each session required pre-work, including readings, Institute for Healthcare Improvement Open School modules, and personal improvement projects. Sessions included brief didactics, group activities, planning, and feedback on curriculum development. An evaluation strategy was employed, including pre- and post-program self-assessment, competency mapping, evaluations of didactics and overall program, and participant satisfaction. RESULTS: Forty individuals from 23 academic programs voluntarily completed FISC, representing 20% of graduate medical education (GME) programs and 50% of primary GME programs in addition to undergraduate medical education (UME) and nursing programs. Median self-assessed competency scores (mid versus final score; scale 1-9, 9 high; P < .05 for all comparisons) improved over the course for all competencies for knowledge (3 versus 7), application (2 versus 7), curriculum design (2 versus 7), and scholarship (2 versus 5). Eighteen new or revised IS curricula were developed across GME, UME, and nursing programs. CONCLUSIONS: FISC offers a feasible model to enhance and support faculty development in IS and IS curriculum design.

A Resident-Led Initiative to Increase Documentation of Surrogate Decision Makers for Hospitalized Patients.

BACKGROUND: Identification of surrogate decision makers (SDMs) is an important part of advance care planning for hospitalized patients. Despite its importance, the best methods for engaging residents to sustainably improve SDM documentation have not been identified. OBJECTIVE: We implemented a hospital-wide quality improvement initiative to increase identification and documentation of SDMs in the electronic health record (EHR) for hospitalized patients, utilizing a Housestaff Quality and Safety Council (HQSC). METHODS: EHR documentation of SDMs for all adult patients admitted to a tertiary academic hospital, excluding psychiatry, were tracked and grouped by specialty in a weekly run chart during the intervention period (July 2015 through April 2016). This also continued postintervention. Interventions included educational outreach for residents, monthly plan-do-study-act cycles based on performance feedback, and a financial incentive of a one-time payment of 0.75% of a resident's salary put into the retirement account of each resident, contingent on meeting an SDM documentation target. Comparisons were made using statistical process control and chi-square tests. RESULTS: At baseline, SDMs were documented for 11.1% of hospitalized adults. The intervention period included 9146 eligible admissions. Hospital-wide SDM documentation increased significantly and peaked near the financial incentive deadline at 48% (196 of 407 admissions, P < 001). Postintervention, hospital-wide SDM documentation declined to 30% (134 of 446 admissions, P < .001), but remained stable. CONCLUSIONS: This resident-led intervention sustainably increased documentation of SDMs, despite a decline from peak rates after the financial incentive period and notable differences in performance patterns by specialty admitting service.

Epidural abscess caused by Mycobacterium abscessus.

BACKGROUND: Mycobacterium abscessus is a member of the Rapidly Growing Mycobacterium (RGM). The incidence of Mycobacterium abscessus infections has steadily been increasing over the last decade. We report the case of an epidural abscess caused by Mycobacterium abscessus. RGM's have infrequently been reported as spinal infections and we found no prior cases reporting M. abscessus as the definitive etiologic agent of an epidural abscess. CASE REPORT: A 50 year old female presented with significant back pain and was found to have an epidural abscess by magnetic resonance imaging. The abscess was drained via needle. Initial cultures were negative for bacterial pathogens, and the patient was discharged to a skilled nursing facility for empiric antibiotic treatment. Eventually the culture grew Mycobacterium abscessus. The patient had unfortunately left the nursing facility and was lost to follow up. CONCLUSIONS: Mycobacterium abscessus is an increasingly recognized pathogen with particular risk factors that physicians should be aware of. Central nervous system infections are rare, but do occur. Treatment is difficult, though multiple antibiotic regimens have been reported successful. Surgical debridement is often needed.