The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors.

OBJECTIVE: To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors. STUDY DESIGN: A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors. RESULTS: From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification. CONCLUSIONS: A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.

Significant Reduction of Central-Line Associated Bloodstream Infections in a Network of Diverse Neonatal Nurseries.

OBJECTIVE: To describe a quality improvement (QI) initiative that was associated with a dramatic reduction in neonatal central-line associated bloodstream infection (CLABSI) rate in a diverse group of 8 intensive care nurseries (Neonatal Services). STUDY DESIGN: A quasi-experimental time series QI initiative using the model for improvement and evidenced-based interventions. RESULTS: The aggregate CLABSI rate for Nationwide Children's Hospital-associated Neonatal Services decreased from 6.0 CLABSI per 1000 catheter days to 1.43 CLABSI per 1000 catheter days in less than 2 years and has remained in control at 0.68 per 1000 catheter days for over 5 years. Each of 8 nurseries has had a 1 year or more CLABSI-free period, including the neonatal intensive care unit with the largest patient volume, acuity, and central line usage. Aggregate Neonatal Services has experienced 3 CLABSI-free quarters since 2007. Key success factors included: (1) engagement of senior executive leadership; (2) bedside "huddles" among clinical and epidemiology staffs conducted within 72 hours after a positive blood culture; (3) implementation of chlorhexidine antisepsis and the use of chlorhexidine-impregnated catheter site discs; and (4) and establishment of a dedicated team for percutaneously inserted central catheter insertion to serve units in which central lines are placed less frequently. CONCLUSIONS: Using the model for improvement and evidenced-based interventions, this QI project has been associated with reduction in the CLABSI rate by 89%, and over 430 CLABSIs likely have been avoided.

Identifying Pediatric Severe Sepsis and Septic Shock: Accuracy of Diagnosis Codes.

OBJECTIVES: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.

Rates and impact of potentially preventable readmissions at children's hospitals.

OBJECTIVE: To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals. STUDY DESIGN: A total of 1 719 617 hospitalizations for 1 531 828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions. RESULTS: The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year). CONCLUSIONS: Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs.

Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units.

Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations.The Children's Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the "SLUG Bug" project designed to reduce central line-associated bloodstream infections (CLABSIs).The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure.CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more ("improvement") was achieved by 94% of centers and a score 4 or more ("significant improvement") was achieved by 35%.Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases.

An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events.

OBJECTIVE: To reduce the rate of harmful adverse drug events (ADEs) of severity level D-I from a baseline peak of 0.24 ADE/1000 doses to 0.08 ADE/1000 doses. STUDY DESIGN: A hospital-wide, quasi-experimental time series quality improvement (QI) initiative to reduce ADEs was implemented. High-reliability concepts, microsystem-based multidisciplinary teams, and QI science methods were used. ADEs were detected through a combination of voluntary reporting, trigger tool analysis, reversal agent review, and pharmacy interventions. A multidisciplinary ADE Quality Collaborative focused on medication use processes, not on specific classes of medications. Effective interventions included huddles and an ADE prevention bundle. RESULTS: The rate of harmful ADEs initially increased by >65% because of increased error reporting, temporally associated with the implementation of a program focused on high reliability and an improved safety culture. The quarterly rate was 0.17 ADE/1000 dispensed doses in Q1 2010. By the end of Q2 2013, the rate had decreased by 76.5%, to 0.04 ADE/1000 dispensed doses (P < .001). CONCLUSION: Using an internal collaborative model and QI methodologies focused on medication use processes, harmful ADEs were reduced hospital-wide by 76.5%. The concurrent implementation of a high-reliability, safety-focused program was important as well.

Pediatric severe sepsis in U.S. children's hospitals.

OBJECTIVES: To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies. DESIGN: Observational cohort study from 2004 to 2012. SETTING: Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database. PATIENTS: Children 18 years old or younger. MEASUREMENTS AND MAIN RESULTS: We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification-based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p < 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p < 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7-21.8] vs 8.2% [95% CI, 8.0-8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p < 0.001) in the sepsis code cohort and 3.8% (p < 0.001) in the combination code cohort. CONCLUSIONS: Prevalence of pediatric severe sepsis increased in the studied U.S. children's hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.

A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.

OBJECTIVE: To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm. STUDY DESIGN: A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured. RESULTS: Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P < .001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P < .01). Observed hospital mortality decreased from 1.0% to 0.75% (P < .001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly. CONCLUSION: Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well.

Variation in Condition-Specific Readmission Rates Across US Children's Hospitals.

OBJECTIVE: Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention. METHODS: Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals. RESULTS: The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities. CONCLUSIONS: Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates.

Quality Improvement Initiative to Improve Healthcare Providers' Attitudes towards Mothers with Opioid Use Disorder.

INTRODUCTION: Individuals with opioid use disorder often report feelings of shame and describe feeling judged negatively. These feelings are especially true for pregnant women with opioid use disorder. The Ohio Perinatal Quality Collaborative conducted a multimodal quality improvement initiative for infants born with Neonatal Abstinence Syndrome (NAS). An important component of the project was focused on improving staff attitudes toward mothers of infants with NAS. METHODS: The Ohio Perinatal Quality Collaborative implemented an education program for healthcare providers at 39 participating hospital units regarding opioid use as a chronic disease and principles of nonjudgmental, trauma-informed care. Healthcare providers partnered with the mother of infants with NAS in the care of the infant and connected with local community resources. This work was a subcomponent of an overall multimodal quality improvement project. Healthcare provider attitudes were measured with the "Attitude Measurement: Brief Scales" questionnaire anonymously, at 3 different time points throughout the project. Attitude change was measured by pretraining and posttraining scores. ANOVA methods were used to compare individual items and a summary score across the 3 surveys. RESULTS: Summary scores improved significantly from 18.99 at baseline (January-March 2014) to 19.94 (P < 0.0001) in February 2015 and were maintained at 20.05 in July 2016. CONCLUSIONS: A nonjudgmental attitude toward mothers of infants with NAS is an important component of compassionate care. Improving healthcare provider attitudes can benefit a mother of an infant with NAS and help preserve the mother-infant dyad.

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

BACKGROUND: Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months. METHODS: We reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July-December 2017; 101 charts were reviewed post-intervention, January-June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a 'complete' DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric. RESULTS: At baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a 'complete' DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41-2.47, p = 0.73), but attending-documented DDx did not improve (2.85-2.82, p = 0.88). CONCLUSIONS: We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs.

OBJECTIVE: To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. METHODS: Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. RESULTS: On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. CONCLUSIONS: Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.

Coming Together to Save Babies: Our Institution's Quality Improvement Collaborative to Improve Infant Safe Sleep Practices.

Many hospitalized infants are not observed in an American Academy of Pediatrics-recommended safe sleep environment, which can translate to unsafe sleep practices at home. We implemented this collaborative to reduce our county's sleep-related death rate by improving infant safe sleep practices in the freestanding children's hospital setting and increasing safe sleep screening and education in our clinics and emergency departments (EDs). METHODS: Physicians from our institution's primary care clinics, EDs, neonatal intensive care units, and general inpatient units created and led multidisciplinary safe sleep teams. Teams have used standardized data tools to collect information on infant patient ages and sleep position and environment, both in the hospital and at home. Based on audit data, teams have implemented multiple Plan-Do-Study-Act cycles during this collaborative. We have calculated changes in safe sleep practices in the hospital and changes in screening and education on safe sleep behaviors over time. RESULTS: Our teams have significantly increased compliance with safe sleep practices in the inpatient and neonatal intensive care unit settings (P < 0.01). We have also increased screening and education on appropriate safe sleep behaviors by ED and primary care providers (P < 0.01). Our county's sleep-related death rate has not significantly decreased during the collaborative. CONCLUSIONS: Our collaborative has increased American Academy of Pediatrics-recommended safe sleep practices in our institution, and we decreased sleep-related deaths in our primary care network. We have created stronger ties to our community partners working to decrease infant mortality rates. More efforts will be needed, both within and outside of our institution, to lower our community's sleep-related death rate.

Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey.

INTRODUCTION: Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion. METHODS: Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018). RESULTS: Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making. CONCLUSIONS: Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.

Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome.

BACKGROUND: Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS: To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS: Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS: OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.

The Vitals Risk Index-Retrospective Performance Analysis of an Automated and Objective Pediatric Early Warning System.

INTRODUCTION: Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation. METHODS: Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration. Five vital sign measurements and supplemental oxygen requirement data were used to build the Vitals Risk Index (VRI) model, using multivariate logistic regression. We compared the VRI to the hospital's existing early warning system, an adaptation of Monaghan's Pediatric Early Warning Score system (PEWS). The patient population included hospitalized children 18 years of age and younger while being cared for outside of the ICU. This dataset included 158 case hospitalizations (102 emergent transfers to the ICU and 56 "code blue" events) and 135,597 control hospitalizations. RESULTS: When identifying deteriorating patients 2 hours before an event, there was no significant difference between Pediatric Early Warning Score and VRI's areas under the receiver operating characteristic curve at false-positive rates ≤ 10% (pAUC10 of 0.065 and 0.064, respectively; P = 0.74), a threshold chosen to compare the 2 approaches under clinically tolerable false-positive rates. CONCLUSIONS: The VRI represents an objective, simple, and automated predictive analytics tool for identifying hospitalized pediatric patients at risk of deteriorating outside of the ICU setting.

Writing Group Increases Quality Improvement Writing Competency.

Quality improvement (QI) is critically important in current medical practice. Although many QI courses teach improvement science and methods, formal education in writing QI manuscripts for academic journal publication is lacking. The authors developed a QI Writing program, consisting of educational sessions with both coach and peer mentors, to improve comfort and productivity in preparing QI manuscripts for publication. Program participants conducted pre- and post-course QI writing skills self-evaluations in 4 competency domains: SQUIRE guidelines, writing for peer-reviewed journals, QI publication submission steps, and critically examining QI results. Course success was measured by the number of manuscripts submitted for publication. QI writing competencies doubled in 3 of 4 domains and increased 70% in the fourth. Fifteen of 17 (88%) course participants submitted manuscripts to a peer-reviewed journal, and 12 have been accepted to date. A formal writing group with didactic content and committed mentors increases QI writing competencies and manuscript submissions to peer-reviewed journals.