Role of Individual Clinician Authority in the Implementation of Informatics Tools for Population-Based Medication Management: Qualitative Semistructured Interview Study.

BACKGROUND: Direct oral anticoagulant (DOAC) medications are frequently associated with inappropriate prescribing and adverse events. To improve the safe use of DOACs, health systems are implementing population health tools within their electronic health record (EHR). While EHR informatics tools can help increase awareness of inappropriate prescribing of medications, a lack of empowerment (or insufficient empowerment) of nonphysicians to implement change is a key barrier. OBJECTIVE: This study examined how the individual authority of clinical pharmacists and anticoagulation nurses is impacted by and changes the implementation success of an EHR DOAC Dashboard for safe DOAC medication prescribing. METHODS: We conducted semistructured interviews with pharmacists and nurses following the implementation of the EHR DOAC Dashboard at 3 clinical sites. Interview transcripts were coded according to the key determinants of implementation success. The intersections between individual clinician authority and other determinants were examined to identify themes. RESULTS: A high level of individual clinician authority was associated with high levels of key facilitators for effective use of the DOAC Dashboard (communication, staffing and work schedule, job satisfaction, and EHR integration). Conversely, a lack of individual authority was often associated with key barriers to effective DOAC Dashboard use. Positive individual authority was sometimes present with a negative example of another determinant, but no evidence was found of individual authority co-occurring with a positive instance of another determinant. CONCLUSIONS: Increased individual clinician authority is a necessary antecedent to the effective implementation of an EHR DOAC Population Management Dashboard and positively affects other aspects of implementation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13012-020-01044-5.

Dynamic interplay between available resources and implementation climate across phases of implementation: a qualitative study of a VA national population health tool.

BACKGROUND: Available resources within an organization can determine the implementation success of an intervention. However, few studies have investigated how the required resources change over the phases of implementation. Using stakeholder interviews, we examined the changes in and interactions between available resources and implementation climate in the implementation and sustainment phases of a national implementation effort for a population health tool. METHODS: We conducted a secondary analysis of the interviews with 20 anticoagulation professionals at 17 clinical sites in the Veterans Health Administration health system about their experiences with a population health dashboard for anticoagulant management. Interview transcripts were coded using constructs from the Consolidated Framework for Implementation Research (CFIR) and according to the phase of implementation (pre-implementation, implementation, and sustainment) as defined by the VA Quality Enhancement Research Initiative (QUERI) Roadmap. We analyzed the factors that may determine successful implementation by examining the co-occurrence patterns between available resources and implementation climate across different implementation phases. To illustrate the variations in these determinants across phases, we aggregated and scored coded statements using a previously published CFIR scoring system (- 2 to + 2). Key relationships between available resources and implementation climate were identified and summarized using thematic analysis. RESULTS: The resources necessary to support the successful implementation of an intervention are not static; both the quantity and types of resources shift based on the phases of the intervention. Furthermore, increased resource availability does not guarantee the sustainment of intervention success. Users need different types of support beyond the technical aspects of an intervention, and this support varies over time. Specifically, available resources in the form of technological support and social/emotional support help users establish trust in a new technological-based intervention during the implementation phase. Resources that foster and maintain collaboration between users and other stakeholders help them stay motivated during sustainment. CONCLUSIONS: Our findings highlight the dynamic nature of available resources and their impacts on the implementation climate across different phases of implementation. A better understanding of the dynamics of available resources over time from the users' perspectives will allow the adaptation of resources to better meet the needs of the intervention stakeholders.

Implementing pharmacist-prescriber collaboration to improve evidence-based anticoagulant use: a randomized trial.

BACKGROUND: Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10-15% of patients receiving these medications get unsafe doses based on a patient's kidney or liver function, potential interactions with other medications, and indication for taking the medication. Alert systems may be beneficial for improving evidence-based prescribing, but can be burdensome and are not currently able to provide monitoring after the initial prescription is written. METHODS/DESIGN: This study will improve upon existing alert systems by testing novel medication alerts that encourage collaboration between prescribers (e.g., physicians, nurse practitioners, physician assistants) and expert pharmacists working in anticoagulation clinics. The study will also improve upon the existing alert system by incorporating dynamic long-term monitoring of patient needs and encouraging collaboration between prescribers and expert pharmacists working in anticoagulation clinics. Incorporating state-of-the-art user-centered design principles, prescribing healthcare providers will be randomized to different types of electronic health record medication alerts when a patient has an unsafe anticoagulant prescription. We will identify which alerts are most effective at encouraging evidence-based prescribing and will test moderators to tailor alert delivery to when it is most beneficial. The aims of the project are to (1) determine the effect of notifications targeting existing inappropriate DOAC prescriptions; (2) examine the effect of alerts on newly prescribed inappropriate DOACs; and (3) examine changes in the magnitude of effects over time for both the new prescription alerts and existing prescription notifications for inappropriate DOACs over the 18-month study period. DISCUSSION: Findings from this project will establish a framework for implementing prescriber-pharmacist collaboration for high-risk medications, including anticoagulants. If effectively implemented at the more than 3000 anticoagulation clinics that exist nationally, hundreds of thousands of patients taking direct oral anticoagulants stand to benefit from safer, evidence-based healthcare. TRIALS REGISTRATION: NCT05351749.

Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System.

BACKGROUND: Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system. METHODS: Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard's use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period. CONCLUSIONS: There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.

Implementing evidence-based anticoagulant prescribing: User-centered design findings and recommendations.

Background: Direct oral anticoagulants (DOACs) are widely used medications with an unacceptably high rate of prescription errors and are a leading cause of adverse drug events. Clinical decision support, including medication alerts, can be an effective implementation strategy to reduce prescription errors, but quality is often inconsistent. User-centered design (UCD) approaches can improve the effectiveness of alerts. Objectives: To design effective DOAC prescription alerts through UCD and develop a set of generalizable design recommendations. Methods: This study used an iterative UCD process with practicing clinicians. In three rapid iterative design and assessment stages, prototype alert designs were created and refined using a test electronic health record (EHR) environment and simulated patients. We identified key emergent themes across all user observations and interviews. The themes and final designs were used to derive a set of design guidelines. Results: Our UCD sample comprised 13 prescribers, including advanced practice providers, physicians in training, primary care physicians, and cardiologists. The resulting alert designs embody our design recommendations, which include establishing intended indication, clarifying dosing by renal function, tailoring alert language in drug interactions, facilitating trust in alerts, and minimizing interaction overhead. Conclusions: Through a robust UCD process, we have identified key recommendations for implementing medication alerts aimed at improving evidence-based DOAC prescribing. These recommendations may be applicable to the implementation of DOAC alerts in any EHR systems.

Informatics and interaction: Applying human factors principles to optimize the design of clinical decision support for sepsis.

In caring for patients with sepsis, the current structure of electronic health record systems allows clinical providers access to raw patient data without imputation of its significance. There are a wide range of sepsis alerts in clinical care that act as clinical decision support tools to assist in early recognition of sepsis; however, there are serious shortcomings in existing health information technology for alerting providers in a meaningful way. Little work has been done to evaluate and assess existing alerts using implementation and process outcomes associated with health information technology displays, specifically evaluating clinician preference and performance. We developed graphical model displays of two popular sepsis scoring systems, quick Sepsis Related Organ Failure Assessment and Predisposition, Infection, Response, Organ Failure, using human factors principles grounded in user-centered and interaction design. Models will be evaluated in a larger research effort to optimize alert design to improve the collective awareness of high-risk populations and develop a relevant point-of-care clinical decision support system for sepsis.

An approach to value-based simulator selection: The creation and evaluation of the simulator value index tool.

BACKGROUND: Currently there is no reliable, standardized mechanism to support health care professionals during the evaluation of and procurement processes for simulators. A tool founded on best practices could facilitate simulator purchase processes. METHODS: In a 3-phase process, we identified top factors considered during the simulator purchase process through expert consensus (n = 127), created the Simulator Value Index (SVI) tool, evaluated targeted validity evidence, and evaluated the practical value of this SVI. A web-based survey was sent to simulation professionals. Participants (n = 79) used the SVI and provided feedback. We evaluated the practical value of 4 tool variations by calculating their sensitivity to predict a preferred simulator. RESULTS: Seventeen top factors were identified and ranked. The top 2 were technical stability/reliability of the simulator and customer service, with no practical differences in rank across institution or stakeholder role. Full SVI variations predicted successfully the preferred simulator with good (87%) sensitivity, whereas the sensitivity of variations in cost and customer service and cost and technical stability decreased (≤54%). The majority (73%) of participants agreed that the SVI was helpful at guiding simulator purchase decisions, and 88% agreed the SVI tool would help facilitate discussion with peers and leadership. CONCLUSION: Our findings indicate the SVI supports the process of simulator purchase using a standardized framework. Sensitivity of the tool improved when factors extend beyond traditionally targeted factors. We propose the tool will facilitate discussion amongst simulation professionals dealing with simulation, provide essential information for finance and procurement professionals, and improve the long-term value of simulation solutions. Limitations and application of the tool are discussed.

Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?

OBJECTIVES: Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA. METHODS: This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis. RESULTS: There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods. CONCLUSIONS: Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.

Computer Modeling to Evaluate the Impact of Technology Changes on Resident Procedural Volume.

BACKGROUND: As resident "index" procedures change in volume due to advances in technology or reliance on simulation, it may be difficult to ensure trainees meet case requirements. Training programs are in need of metrics to determine how many residents their institutional volume can support. OBJECTIVE: As a case study of how such metrics can be applied, we evaluated a case distribution simulation model to examine program-level mediastinoscopy and endobronchial ultrasound (EBUS) volumes needed to train thoracic surgery residents. METHODS: A computer model was created to simulate case distribution based on annual case volume, number of trainees, and rotation length. Single institutional case volume data (2011-2013) were applied, and 10 000 simulation years were run to predict the likelihood (95% confidence interval) of all residents (4 trainees) achieving board requirements for operative volume during a 2-year program. RESULTS: The mean annual mediastinoscopy volume was 43. In a simulation of pre-2012 board requirements (thoracic pathway, 25; cardiac pathway, 10), there was a 6% probability of all 4 residents meeting requirements. Under post-2012 requirements (thoracic, 15; cardiac, 10), however, the likelihood increased to 88%. When EBUS volume (mean 19 cases per year) was concurrently evaluated in the post-2012 era (thoracic, 10; cardiac, 0), the likelihood of all 4 residents meeting case requirements was only 23%. CONCLUSIONS: This model provides a metric to predict the probability of residents meeting case requirements in an era of changing volume by accounting for unpredictable and inequitable case distribution. It could be applied across operations, procedures, or disease diagnoses and may be particularly useful in developing resident curricula and schedules.

Continuous quality improvement in nephrology: a systematic review.

BACKGROUND: Continuous quality improvement (CQI) has been successfully applied in business and engineering for over 60 years. While using CQI techniques within nephrology has received increased attention, little is known about where, and with what measure of success, CQI can be attributed to improving outcomes within nephrology care. This is particularly important as payors' focus on value-based healthcare and reimbursement is tied to achieving quality improvement thresholds. We conducted a systematic review of CQI applications in nephrology. METHODS: Studies were identified from PubMed, MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, ProQuest Dissertation Abstracts and sources of grey literature (i.e., available in print/electronic format but not controlled by commercial publishers) between January 1, 2004 and October 13, 2014. We developed a systematic evaluation protocol and pre-defined criteria for review. All citations were reviewed by two reviewers with disagreements resolved by consensus. RESULTS: We initially identified 468 publications; 40 were excluded as duplicates or not available/not in English. An additional 352 did not meet criteria for full review due to: 1. Not meeting criteria for inclusion = 196 (e.g., reviews, news articles, editorials) 2. Not nephrology-specific = 153, 3. Only available as abstracts = 3. Of 76 publications meeting criteria for full review, the majority [45 (61%)] focused on ESRD care. 74% explicitly stated use of specific CQI tools in their methods. The highest number of publications in a given year occurred in 2011 with 12 (16%) articles. 89% of studies were found in biomedical and allied health journals and most studies were performed in North America (52%). Only one was randomized and controlled although not blinded. CONCLUSIONS: Despite calls for healthcare reform and funding to inspire innovative research, we found few high quality studies either rigorously evaluating the use of CQI in nephrology or reporting best practices. More rigorous research is needed to assess the mechanisms and attributes by which CQI impacts outcomes before there is further promotion of its use for improvement and reimbursement purposes.

Evaluation of a simulation-based curriculum for implementing a new clinical protocol.

OBJECTIVE: To evaluate the implementation of a new clinical protocol utilizing on-unit simulation for team training. METHODS: A prospective observational study was performed at the obstetrics unit of Von Voightlander Women's Hospital, Michigan, USA, between October 1, 2012 to April 30, 2013. All members of the labor and delivery team were eligible for participation. Traditional education methods and in-situ multi-disciplinary simulations were used to educate labor and delivery staff. Following each simulation, participants responded to a survey regarding their experience. To evaluate the effect of the interventions, paging content was analyzed for mandated elements and adherence to operating room entry-time tracking was examined. RESULTS: In total, 51 unique individuals participated in 12 simulations during a 6-month period. Simulation was perceived as a valuable activity and paging content improved. Following the intervention, the inclusion of a goal time for reaching the operation room increased from 7% to 61% of pages and the proportion of patients entering to operating room within 10 minutes of the stated goal increased from 67% to 85%. CONCLUSION: The training program was well received, and the accuracy of the communication and the goal set for reaching the operating room improved.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.

Achieving Accreditation Council for Graduate Medical Education duty hours compliance within advanced surgical training: a simulation-based feasibility assessment.

BACKGROUND: Certain operative cases occur unpredictably and/or have long operative times, creating a conflict between Accreditation Council for Graduate Medical Education (ACGME) rules and adequate training experience. METHODS: A ProModel-based simulation was developed based on historical data. Probabilistic distributions of operative time calculated and combined with an ACGME compliant call schedule. RESULTS: For the advanced surgical cases modeled (cardiothoracic transplants), 80-hour violations were 6.07% and the minimum number of days off was violated 22.50%. There was a 36% chance of failure to fulfill any (either heart or lung) minimum case requirement despite adequate volume. CONCLUSIONS: The variable nature of emergency cases inevitably leads to work hour violations under ACGME regulations. Unpredictable cases mandate higher operative volume to ensure achievement of adequate caseloads. Publically available simulation technology provides a valuable avenue to identify adequacy of case volumes for trainees in both the elective and emergency setting.

Developing an educational video on lung lobectomy for the general surgery resident.

BACKGROUND: The educational resources available to general surgery residents preparing for complex thoracic surgeries vary greatly in content and target audience. We hypothesized that the preparatory resources could be improved in both efficiency of use and targeting. METHODS: A formal needs analysis was performed to determine residents' knowledge gaps and desired format and/or content of an educational tool while preparing for their first lung resections. The results of the needs assessment then guided the creation of a 20-min video tool. The video was evaluated by a focus group of experts for appropriateness to the target audience, ease of use, and relevance. RESULTS: The needs assessment illustrated that residents feel there is a paucity of appropriate resources available to them while preparing for the lung resection procedure; 82% of respondents felt that easy-to-use and concise resources on the lobectomy procedure were either "not at all" or "somewhat" accessible. Residents reported that video was their preferred format for a learning tool overall and identified a broad spectrum of most challenging procedural aspects. These results were used to guide the creation of a 20-min video tool. A focus group validated the efficacy and appropriateness of the video. CONCLUSIONS: Targeted and efficient tools for residents preparing for complex subspecialty procedures are needed and valued. These results clearly encourage further work in the creation of focused educational tools for surgical residents, especially in the format of short video overviews.

Radiology report turnaround time: effect on resident education.

RATIONALE AND OBJECTIVES: To compare resident workload from Emergency Department (ED) studies before and after the implementation of a required 1-hour report turnaround time (TAT) and to assess resident and faculty perception of TAT on resident education. MATERIALS AND METHODS: Resident study volume will be compared for 3 years before and 1 year after the implementation of a required 1-hour TAT. Changes to resident workload will be compared among the different radiology divisions (body, muscuolskeletal (MSK), chest, and neuro), as well as during different shifts (daytime and overnight). Residents and faculty at two Midwest institutions, both of which have a required report TAT, will be invited to participate in an online survey to query the perceived effect on resident education by implementation of this requirement. A P < .05 was considered statistically significant. RESULTS: A significant decrease in resident involvement in ED studies was noted in the MSK, chest, and neuro sections with average involvement of the 3 years before the 1-hour TAT of 89%, 88%, and 82%, respectively, which decreased to 66%, 68%, and 51% after the 1-hour TAT requirement (P < .05). The resident involvement in ED studies only mildly decreased in the body section from an average before the 1-hour TAT of 87% to 80% after the 1-hour TAT requirement (P < .1). There was an overall significant decrease in resident ED study involvement during the daytime (P = .01) but not after hours during resident call (P = .1). Seventy percent of residents (43 of 61) and 55% of faculty (63 of 114) responded to our surveys. Overall, residents felt their education from ED studies during the daytime and overnight were good. However, residents who were present both before and after the implementation of a required TAT felt their education had been significantly negatively affected. Faculty surveyed thought that the required TAT negatively affected their ability to teach and decreased the quality of resident education. CONCLUSIONS: Residents are exposed to fewer ED studies after the implementation of a required 1-hour TAT. Overall, the current residents do not feel this decreased exposure to Emergency room studies affects their education. However, residents in training before and after this requirement feel their education has been significantly affected. Faculty perceives that the required TAT negatively affects their ability to teach, as well as the quality of resident education.

Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices.

BACKGROUND: Simulation-based education (SBE) has advanced greatly in surgery the past decade, partly through development of validated performance measurement. Standard measures are commonly used to evaluate performance (eg, Objective Structured Assessment of Technical Skills, Fundamentals of Laparoscopic Surgery, Global Operative Assessment of Laparoscopic Skills [GOALS]). However, subjective measures are necessary for ensuring content validity during evaluation of novel simulations or simulators. Although commonly assessed, there are no standardized instruments for such surveys of participants. This lack of standardization limits the ability to compare simulations and/or simulators. We performed a focused literature review to assess current uses of subjective measures, and develop a template for a standardized assessment tool. METHODS: A representative sample of recently collected subjective measures was generated through a focused literature review of the journals Surgery, Journal of Surgical Education, and Journal of the American College of Surgeons (January 2008-November 2012) using the key words "surgical" and "simulation." RESULTS: Of the 137 articles relevant to development and/or evaluation of surgical skills curricula or simulators, 19 (12%) reported subjective measures from participants. Ten domains were identified, including Self-efficacy/Confidence/Comfort (11, 57%), Model quality/characteristics (7, 37%), Educational/Program value (6, 32%), Previous experience with procedure/simulation (5, 26%) Relevance to practice (3, 16%), Quality- trainer feedback (3, 16%), Quality-experience (2, 11%), Attitude toward specific aspects (2, 11%), Satisfaction/Enjoyability (2, 11%), Ability to perform relevant task(s) (2, 11%). Response options varied and included 4-, 5-, and 10-point rating scales, Visual Analog Scales, and open written responses. CONCLUSION: These results suggest that simulation experiences are not currently assessed in a systematic manner. However, analysis of the literature suggests that the full range of subjective measures commonly used for subjective assessment could be addressed by a unified assessment instrument. To this end, the Michigan Standard Simulation Experience Scale (MiSSES) template has been developed and is available on-line. Such a tool would provide practitioners a freely available resource used to measure performance and preferences in SBE.

Residents' ability to interpret radiology images: development and improvement of an assessment tool.

RATIONALE AND OBJECTIVES: Despite increasing radiology coverage, nonradiology residents continue to preliminarily interpret basic radiologic studies independently, yet their ability to do so accurately is not routinely assessed. MATERIALS AND METHODS: An online test of basic radiologic image interpretation was developed through an iterative process. Educational objectives were established, then questions and images were gathered to create an assessment. The test was administered online to first-year interns (postgraduate year [PGY] 1) from 14 different specialties, as well as a sample of third- and fourth-year radiology residents (PGY3/R2 and PGY4/R3). RESULTS: Over a 2-year period, 368 residents were assessed, including PGY1 (n = 349), PGY3/R2 (n = 14), and PGY4/R3 (n = 5) residents. Overall, the test discriminated effectively between interns (average score = 66%) and advanced residents (R2 = 86%, R3 = 89%; P < .05). Item analysis indicated discrimination indices ranging from -0.72 to 48.3 (mean = 3.12, median 0.58) for individual questions, including four questions with negative discrimination indices. After removal of the negatively indexed questions, the overall predictive value of the instrument persisted and discrimination indices increased for all but one of the remaining questions (range 0.027-70.8, mean 5.76, median 0.94). CONCLUSIONS: Validation of an initial iteration of an assessment of basic image-interpretation skills led to revisions that improved the test. The results offer a specific test of radiologic reading skills with validation evidence for residents. More generally, results demonstrate a principled approach to test development.

Disparities between industrial and surgical ergonomics.

A surgeon's work environment and working conditions are often harsher than those of an industrial worker. Accepted principles and regulations of ergonomics in manufacturing are largely ignored or absent in the medical/surgical domain. Examples include poor surgical tool handle design, awkward and stressful surgical postures, and prolonged standing without breaks and without a foot mat. In these and other areas, there are documented "best practices" for industrial hygiene and ergonomics that are not yet widely accepted for surgery. There is support in the literature for innovations in surgical ergonomics, yet adoption is not widespread. In the absence of these ergonomic principles, surgical repetitive strain injuries in minimally invasive surgery are reaching epidemic levels. As ergonomists, it falls upon us to understand why current solutions have not been widely adopted within this domain, and to derive solutions to the unique challenges of surgery.