In EPAs we trust, is quality and safety a must? A cross-specialty analysis of entrustable professional activity guides.

PURPOSE: The inclusion of quality improvement (QI) and patient safety (PS) into CanMEDS reflects an expectation that graduating physicians are competent in these areas upon training completion. To ensure that Canadian postgraduate specialty training achieves this, the translation of QI/PS competencies into training standards as part of the implementation of competency-based medical education requires special attention. METHODS: We conducted a cross-specialty, multi-method analysis to examine how QI/PS was incorporated into the EPA Guides across 11 postgraduate specialties in Canada. RESULTS: We identify cross-specialty variability in how QI/PS is incorporated, positioned, and emphasized in EPAs and milestones. QI/PS was primarily referenced alongside clinical activities rather than as a sole competency or discrete activity. Patterns were characterized in how QI/PS became incorporated into milestones through repetition and customization. QI/PS was also decoupled, conceptualized, and emphasized differently across specialties. CONCLUSIONS: Variability in the inclusion of QI/PS in EPAs and milestones has important implications considering the visibility and influence of EPA Guides in practice. As specialties revisit and revise EPA Guides, there is a need to balance the standardization of foundational QI/PS concepts to foster shared understanding while simultaneously ensuring context-sensitive applications across specialties. Beyond QI/PS, this study illuminates the challenges and opportunities that lie in bridging theoretical frameworks with practical implementation in medical education, prompting broader consideration of how intrinsic roles and emergent areas are effectively incorporated into competency-based medical education.

Patient Safety and Quality of Care are Everybody's Business: Evaluating the Impact of a Continuing Professional Development Program beyond Satisfaction.

This article was migrated. The article was marked as recommended. Background Research integrating Continuing Professional Development (CPD) with patient safety (PS) and quality improvement (QI) is still in its infancy despite advocacy by leaders in the field. Objectives This theory-driven study explored the feasibility to implement and evaluate the impact of a CPD intervention focused on teaching and practicing PS and QI at the levels of satisfaction, usefulness, knowledge, confidence, intention to change behaviour and reported changes in practice. Methods Three workshops targeting healthcare professionals were delivered live between 2014 and 2016. Data was collected longitudinally through four questionnaires and analyzed with descriptive statistics and triangulation of sources. Thematic analysis of qualitative data was guided by the Theoretical Domains Framework. Results Sixty-seven healthcare professionals participated in the study. Across workshops, satisfaction was high and a significant increase in knowledge and confidence were reported immediately post-intervention. Intention to change behavior was high across workshops. 'Moral norm' and ' beliefs about consequences' were consistently rated as the most influential factors in participants' intention to change behavior while ' social influence' was consistently rated as the least influential. At the workshops, participants anticipated improving communication, increasing their knowledge on PS-QI, applying content learned and building teamwork. Commonly anticipated barriers to implementation included lack of resources, environmental stressors, and the organizational climate/culture. These barriers were confirmed six-month post where participants reported partially implementing 78% (18/23) anticipated goals. Conclusions This study showed the feasibility to develop and implement an effective CPD intervention supporting healthcare professionals' knowledge, confidence, and reported change in teaching and practicing PS-QI.

"We Should Talk"-Moving knowledge into action by learning to engage patients, families, and healthcare staff to communicate for patient safety.

Innovation in patient engagement and empowerment has been identified as a priority area in the Canadian healthcare system. This article describes the development and implementation of the We Should Talk campaign at an academic pediatric hospital. Through the use of a guiding theoretical framework and a multidisciplinary project team, a multimedia campaign was designed to inspire staff, patients and families to effectively communicate to improve patient safety. The We Should Talk campaign provides a case study for how an organization can foster frontline improvement through the engagement of patient, families, and healthcare providers.

Presence of a Physician Safety Champion Is Associated with a Reduction in Urinary Catheter Utilization in the Pediatric Intensive Care Unit.

BACKGROUND: Safety champions are effective in a variety of safety initiatives; however, there are no reports of their role in hospital-acquired infections prevention. OBJECTIVE: We aimed to describe the association of the presence of a physician safety champion with our urinary catheter device utilization ratios (DUR) in the Pediatric Intensive Care Unit (PICU). METHODS: Our PICU has incidence rates of catheter-associated urinary tract infections (CAUTI) and urinary catheter DUR above the 90th percentile. Using a quasi-experimental design, we compared our DUR when the PICU team was exposed and unexposed (champion's maternity leaves) to a physician safety champion. Hospital acquired infection (HAI) surveillance of all PICU admissions between April 1st 2009 and June 29th 2013 was done prospectively. To ensure stable acuity of the patient population over time, we used the central venous catheter (CVC) DUR as a control. RESULTS: The urinary catheter DUR was 0.44 (95% confidence interval [CI] 0.42-0.45) during the unexposed period versus 0.39 (95%CI 0.38-0.40) during the exposed period, for an absolute difference of 0.05 (95%CI 0.03-0.06; p<0.0001). The overall CVC DUR increased from 0.57 (95%CI 0.55-0.58) during the unexposed period to 0.63 (95%CI 0.61-0.64) during the exposed period, an absolute increase of 0.06 (95%CI 0.04-0.08; p<0.0001). Comparing the exposed and unexposed periods, adjusting for time trend, we observed a 17% decrease in the urinary catheter DUR when the safety champion was present (odds ratio [OR] 0.83; 95%CI 0.77-0.90). The rate of catheter-associated urinary tract infections did not change. CONCLUSIONS: The presence of a unit-based safety champion can have a positive impact on urinary catheter DUR in a PICU.

Structural alterations of epididymal epithelial cells in cathepsin A-deficient mice affect the blood-epididymal barrier and lead to altered sperm motility.

Past studies have shown that the epithelial lining of the epididymis in adult mice deficient in protective protein cathepsin A (PPCA -/-) becomes swollen and vacuolated as a result of an accumulation of pale lysosomes, some very large, in addition to the presence of an abundance of macrophages infiltrating the intertubular spaces. The purpose of this study was to assess the integrity of the epididymal epithelial-blood barrier in these altered mice by characterizing the distribution of claudins (Cldns) and the leakiness of tight junctions to lanthanum nitrate. A second goal was to characterize sperm motility behavior in PPCA -/- mice using computer-assisted sperm analyses (CASA). The results indicated that lanthanum nitrate penetrated apical junctional complexes between adjacent epithelial cells and entered the epididymal lumen in PPCA -/- mice but not in control PPCA +/+ mice. Immunostaining for Cldns 1, 3, 8, and 10 revealed unique patterns of expression based on cell type and region specificity in PPCA +/+ mice, which were much different in PPCA -/- mice. PPCA -/- mice showed reduced intensities of immunoreactions, complete absence of immunoreactions, and appearance of atypical cytoplasmic immunoreactions. CASA indicated that sperm counts in the PPCA -/- mice were 70% reduced, and among other problems, there was a fourfold higher percentage of static sperm in PPCA -/- mice compared with controls. These results suggest that PPCA deficiency causes structural changes to the blood-epididymal barrier as evidenced by lanthanum nitrate and Cldns expression that affects the luminal environment of the epididymis, resulting in altered sperm motility.

Expression and localization of cathepsin k in adult rat sertoli cells.

The cathepsins are a family of cysteine proteases that have been broadly implicated in proteolytic processes during cell growth, cell development, and normal adult cellular function. Cathepsin L is a major secretory product of rat and mouse Sertoli cells, the absence of which in furless mice is associated with atrophy of some seminiferous tubules. However, furless mice produce viable sperm, suggesting the possibility that other members of the cathepsin family of proteases may complement cathepsin L action in the testis. Our objective herein was to begin to test this hypothesis. To this end, we first utilized cDNA microarray technology to identify the members of the cathepsin gene family expressed by freshly isolated adult rat Sertoli cells. This approach, complemented by Northern blot analyses, showed that in addition to cathepsin L, cathepsin K is highly and specifically expressed in Sertoli cells. As is also true of cathepsin L, cathepsin K mRNA was found to be expressed by Sertoli cells at specific stages of the cycle of the seminiferous epithelium, with maximal expression at stages VI-VII. The use of immunocytochemical methods revealed that cathepsin K protein localizes to the cytoplasm of Sertoli cells at stages VI-VIII, to small punctuate lysosomes at stages I-VIII and XIII-XIV, and to early and late residual bodies at stages IX-XII. This localization was found to be similar to that of cathepsin L. The similarity in the expression and localization of cathepsin K and cathepsin L suggest that the two proteases may have similar functions. If true, this might explain the fertility of furless mice. Further, the results suggest that cathepsin K, in both its secreted and lysosomal forms, may play a role in the degradation of Sertoli cell residual bodies.

Characterization of cell- and region-specific abnormalities in the epididymis of cathepsin A deficient mice.

Cathepsin A (PPCA), a lysosomal carboxypeptidase that functions as a protective protein for alpha-neuraminidase and beta-galactosidase in a multi-enzyme complex, has been shown to be expressed in the epithelial cells of the epididymis. In the present study, the epididymis of PPCA-/- mice from 2 to 10 months of age was compared with those of their wild-type counterparts. Major accumulations of pale vacuoles, corresponding to lysosomes, were noted in principal and narrow/apical cells in PPCA-/- mice, and clear cells also appearing highly vacuolated, were grossly enlarged in size. This was especially evident in the caput and corpus regions, where quantitative analyses confirmed that the epithelium of the tubules in these regions was expanding in profile area. In addition, the base of the epithelium in these regions was often greatly vacuolated, corresponding to cells that presented no identifiable features and appeared to be degenerating. Halo cells dispersed at various levels in the epithelium also appeared to be abnormal, accumulating pale lysosomes. Furthermore, numerous macrophages were observed in the intertubular space of the entire duct, presenting a large size and plethora of pale lysosomes. Taken together, the present data indicate major lysosomal abnormalities in the epididymis of PPCA-/- mice in a cell type and region specific manner. In addition, it is suggested that the compromised halo cells, due to PPCA deficiency within their lysosomes, cannot function properly and as a result there is a recruitment of macrophages in the intertubular space.

Increase in macrophages in the testis of cathepsin a deficient mice suggests an important role for these cells in the interstitial space of this tissue.

Cathepsin A (PPCA) is a lysosomal carboxypeptidase that functions as a protective protein for alpha-neuraminidase and beta-galactosidase in a multienzyme complex. In the present study, the testes of PPCA -/- mice from 2 to 10 months of age were compared with those of their wild type counterparts. While germ and Sertoli cells appeared comparable in appearance and distribution, the mean profile area of seminiferous tubules showed a significant decrease between wild type and PPCA -/- mice, suggesting changes to the seminiferous tubules and their contents. In addition, macrophages in the interstitial space (IS) of PPCA -/- mice were large, spherical, and filled with pale lysosomes, unlike those seen in wild type mice, and a quantitative analysis of their frequency per unit area of IS in PPCA -/- mice revealed a significant increase compared to that of wild type mice; this was also the case for their mean profile area. Absence of mitotic figures, cycling cells, or degenerating figures in the IS suggests that the major recruitment of macrophages appears to be from the circulation. In the IS, Leydig cells also showed an accumulation of large pale lysosomes in PPCA -/- mice, and their frequency also increased significantly as compared to wild type mice. In the electron microscope, a close association of Leydig cell microvilli with the surface of macrophages was pronounced in PPCA -/- mice. Since macrophages and Leydig cells interact by secreting various factors between each other, and considering the fact that Leydig cells show an accumulation of large pale lysosomes in PPCA -/- mice, it is suggested that macrophages accumulate as a result of abnormalities occurring in Leydig cells. Taken together, the data on increase in frequency of macrophages suggests important functions for these cells in both wild type and PPCA -/- mice.