A Quality Education: A Comprehensive Review of a Combined Longitudinal and Specialty Track Quality Improvement and Patient Safety Medical School Curriculum.

Structured quality improvement and patient safety (QI/PS) education has increased at every level of medical education; however, great variability exists in the content taught. Here, the authors present a longitudinal model for medical student QI/PS education that is currently implemented at the University of Florida College of Medicine. The curriculum is taught with a variety of teaching methods incorporated into each year with increasing levels of clinical implementation. This curriculum is multimodal and introduces students to QI/PS concepts, presents mock scenarios, and eventually encourages clinical application to situations students experience during their own clinical practice. Additionally, a specialized track for students to have further immersion into this field of medicine is described, which involves specialized training, expanded educational opportunities, and a capstone project. Both the curriculum and specialized track contain explicit clinical integration to ensure students are prepared to enter the medical profession to engage in QI/PS endeavors.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value.

OBJECTIVES: The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS: A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS: Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS: We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center.

OBJECTIVES: Although many health care institutions believe that clinical peer review is vital for identifying and improving quality of care, peer review is perceived by many clinicians as variable and inherently punitive. Successful peer review requires institutional leadership and adoption of a just culture approach to investigating and determining accountability for medical errors that result in harm. METHODS: We describe how an academic medical center implemented and adapted its clinical peer review processes to be consistent with just culture theory and provide a roadmap that other institutions may follow. Specific examples of peer review are highlighted to show how the process improved patient safety in the departments of emergency medicine, internal medicine, and pediatrics. RESULTS: The most significant process improvement was shifting from a tradition of assigning letter grades of "A," "B," or "C" to determine whether preventable adverse events were caused by "human error," "at-risk behavior," or "reckless behavior." This categorization of human behaviors enabled patient safety officers within 3 departments to develop specific interventions to protect patients and enlist physician support for improving clinical systems. CONCLUSIONS: Each department's success was due to recognition of different patient and provider cultures that offer unique challenges. The transformation of peer review was a crucial first step to shift perceptions of peer review from a punitive to a constructive process intended to improve patient safety. Our experience with reengineering clinical peer review shows the importance of focusing on just culture as a key method to prevent patient harm.

Hypercalcemia from hypervitaminosis A in a child with autism.

Objectives Vitamin A is essential for normal cellular physiology and is often taken as a dietary supplement. Hypervitaminosis A can lead to hypercalcemia by increasing osteoclasts and subsequent bone resporption. Dietary supplements including vitamin A are new popular treatment stategies for autism. Case presentation We report a five-year old boy with autism spectrum disorder presenting with severe abdominal pain and bilateral lower extremity pain, who was found to have persistent hypercalcemia due to hypervitaminosis A. The patient ingested over 700 times the recommended intake of Vitamin A per day for age. Retention of vitamin A in the liver and adipose tissue causes toxic levels of retinoids and hypercalcemia. Conclusions Acute treatment included intravenous rehydration, furosemide, and calcitonin. Pamidronate was the definitive treatment for hypercalcemia from hypervitaminosis A due to its osteoclast inhibition and long biologic half-life. Parents should be counseled on risks of toxicity and absence of evidence showing benefits of vitamin A therapy for autism.

Implementing Parental Tobacco Dependence Treatment Within Bronchiolitis QI Collaboratives.

BACKGROUND AND OBJECTIVES: We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives. METHODS: This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks. RESULTS: Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8-1.1). CONCLUSIONS: Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.

Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care.

BACKGROUND AND OBJECTIVES: There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment. METHODS: Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure. RESULTS: Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated. CONCLUSIONS: Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.

Respiratory Scores as a Tool to Reduce Bronchodilator Use in Children Hospitalized With Acute Viral Bronchiolitis.

BACKGROUND AND OBJECTIVES: Adoption of clinical respiratory scoring as a quality improvement (QI) tool in bronchiolitis has been temporally associated with decreased bronchodilator usage. We sought to determine whether documented use of a clinical respiratory score at the patient level was associated with a decrease in either the physician prescription of any dose of bronchodilator or the number of doses, if prescribed, in a multisite QI collaborative. METHODS: We performed a secondary analysis of data from a QI collaborative involving 22 hospitals. The project enrolled patients aged 1 month to 2 years with a primary diagnosis of acute viral bronchiolitis and excluded those with prematurity, other significant comorbid diseases, and those needing intensive care. We assessed for an association between documentation of any respiratory score use during an episode of care, as well as the method in which scores were used, and physician prescribing of any bronchodilator and number of doses. Covariates considered were phase of the collaborative, hospital length of stay, steroid use, and presence of household smokers. RESULTS: A total of 1876 subjects were included. There was no association between documentation of a respiratory score and the likelihood of physician prescribing of any bronchodilator. Score use was associated with fewer doses of bronchodilators if one was prescribed (P = .05), but this association disappeared with multivariable analysis (P = .73). CONCLUSIONS: We found no clear association between clinical respiratory score use and physician prescribing of bronchodilators in a multicenter QI collaborative.

Evaluation of a Cross Cultural Curriculum: Changing Knowledge, Attitudes and Skills in Pediatric Residents.

Objectives The purpose of this study was to evaluate the effectiveness of six online modules, the Cross Cultural Case Stories, designed to teach healthcare professionals and trainees to provide culturally competent care to children with chronic respiratory conditions and their families. Modules increase provider awareness of the types of factors that may vary between cultures. This study assessed learner change in the three domains of knowledge, attitudes and self-reported skills. Improving on earlier studies, this evaluation included a control group for comparison. Methods Subjects comprised 66 first and second year pediatric residents at the University of Florida. Each module includes Objectives, Key Word definitions, Case Story, Lecture, Interactive Exercises and References. Intervention subjects completed an assessment tool before and after training. Control subjects completed the spaced assessments without completing the modules in-between. Results Within the intervention group there was a significant effect associated with the intervention. On average, participants within this group improved 1.67 points on the knowledge assessment (p < .01), 13.64 points on the attitudes self-assessment (p = .01) and 6.86 points on the skills assessment (p ≤ 0.01). When comparing between the intervention and control group significant differences were found in the post knowledge, post skills and post attitudes assessment, with the intervention group exceeding scores from the control group. Conclusions The Cross Cultural Cases provide an accessible, comprehensive and effective means for teaching healthcare and public health professionals and trainees. These cases can potentially provide training for students and practicing professionals from multiple medical and public health related disciplines.

The Community Pediatrics Training Initiative Project Planning Tool: A Practical Approach to Community-Based Advocacy.

Introduction: To impact social determinants of health, physicians require knowledge, skills, and attitudes to work with communities beyond the clinical milieu. The American Academy of Pediatrics (AAP) Community Pediatrics Training Initiative (CPTI) project planning tool can guide health care professionals and trainees to identify and define issues, build coalitions, assess interventions, and ensure sustainability of successful programs. The Accreditation Council for Graduate Medical Education guidelines for pediatric training require experiences in community health. To date, there have been no widely available tools to ensure both robust learning and validated assessment for pediatric residents in community pediatrics and advocacy training. Methods: The AAP CPTI project planning tool engages learners with a step-by-step process involving investigation, guided reflection, and structured assessment. Learners practice the skills necessary to plan, implement, and evaluate a community pediatrics/child health advocacy proposal focused upon a learner-defined area of interest. An assessment rubric maps to milestones. Results: This project planning tool has been used in a number of programs with learners at multiple levels, including undergraduate education, graduate education, and practicing health care providers. It can be employed to design and implement a community advocacy intervention or as a thought exercise and can be incorporated in a single block rotation or as a longitudinal experience. It can be used with individual learners or as a group exercise. Discussion: The project planning tool can be used by residency programs to demonstrate resident competence in community health and advocacy, either as a learning exercise or to guide actual implemented projects.

An Interprofessional Small-Group Learning Experience in Early Childhood Caries With Fluoride Varnish Application.

INTRODUCTION: Early childhood caries has become a significant public health issue in selected populations in the US and is one of the most common infectious diseases of childhood. It is imperative therefore that medical and dental professionals collectively advocate for children's oral health and establish a medical workforce that is comfortable screening and providing anticipatory guidance related to dental caries. To address this issue, we used an interprofessional small-group approach to teach oral health concepts to both first-year medical and dental students, who are at the same learning stage regarding infectious disease knowledge and its relationship to oral health. METHODS: This small-group learning exercise uses the concept of the flipped classroom, in which students acquire foundational knowledge prior to the classroom experience, demonstrate their understanding prior to class by means of an online assessment, and actively apply this knowledge to a specific case. The instructional activities include a preparatory reading and assessment, a case-based interactive exercise, and a concluding hands-on oral exam and fluoride varnish application exercise. RESULTS: More than 81% of participating faculty members and dental and medical students rated the experience as excellent or very good. Students stated they valued the presence of their peer counterparts in the learning experience. DISCUSSION: This interprofessional experience, conducted early in professional school curricula, establishes a foundation for future cooperative working relationships as well as faculty development regarding oral health and local community health resources.

Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network.

BACKGROUND: Acute viral bronchiolitis is the most common diagnosis resulting in hospital admission in pediatrics. Utilization of non-evidence-based therapies and testing remains common despite a large volume of evidence to guide quality improvement efforts. OBJECTIVE: Our objective was to reduce utilization of unnecessary therapies in the inpatient care of bronchiolitis across a diverse network of clinical sites. METHODS: We formed a voluntary quality improvement collaborative of pediatric hospitalists for the purpose of benchmarking the use of bronchodilators, steroids, chest radiography, chest physiotherapy, and viral testing in bronchiolitis using hospital administrative data. We shared resources within the network, including protocols, scores, order sets, and key bibliographies, and established group norms for decreasing utilization. RESULTS: Aggregate data on 11,568 hospitalizations for bronchiolitis from 17 centers was analyzed for this report. The network was organized in 2008. By 2010, we saw a 46% reduction in overall volume of bronchodilators used, a 3.4 dose per patient absolute decrease in utilization (95% confidence interval [CI] 1.4-5.8). Overall exposure to any dose of bronchodilator decreased by 12 percentage points as well (95% CI 5%-25%). There was also a statistically significant decline in chest physiotherapy usage, but not for steroids, chest radiography, or viral testing. CONCLUSIONS: Benchmarking within a voluntary pediatric hospitalist collaborative facilitated decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis.

Preventive oral health care in early childhood: knowledge, confidence, and practices of pediatricians and family physicians in Florida.

OBJECTIVE: To examine the relationships among pediatricians' and family physicians' oral health training, knowledge, confidence, and practice patterns. STUDY DESIGN: A survey of physicians identified through the membership databases of the Florida Academy of Family Physicians and the Florida Pediatric Society was conducted in 2008. Responses of pediatricians and family physicians were compared through bivariate and multivariate analyses. RESULTS: Although training was not directly associated with performing recommended practices, there were positive associations between training and confidence and between confidence and performing recommended practices (P <.05). Pediatricians were more likely than family physicians to answer fluoride-related knowledge questions correctly and reported greater confidence (P <.05). Less than 20% of the respondents reported counseling parents about bringing their child to the dentist before age 1 year or inquiring about the parents' dental health. CONCLUSIONS: Oral health training appears to promote confidence in performing recommended oral health practices. Differences in fluoride knowledge by provider type suggest that fluoride guidance has been disseminated more effectively among pediatricians than among family physicians. Educational content of oral health training programs should place increased emphasis on current fluoride guidance, early dental visits, and assessing parents' oral health. Instructional methods should address physicians' confidence, particularly among family physicians.