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Resident Elective Syllabus 2014-2015; Page 1

Department of Medicine Internal Medicine Residency Program

Stanford University School of Medicine

Elective in Quality Improvement, Patient Safety, and Organizational Change

Syllabus and Reader

2014-2015

Lisa Shieh, MD, PhD, FHM

Clinical Associate Professor of Medicine Medical Director of B3/C3 Inpatient Unit

Kambria H. Evans, MEd Program Officer, Quality and Organizational Improvement

Specialist, Education and Evaluation

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TABLE OF CONTENTS Part I: Guidelines and Requirements for the Elective 3 About the elective/Goals of the elective 4 Course Contacts 5 List of Roles and Responsibilities 6 Timeline of Roles and Responsibilities 7

Required activities: IHI Open School Modules 8 Required activities: Readings 9 Required activities: PDSA Project Plan/IRB 10 Required activities: QI M&M Noon Conference 12 Required activities: QI Project Noon Conference/Visibility Wall 14 Required activities: Handoff Video 15

Required activities: Course Evaluation 16 Optional activities at the VA 17

Part II: National and Stanford QI Resources 18

National resources 19 Resource reading list 21

History of QI elective resident projects 28

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PART I: GUIDELINES AND REQUIREMENTS FOR THE ELECTIVE

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About the Elective in QI, Patient Safety & Organizational Change This elective is a 4-week training and mentorship experience at Stanford University Hospitals and Clinics. The overarching goal of the elective is to provide mentored practice and growth in residents’ knowledge, skills, and attitudes in quality improvement, patient safety, and organizational change. The resident will engage in directed readings in quality, patient safety, and organizational change, attend sessions with experienced “QI Champions”, learn about quality improvement projects and processes at Stanford University, participate in ongoing quality and patient safety activities within the Department of Medicine and Stanford Hospital & Clinics, and design and begin a quality improvement /patient safety/organizational change project. Residents should receive regular verbal feedback. The quality improvement elective is also designed to allow the resident to develop mentoring relationships with “QI Champions” who will serve as role models, mentors, and educators. Goals of the quality improvement elective At the end of the quality improvement elective, residents should be able to see increases in:

• Knowledge of key components of reflective practice • Skill in applying reflective practice • Knowledge in the definition of quality improvement (QI) • Knowledge of key steps in a QI project • Knowledge of criteria for selecting a QI project team • Knowledge of practice-based learning and improvement • Knowledge of systems-based practice • Familiarity with QIPS infrastructure at Stanford Hospital and Clinics • Familiarity with publicly reported core measures, national data on

quality/patient safety • Appreciation of QI as part of the physician’s professional role • Confidence in participating in a QI project • Ability to communicate with peers about QI principles, as well as specific

projects and resources at Stanford • Ability to synthesize QI concepts from key readings • Ability to apply knowledge to a QI project at Stanford

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Course Contacts Rotation Directors and Educators: Lisa Shieh, MD, PhD, FHM Clinical Associate Professor of Medicine Medical Director of B3/C3 Inpatient Unit (650) 724-2917 (voicemail) (650) 725-9002 (fax) pager #23034 [emailprotected] Kambria H. Evans, MEd Program Officer, Quality and Organizational Improvement Specialist, Education and Evaluation Email: [emailprotected] Phone: (650) 725-8803 Quality Improvement Elective Consultants: Joe Hopkins, MD Senior Medical Director of Quality Clinical Professor of Medicine/Family and Community Medicine Email: [emailprotected] Phone: (650) 723-6963 Kate Bombach, MS Director of Quality [emailprotected] Janet Rimicci, RN, MSN Executive Director, Emergency and Medicine Services [emailprotected]

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tel:%28650%29%20725-9002

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List of Roles and Responsibilities What are the responsibilities of the resident?

• Learn and follow all guidelines in this syllabus. • Satisfactorily complete of all quality improvement elective requirements:

o Complete required online IHI modules (see pgs.7, 8) o Complete required readings (see pg. 9) o Attend departmental and hospital QI/PS meetings (see calendar) o Meet regularly with the rotation team (see calendar) o Complete a PDSA project plan (see pg. 10) o At the end of the rotation, the resident should present their project

and/or key learning from their rotation experience to colleagues through the following three activity areas: Lead a QI M&M noon conference (see pg. 12) Lead a QI Project Presentation noon conference with 5

minute overview of Visibility Wall data (see pg. 14) Complete an end-rotation status report through a handoff

video (see pg. 15) o Complete a final course evaluation (see pg. 16)

• Meet with individuals as relevant to project area • Seek ongoing evaluative feedback and incorporate suggestions for

improvement into ongoing assignments and projects. • Adhere to academic and professional standards. • Contact the rotation team if there are concerns about resident

responsibilities. • Serve as "QI Ambassadors" to resident colleagues.

What are the responsibilities of the QI elective team?

• Orient and instruct the resident regarding QI elective academic program requirements, professional behavior and evaluation procedures.

• Be available to the resident on a formal or informal basis to facilitate the progress of the resident.

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Timeline of Roles and Responsibilities Each Monday afternoon during weekly check-in, there will be time for your reflections and questions about QI meetings attended and IHI modules. Week One: Introduction to QI at Stanford Activity Literature review on topic area QI meetings Online IHI modules: - Introduction to QI (QI 101; QI 102) - Introduction to PS (PS 102)

Outcomes due Friday PDSA plan: topic area and outcomes (e.g. scholarship) defined Summary of literature review for presentation on Monday next week

Week Two: Project Development and Peer Education Activity Review and prep for QI M&M QI meetings Online IHI modules: - Methodology (QI 103; PS 105) - Culture change (PS 106; QI 104)

Outcome due Friday PDSA plan: progress plan defined M&M outline for feedback

Week Three: QI implementation and data collection Activity Review of handoff video assignment Finalize two noon conferences; invite stakeholders QI meetings Online IHI modules: - Methodology (QI 106) - Teams (PS 103)

Outcome due Friday PDSA plan: project underway, data collected Project presentation outline for feedback Visibility Wall updated for peers

Week Four: Summarizing and Handing off Activity Present QI M&M (Wed) Present QI Project (Fri) QI meetings Develop end-rotation status report through handoff video Course feedback

Outcome due Friday PDSA plan: project completed, data analyzed, findings summarized, next steps Handoff video Course evaluation

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Required activities: IHI Open School modules The IHI Open School is located online http://www.ihi.org/lms/onlinelearning.aspx Login registration for the IHI Open School should be set up as “student” or “resident” role to access the curriculum. The following modules are required during the rotation (see pg. 7 for schedule):

- Patient Safety: 102: Human Factors and Patient Safety; 103: Teamwork and Communication; 105: Root Cause and Systems Analysis; 106: Introduction to Culture of Safety

- Quality Improvement: 101: Fundamentals of Improvement; 102: The Model For Improvement; 103: Measuring for Improvement; 104: How QI Works in Real Health Care Settings; 106: QI Tools

We encourage you to participate in any additional IHI Open School Modules for self-directed learning.

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Required activities: Readings

1) Before the rotation, please purchase the book “Understanding Patient Safety” by Robert Wachter.

2) Before the rotation, please watch: http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html

3) For the first day of the rotation, residents should come prepared to

discuss 3 articles (see pg. 32 for readings): • Quality: The Mayo Clinic Approach. • Involving Residents in Quality Improvement: Contrasting “Top-Down”

and “Bottom-Up” Approaches (ACGME, 2008). • Physicians’ Professional Responsibility to Improve the Quality of Care

(AMJ 2002).

4) All other course readings are available as resources (see reading list pg. 21), and can be found online on MedHub; PDFs available upon request.

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Required activities: PDSA Project Plan/ IRB The project plan should be completed each Friday of the rotation for review/ modification with rotation team each Monday. Complete IRB if publishing work.

Overall aim: Test population: Team members: PLAN: Briefly describe the test: How will you know that the change is an improvement? What driver does the change impact? What do you predict will happen? Plan for change or test: who, what, when, where

Test start date: Target test completion date:

List the tasks necessary to complete this test (what)

Person responsible

(who) When Where 1.

2.

3.

4.

5.

Plan Do

Study Act

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Plan for collection of data: DO: Test the changes. Was the cycle carried out as planned? Record data and observations. What did you observe that was not part of our plan? STUDY: Did the results match your predictions? Compare the result of your test to your previous performance: What did you learn? ACT: Decide to Adopt, Adapt, or Abandon.

Adapt: Improve the change and continue testing plan. Plans/changes for next test:

Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability

Abandon: Discard this change idea and try a different one

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Required activities: QI M&M Noon Conference QI M&M goals:

• Educate housestaff in practice based learning and improvement and systems based practice

• Gain housestaff input and involvement in ongoing systems improvement • Partner with housestaff to better understand contributing factors that

impact patient care • Provide follow up on cases and action plan

QI M&M learning objectives: By the end of the M&M Conference, participants will have increased …

1) Confidence and competence in utilizing QI methodologies ( including, but not limited to: Root Cause Analysis, Healthcare Failure Modes and Effects Analysis, and Just Culture)

2) Knowledge in the definition of quality improvement (QI) 3) Knowledge of key steps in a QI project 4) Knowledge of practice-based learning and improvement 5) Knowledge of systems-based practice 6) Familiarity with QIPS infrastructure at Stanford Hospital and Clinics 7) Familiarity with publicly reported core measures, national data on

quality/patient safety 8) Appreciation of QI as part of the physician’s professional role 9) Confidence in participating in a QI project 10) Ability to communicate with colleagues about QI principles, as well as

specific projects and resources at Stanford 11) Ability to identify QI opportunities in case presentations and day-to-day

patient care QI M&M Educational Format: (60 mins, but formatted for 45 since it starts late)

- Review of goals (3-5 mins) o What are we learning today? (These can be case-specific or

system-specific, but should map onto our overall goals and objectives above)

- Case presentation (10-15 mins) - Explanation of methodologies used in the case review (5 mins)

o What is the framework? (Just Culture, RCA, processing mapping, FMEA)

- Identify systems issue(s) in small groups (5 mins) - Discuss with large group (10 mins) - Background/data (3-5 mins)

o Literature/best practices on topic for benchmarking

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o Any Stanford or national data we can show for this clinical or systems issue (compare?)

o Review slides with project selection criteria - ACTION PLAN: Where are we now and what happens next? (15 mins)

o Action plan developed with large group o Identify where we are in the QI infrastructure slide to show process

of systems improvement at Stanford (identify resources, etc) o Identify where we are in the10 steps of QI project to show where

we are in process QI resident does steps 1-3; group does steps 4-6 for the

most part

For examples of previous presentations, please speak with Kambria H. Evans, M.Ed.

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Required activities: QI Project Noon Conference Your QI Project presentation’s purpose is to gather peer input on your intervention idea and to communicate with peers about QI principles, as well as specific projects and resources at Stanford. Part of your presentation will be a 5 minute overview of the Resident Performance Dashboard on the Visibility Wall, which you will have updated by the Friday before. For examples of previous presentations, please speak with Kambria H. Evans, M.Ed.

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Required activities: End-rotation Status Report through a Handoff Video At the end of the rotation, the resident should complete an end-rotation status report in Powerpoint. This is intended to summarize progress to date and outline steps to keep the initiative going, even in the resident’s absence. The report should include specific resources needed for ongoing data monitoring and evaluation. Think about what you would want to know if you were next month’s QI resident coming into this project. This will be videotaped/ recorded as a virtual handoff in LKSC with EdTech. Prepare for about a 30 minute handoff video. Request through SMILI: http://smili.stanford.edu/consultation/index.html For more specific instructions, please speak with Kambria H. Evans, M.Ed.

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Required activities: Course Evaluation

Your responses on this instrument are entirely confidential. They will be used for programmatic evaluation research purposes only and will be reported only as grouped data.

We appreciate your cooperation in completing every item. Rate yourself on each of the following BEFORE participating in the rotation (as viewed retrospectively) and CURRENTLY. BEFORE ROTATION CURRENTLY Low High Low High

Knowledge of key components of reflective practice 1 2 3 4 5 1 2 3 4 5

Skill in applying reflective practice 1 2 3 4 5 1 2 3 4 5

Knowledge in the definition of quality improvement (QI) 1 2 3 4 5 1 2 3 4 5

Knowledge of key steps in a QI project 1 2 3 4 5 1 2 3 4 5

Knowledge of criteria for selecting a QI project team 1 2 3 4 5 1 2 3 4 5

Knowledge of practice-based learning and improvement 1 2 3 4 5 1 2 3 4 5

Knowledge of systems-based practice 1 2 3 4 5 1 2 3 4 5

Appreciation of QI as part of the physician’s

professional role 1 2 3 4 5 1 2 3 4 5

Confidence in participating in a QI project 1 2 3 4 5 1 2 3 4 5

Familiarity with QIPS infrastructure at

Stanford Hospital and Clinics 1 2 3 4 5 1 2 3 4 5

Familiarity with publicly reported core measures,

national data on quality/patient safety 1 2 3 4 5 1 2 3 4 5

Ability to communicate with peers about QI principles,

as well as specific projects & resources at SU 1 2 3 4 5 1 2 3 4 5

Ability to synthesize QI concepts from key readings 1 2 3 4 5 1 2 3 4 5

Ability to apply knowledge to a QI project at Stanford 1 2 3 4 5 1 2 3 4 5

What worked well in the rotation? What can be improved in the rotation?

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Optional activities If you’d like skill development in (1) creating curriculum and teaching in patient safety topics to nurses at the VA or (2) participating in a rapid improvement project (RPIW), please contact: Nazima Allaudeen, MD Hospitalist, Department of Medicine Veterans Affairs Palo Alto Healthcare System VA- Palo Alto Healthcare System 3801 Miranda Ave, MC 111 Palo Alto CA 94304 Office: 650 493 5000, Ext 68982 Fax: 650 849 1213 email: [emailprotected]

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PART II: NATIONAL AND STANFORD QI RESOURCES

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Resources

JCAHO National Patient Safety Goals

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

AHRQ http://www.ahrg.gov/qual/

JCAHO Core Measures http://www.jointcommission.org/PerformanceMe

asurement/PerformanceMeasurement/default.htm

UHC Core Measures & Mortality http://www.uhc.edu/

Society of Hospital Medicine http://www.hospitalmedicine.org/AM/Template.cf

m?Section=Quality_Improvement

Institute for Healthcare Improvement

http://www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.htm

HHS Hospital Compare http://www.hospitalcompare.hhs.gov/Hospital/Se

arch/Welcome.asp?version=default&browser=IE%7C7%7CWinXP&language=English&defaultstatus=0&pagelist=Home

Cal Hospital Compare http://www.calhospitalcompare.org/

Leapfrog http://www.leapfroggroup.org/

Picker Institute http://www.pickerinstitute.org/index.html

3M Consulting Group http://solutions.3m.com/wps/portal/3M/en_US/3

M_Health_Information_Systems/HIS/Services_Support/Consulting/

Health Grades http://www.healthgrades.com/

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Additional online module and resources • Mayo Clinic Quality Academy Educational Resources:

http://qiresources.mayo.edu/ • IHI Open School Modules: http://www.ihi.org/lms/onlinelearning.aspx • Vanderbilt: www.improvementskills.org (small fee to register) • Interprofessional Healthcare Informatics (online course)

https://www.coursera.org/course/newwayhealthcare

Research and survey design • Manuscript guidelines

http://www.aacc.org/publications/clin_chem/ccgsw/Pages/default.aspx# • Survey design

o http://www.keene.edu/crc/forms/designingsurveysthatcount.pdf o http://www.sagepub.com/upm-data/14496_Chapter5.pdf o http://www.socialresearchmethods.net/kb/survey.php

• Writing in the Sciences (online course) https://www.coursera.org/course/sciwrite

Thompson Reuters Top Hospitals http://www.100tophospitals.com

CMS Value Based Purchasing http://www.cms.hhs.gov/Acute

InpatientPPS/downloads/hospital_VBP_plan issues_paper.pdf

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Resource Readings Course readings can be found online on MedHub, and are available as PDF upon request. Reflective Practice: Concepts and Applications Gruen RL, Pearson SD, Brennan TA. Physician-citizens--public roles and professional obligations. Jama. Jan 7 2004;291(1):94-98. Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the role and place of practice reflection. J Contin Educ Health Prof. Winter 2004;24(1):50-56. Mamede S, Schmidt HG. The structure of reflective practice in medicine. Med Educ. Dec 2004;38(12):1302-1308. Schön DA. The reflective practitioner : how professionals think in action. New York: Basic Books; 1983. Ziegelstein RC, Fiebach NH. "The mirror" and "the village": a new method for teaching practice-based learning and improvement and systems-based practice. Acad Med. Jan 2004;79(1):83-88. Formulating new rules to redesign and improve care. Crossing the quality chasm: a new health system for the 21st century. Chapter 3. Washington, D.C.: National Academy Press; 2001:61-88. Patient Safety Chassin MR, Becher EC. The wrong patient. Ann Intern Med. Jun 4 2002;136(11):826- 833. Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. Feb 2006;21(2):165-170. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. Aug 2006;15(4):272- 276. Wachter RM, Shojania KG. Internal bleeding : the truth behind America's terrifying epidemic of medical mistakes. 2nd ed. New York City, NY: Rugged Land; 2005. AHRQ: Quality and Patient Safety http://www.ahrq.gov/qual/ Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. Mar 18 2000;320(7237):759- 763.

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Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. Jama. Jul 5 1995;274(1):29-34. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. Jama. Jan 18 2006;295(3):324-327. Blendon RJ, DesRoches CM, Brodie M,et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002 Dec 12;347(24):1933-40. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care. Apr 2004;13(2):145-151; discussion 151-142. Brewer T, Colditz GA. Postmarketing surveillance and adverse drug reactions: current perspectives and future needs. Jama. Mar 3 1999;281(9):824-829. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med. 2004 Dec;11(12):1341-5. Engel KG, Rosenthal M, Sutcliffe KM. Residents' responses to medical error: coping, learning, and change. Acad Med. Jan 2006;81(1):86-93. Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. Learning from mistakes. Factors that influence how students and residents learn from medical errors. J Gen Intern Med. May 2006;21(5):419-423. Gaba DM. Anaesthesiology as a model for patient safety in health care. Bmj. Mar 18 2000;320(7237):785-788. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. Apr 17 2003;348(16):1556-1564. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. Sep 3 2002;137(5 Part 1):327-333. Ilan R, Fowler R. Brief history of patient safety culture and science. J Crit Care. Mar 2005;20(1):2-5. Ioannidis JP, Lau J.Evidence on interventions to reduce medical errors: an overview and recommendations for future research. J Gen Intern Med. 2001 May;16(5):325-34. IOM Report: To err is human: building a safer health care system. November, 1999; 1-8. Available at. http://www.iom.edu/Object.File/Master/4/117/0.pdf

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Kachalia A, Johnson JK, Miller S, Brennan T. The incorporation of patient safety into board certification examinations. Acad Med. Apr 2006;81(4):317-325. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? Jama. May 18 2005;293(19):2384-2390. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. Feb 7 1991;324(6):377-384. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. Jama. Jul 24-31 2002;288(4):501-507. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. Jama. Dec 14 2005;294(22):2858-2865. Mazor KM, Fischer MA, Haley HL, Hatem D, Quirk ME.Teaching and medical errors: primary care preceptors' views. Med Educ. 2005 Oct;39(10):982-90. McCarthy D, Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Q. 2006;84(1):165-200. Millenson ML. A brief history of the patient safety movement. Available at http://www.healthjournalism.org/qualityguide/pdf/timeline.pdf “History of Patient Safety Timeline” Moore C, Wisnivesky J, Williams S, McGinn T..Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 Aug;18(8):646-51. Nicklin W, McVeety JE. Canadian nurses' perceptions of patient safety in hospitals. Can J Nurs Leadersh. Sep-Oct 2002;15(3):11-21. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. Jama. 2003 Dec 3;290(21):2838- 42. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. Jama. Aug 9 2006;296(6):696-699. Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. A national profile of patient safety in U.S. hospitals. Health Aff (Millwood). Mar-Apr 2003;22(2):154-166. Rosner F, Berger JT, Kark P, Potash J, Bennett AJ. Disclosure and prevention of

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medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med. Jul 24 2000;160(14):2089-2092. Snyder L, Leffler C. Ethics manual: fifth edition. Ann Intern Med. Apr 5 2005;142(7):560-582. Volpp KG, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med. Feb 27 2003;348(9):851-855. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? Jama. Apr 24 1991;265(16):2089-2094. AHRQ (2001). Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058; 2001 http://www.ahrq.gov.laneproxy.stanford.edu/clinic/ptsafety/ Quality Improvement Audet AM, Doty MM, Shamasdin J, Schoenbaum SC. Measure, learn, and improve: physicians' involvement in quality improvement. Health Aff (Millwood). May-Jun 2005;24(3):843-853. Becher EC, Chassin MR. Taking health care back: the physician's role in quality improvement. Acad Med. Oct 2002;77(10):953-962. Chassin MR. Is health care ready for Six Sigma quality? Milbank Q. 1998;76(4):565-591, 510. Coleman MT, Nasraty S, Ostapchuk M, Wheeler S, Looney S, Rhodes S. Introducing practice-based learning and improvement ACGME core competencies into a family medicine residency curriculum. Jt Comm J Qual Saf. May 2003;29(5):238-247. Fernandopulle R, Ferris T, Epstein A, et al. A research agenda for bridging the 'quality chasm.' Health Aff (Millwood). Mar-Apr 2003;22(2):178-190. Holmboe E, Kim N, Cohen S, et al. Primary care physicians, office-based practice, and the meaning of quality improvement. Am J Med. Aug 2005;118(8):917-922. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320(1):53-56. Berwick DM. The clinical process and the quality process. Qual Manag Health Care. Fall 1992;1(1):1-8.

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Berwick DM. A primer on leading the improvement of systems. Bmj. Mar 9 1996;312(7031):619-622. Berwick DM. Disseminating innovations in health care. Jama. Apr 16 2003;289(15):1969-1975. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team. Crit Care Med. Jan 2006;34(1):211- 218. Denton GD, Smith J, Faust J, Holmboe E. Comparing the efficacy of staff versus housestaff instruction in an intervention to improve hypertension management. Acad Med. Dec 2001;76(12):1257-1260. Endsley S. Putting measurement into practice with a clinical instrument panel. Family Practice Management 2004 Available at http://www.aafp.org/fpm/20030200/43putt.html Farmer EA, Beard JD, Dauphinee WD, LaDuca T, Mann KV. Assessing the performance of doctors in teams and systems. Med Educ. Oct 2002;36(10):942- 948. Goode LD, Clancy CM, Kimball HR, Meyer G, Eisenberg JM. When is "good enough"? The role and responsibility of physicians to improve patient safety. Acad Med. Oct 2002;77(10):947-952. McCarthy D, Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Q. 2006;84(1):165-200. Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. Aug 2006;15(4):264-271. Ornstein S, Jenkins RG, Nietert PJ, et al. A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial. Ann Intern Med. Oct 5 2004;141(7):523-532. Palmer RH, Louis TA, Peterson HF, Rothrock JK, Strain R, Wright EA. What makes quality assurance effective? Results from a randomized, controlled trial in 16 primary care group practices. Med Care. Sep 1996;34(9 Suppl):SS29-39. Prather SE, Jones DN. Physician leadership: influence on practice-based learning and improvement. J Contin Educ Health Prof. Spring 2003;23 Suppl 1:S63-72. Rider. Twelve startegies for effective communication and collaboration in medical teams. BMJ. August 10,2002 2002;325(10 August):S45.

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Staker LV. Practice-based learning for improvement: the pursuit of clinical excellence. Tex Med. Oct 2000;96(10):53-60. Stevenson K, Baker R, Farooqi A, Sorrie R, Khunti K. Features of primary health care teams associated with successful quality improvement of diabetes care: a qualitative study. Fam Pract. Feb 2001;18(1):21-26. Walley P, Gowland B. Completing the circle: from PD to PDSA. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2004;17(6):349-358. Facilitating Change through Leadership and Teams Blattner S, Wenneker M. Getting physician buy-in--even without direct authority. Physician Exec. Sep-Oct 2005;31(5):14-18. Collins BA, Hawks JW, Davis R. From Theory to Practice: Identifying Authentic Opinion Leaders to Improve Care. Manag Care Magazine. Jul 2000;9(7):56-62. Feldman AM, Weitz H, Merli G, et al. The physician-hospital team: a successful approach to improving care in a large academic medical center. Acad Med. Jan 2006;81(1):35-41. Goleman D. Leadership That Gets Results. Harv Bus Rev. Vol 78; 2000:78. Lemieux-Charles LL. The effects of quality improvement practices on team effectiveness: A mediational model. J organ behav. 2002;23(5):533-553. Lemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. Jun 2006;63(3):263-300. Lobas JG. Leadership in academic medicine: capabilities and conditions for organizational success. Am J Med. Jul 2006;119(7):617-621. Building organizational supports for change. Crossing the quality chasm : a new health system for the 21st century. Ch. 5. Washington, D.C.: National Academy Press; 2001:111-144. Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. The roles of senior management in quality improvement efforts: what are the key components? J Healthc Manag. Jan-Feb 2003;48(1):15-28; discussion 29. Epstein AL. The state of physician leadership in medical groups. Group Practice Journal. February 2005 2005;54(2). Heifetz RA, Laurie DL. The work of leadership. Harv Bus Rev. Jan-Feb 1997;75(1):124-134. Holmboe ES, Bradley EH, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM.

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Characteristics of physician leaders working to improve the quality of care in acute myocardial infarction. Jt Comm J Qual Saf. Jun 2003;29(6):289-296. Kotter JP. What leaders really do. Harv Bus Rev. Vol 68; 1990:103. Martin WE, Keogh TJ. Managing medical groups: 21st century challenges and the impact of physician leadership styles. J Med Pract Manage. Sep-Oct 2004;20(2):102-106. Mosser NR, Walls RT. Leadership frames of nursing chairpersons and the organizational climate in baccalaureate nursing programs. Southern Online Journal of Nursing Research 2002. July 2002 2002;3(2):11. Rogers J. Aspiring to leadership--identifying teacher-leaders. Med Teach. Nov 2005;27(7):629-633. Savage GT, Blair JD. The importance of relationships in hospital negotiation strategies. Hosp Health Serv Adm. Summer 1989;34(2):231-253. Schulte T. Facilitating skills: the art of helping teams succeed. Hosp Mater Manage Q. Aug 1999;21(1):13-26. Schwartz RW, Pogge C. Physician leadership: essential skills in a changing environment. Am J Surg. Sep 2000;180(3):187-192. Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. Nov 2004;42(11):1040-1048. Wallin CJ, Meurling L, Hedman L, Hedegard J, Fellander-Tsai L. Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude. Med Educ. Feb 2007;41(2):173-180. Organizational Development and Process Planning Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75(7):708-717. O'Sullivan MJ. Strategic learning in healthcare organizations. Hosp Top. Summer 1999;77(3):13-21.

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Resident QI Project Themes Alcohol withdrawal treatment best practices

− February 2011: Judy Ashouri

Discharge process improvements

− November 2010: Marianne Yeung; March 2011: Hugh Keegan; July 2011: James Wantuck; August 2011: Mai Shiota; November 2011: Rena Patel; October 2012: Shanshan Bond; May 2012: Jane He; August 2012: Emilee Wilhelm; September 2013: Molly Kantor; September 2013: Shobha Stack; January 2014: Ping Wang; August 2014: Mala Mandyam

EPIC: utilization for documentation and BPAs

− July 2008: Jason Adams; April 2009: Crystal Evey; November 2009: Roni Brar; December 2013: Daniel Fang; September 2014: Justin Lofti (nutrition)

Engaging housestaff in quality and core measures

− September 2008: Chris Eversull; November 2008:Manali Patel; January 2009: John Kim; August 2009: Dan Brennen; September 2013: Wendy Caceres; December 2013: Daniel Fang; June 2014: Kirsten Brandt

Goals of care

− December 2008: Zach Koontz; January 2010: Sarah McGill; October 2011: Tyler Johnson; February 2012: Becky Chase

Hand hygiene compliance

− July 2009: Sidharta Sinha; August 2012: Wendy Caceres

Handovers and transfers (e.g. ICU, day to night team, outside records)

− May 2010: Chanu Rhee; November 2012: Annie Katz; September 2013: Wendy Caceres; March 2014: Robert Fairchild; July 2014: Thomas Lew; August 2014: Mike Turken; October 2014: Brian Dietrich

Impact of resident call schedules

− November 2013: Nathaniel Myall; James Barnes

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Resident Elective Syllabus 2014-2015; Page 29

MD-RN communication/ MD-RN rounding

− August 2008: Prateeti Khazanie; May 2009: Lily Kao; April 2011: Aaliya Yaqub; May 2011: Tyler Johnson; September 2011: David Iberri

Outpatient diabetes improvement

− August 2009: Ellen Eaton; April 2010: Kat Cheung

Patient satisfaction and experience

− December 2009: Troy Leo (teamcards); January 2012: Marilyn Tan (whiteboards); January 2013: Neera Narang (language placards); January 2014: Anna Postolova

Procedures: increasing resident confidence

− February 2009: Azar Mehdizadeh; June 2012: Jason Bartos

Sepsis identification and treatment best practices

− September 2009: Vickie Kelly; June 2010: Steve Pan; October 2010: Jessica Zhou; April 2012: Janet Leung

Value and Cost

− October 2009: Andy Samuelson; March 2012: Gurmeet Sran

Resident QI Publications M. Tan, K. Hooper, C. Braddock, L. Shieh, “Patient Whiteboards to Improve Patient Centered Care in the Hospital”, Postgrad Med J; 89(1056): 604-9, Oct 2013 J. Chen, D. Fang, L. Goodnough, K. Evans, M. Porter, L. Shieh, “Why providers transfer blood products outside recommended guidelines in spite of integrated electronic best practice alerts”, J Hospital Medicine, Jul 7, 2014 D. Fang, G. Sran, D. Gessner, P. Loftus, A. Folkins, J. Christopher, L Shieh, “The Effect of Cost and Turn-Around Time Display on Inpatient Ordering of Reference Laboratory Tests”, BMJ Qual Saf. Aug 27, 2014 K. Evans, W. Daines, J. Tsui, M. Strehlow, P. Maggio, L. Shieh, “Septris: A novel, mobile, online, game improves sepsis recognition and management”, accepted to Academic Medicine Innovation Jul 2014

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M. Kantor, K. Evans, L. Shieh, “Pending studies at hospital discharge: A pre-post analysis of an electronic medical record tool to improve communication at hospital discharge”, accepted to JGIM, Sept 2014 T. Garg, J. Lee, J. Chen, K Evans, L. Shieh. “Development of a best practice discharge checklist for hospital patients using the electronic medical record.” Accepted to Jt Comm J Qual Patient Safety, Oct 2014

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