Class of 2015 Abstract / Objectives: To analyze the state of quality improvement (QI) education across ACPE-accredited pharmacy schools in the United States. Methods: Stage one of data collection consisted of an inspection of each pharmacy school website to reveal the presence of published QI curriculum or other related content. In the second stage, an e-mail questionnaire was sent to one representative of each of the 129 accredited schools in the U.S. who was interested in or who teaches QI at his/her school. Respondents could complete the questionnaire via: 1) electronic; 2) paper; or 3) phone. Later, the questionnaire was shortened and a raffle was initiated to increase response rate. The survey instrument contained both multiple choice and open-ended items. Results: Sixty responses were returned from the 129 accredited schools (47% response rate). The least-covered QI topics in respondents’ QI curricula were: Quality dashboards and sentinel systems (30%); Six-sigma, or other QI methodologies (45%); Measures of safety and quality (57%); Medicare Star measures (a national measurement program) and payment incentives (58%); and How to implement changes to improve quality (60%). More private schools covered Adverse Drug Events than public schools (p=0.039). Requiring a specific QI class was more likely in private schools (p=0.003) while requiring a QI project was more often reported by public schools (p=0.014). Conclusions: To the investigators’ knowledge, this is the first national study to map QI education in U.S. pharmacy schools. These results will inform pharmacy and other health-related professional programs in the integration of QI concepts into their curriculum.

Evaluation of quality of surgical care begins with the Donabedian triad focusing on structure, process, and outcomes. Outcomes, which are inherently patient-centered, are most easily and commonly measured, and are indeed fundamental to evaluating the quality of surgical care. Specifically, post-operative adverse events (AEs) remain the most frequently measured and reported outcomes, as they represent harm to the patient; and thus, are often used as a means for comparing institutional, as well as, individual surgeon performance. The importance of rigorous recording of clearly defined AEs, although widely recognized, is poorly performed in practice. In previous work, created in accordance to the Clavien-Dindo classification, we developed and integrated a classification of Thoracic Morbidity & Mortality (TM&M) within The Ottawa Hospital’s Division of Thoracic Surgery allowing objective and standardized assessment of all post-operative AEs following all surgeries. In this thesis, the complementary studies that were conducted surrounding the continued clinical application and critical appraisal of the TM&M classification system as a means toward quality improvement are described. Using standardized reporting of both incidence and severity of post-operative complications, we first provide an overview of the burden and distribution that the two most pervasive post-operative AEs have on the thoracic surgical patient population, including prolonged alveolar air leak and atrial fibrillation (Chapter I and II). Next, we explore the inter-system reliability of reported AEs following thoracic surgery from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), which is widely considered the most prominent surgical quality improvement effort, and the TM&M classification system in order to better understand to what extent the methods used to collect data may be impacting results (Chapter III). The disparity between the two systems and the duplicate participation indicates distinct value to the two quality reporting systems. An absence of evidence in the literature regarding individual surgeon outcome reporting and its impact on the quality of care prompted us to create risk-adjusted, surgeon-specific outcome reports to enable individualized performance measurement and feedback (Chapter IV). A priority for the division has been to ensure such measurement translates into reproducible improvements in surgical performance. To do so, we implemented complementary continuous quality improvement seminars to provide an additional forum for discussion regarding collective results, utilizing positive deviance, to unmask best performers as a catalyst for discussing practice measures to improve specific AEs. Lastly, an evolutionary understanding of the heterogeneity of TM&M data was considered as a critical next step to following improvements in care (Chapter V). Recognizing that software was necessary to efficiently record and review TM&M data, iterative development led to an evolution of a real-time, web-based, point-of-care Thoracic Surgery Quality monitoring, Information management, and Clinical documentation (TSQIC) software system. The TSQIC system has enabled bedside data recording and storage, and automated dynamic analysis and reporting of surgical volume and quality. We observe that measurement of TM&M data alone, while necessary, is not sufficient for quality improvement. We suggest that in addition to implementing a complementary point-of-care, interactive, web-based quality monitoring system, key factors for improving quality and patient safety include a combination of temporal analyses of AEs, effective surgeon-specific feedback mechanisms, actionable information based on best practice measures, standardization of case reviews, and a unit-based approach conducive of team-work and safety culture, led by open and collegial dialogue.

Background: Previous research has identified four distinct developmental stages associated with organizational learning in high-performing hospital units: identity and ownership, team and respect, accountability and support, and reliability and sustainability. We designed a research instrument to measure these constructs. The purpose of this thesis was to establish the content and predictive validity of this instrument.Methods: The Organizational Learning Development Instrument (OLDI) consists of a total of 35 items in Likert-scale format. Item-level and instrument-level content validity were assessed using three cycles of cognitive interviewing with 28 nurses, and eight expert ratings. The OLDI was administered to nurses in Magnet® hospitals via a web-based survey. National Database of Nursing Quality Indicators (NDNQI) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) reports were used for comparison of hospital performance. Predictive validity was tested using multiple linear regression. Based on a power analysis for multiple linear regression, reaching 80% power, with a medium effect size of 0.15, an alpha of 0.05, and five predictor variables, the target sample size was 92 hospital units.Results: Results from 63 inpatient units in 11 Magnet® hospitals were used. The scale- level content validity for this instrument was 0.95 and item-level content validity index scores ranged from 0.86 to 1.0, suggesting excellent content validity. No significant relationships were found between OLDI results and NDNQI measures. Significant correlations (P<.05) were found between several OLDI constructs and HCAHPS composites.Discussion: Correlations with HCAHPS scores help validate the OLDI, as well as the theory underlying the instrument. The OLDI may not have predicted NDNQI measures due to a lack of instrument sensitivity or because NDNQI results are strongly influenced by other factors. Nurse managers can use the OLDI to predict unit performance related to patient satisfaction and to determine actions that may improve unit performance. Replicating this study with a larger sample size and more diverse hospital performance and more uniform unit type could further validate this instrument.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23384号 / 社医博第117号 / 新制||社医||11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 佐藤 俊哉, 教授 滝田 順子, 教授 万代 昌紀 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Title: The path(way) to a clean colon: Improving the management of functional constipation Authors: Sarah Nichols, D.O. Pediatrics Resident, Nathan Justice, M.D. Pediatrics Hospital Medicine, Anjali Malkani, M.D. Pediatric Gastroenterology, David Wood, M.D., MPH General Pediatrics and Adolescent Medicine Purpose / Objectives: Hospitalization for the treatment of functional constipation is a leading cause among encounters that incur a financial loss at our institution. There are few resources that describe best practices or quality improvement efforts in the management of children who are hospitalized with functional constipation. A clinical pathway was implemented to promote interventions that improve hospital resource utilization for this group of children. Design / Methods: A clinical pathway was developed by a multidisciplinary team of stakeholders. The pathway emphasized interventions known to improve resource utilization and believed to facilitate a more effective and efficient cleanout. The inpatient arm of the pathway was implemented on a 24-bed medical/surgical unit; members of the medical and clinical staff of this unit received education with dissemination of the pathway. An electronic order set was implemented concurrently to facilitate practitioners’ application of pathway recommendations. Plan-Do-Study-Act (PDSA) cycles were used to monitor process measures and outcomes. Inpatient utilization was selected as the primary outcome for this effort’s first iteration; length of stay and frequency of readmissions were monitored as a secondary outcome and balancing measure, respectively. Results: Pathway utilization reached 65% within two periods of implementation. Adherence to selected process measures exceeded 80% within two periods. Inpatient utilization demonstrated initial improvement, increasing from 20% at baseline to 50% post-implementation; however, it subsequently fell below baseline performance after third-party payers revised admission criteria during period 6. Length of stay and frequency of readmissions remained unchanged post-intervention. Conclusion / Discussion: A clinical pathway for the treatment of functional constipation was quickly adopted by clinicians within two periods of implementation (spanning two months). The pathway was effective at promoting interventions that improved inpatient utilization; however, these improvements could not be sustained in the face of an unanticipated, external force. Future improvement cycles will be directed at reducing the length of stay to improve hospital resource utilization.

BACKGROUND AND OBJECTIVES: East Tennessee State University’s (ETSU) Department of Family Medicine initiated Quality Improvement (QI) training in its three residency programs in 2008. The purpose of the project was to develop, implement, and assess a formal curriculum and experiential learning process to train family medicine residents in QI knowledge and skills. METHODS: Family medicine faculty members received training in QI theory and design. Rising second-year residents received a daylong workshop on the basics of QI principles. Residents worked in teams to develop and implement QI projects. Self-assessed QI proficiency was measured prior to and immediately following the workshop. QI knowledge was assessed with the Quality Improvement Knowledge Application Tool (QIKAT) at baseline and following project completion. RESULTS: Two groups of residents (n=37) received training and completed at least 1 year on their projects. Analyses revealed that residents’ self-assessed QI proficiency improved after receiving a day-long training workshop and was consistent for both groups of resident training. Application of QI knowledge as assessed by the QIKAT did not improve following QI project participation in resident Group 1 but did improve in resident Group 2. CONCLUSIONS: A formal QI curriculum was successfully developed and implemented into three family medicine residency programs. Residents’ QI knowledge and skills improved following training and experience conducting QI projects. Faculty and resident commitment to the program and competing time demands proved challenging to the introduction of QI training. Future studies should assess residents’ sustained learning and translating QI residency experiences into practice.

Objective: To develop and implement a formal didactics and experiential curriculum to train Family Medicine (FM) residents in Quality Improvement (QI) knowledge and skills. Method: 1) All FM faculty participated in seven workshops on QI theory and design. 2) All second year residents received a day-long workshop on knowledge and skills of QI and conducted QI projects for up to two years. Results: Knowledge and confidence scores significantly improved following training, p

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