• AAMC Patient Safety and Quality Resources
  https://www.aamc.org/initiatives/cei/quality/52456/qi_learning.html Provides links for professional development in quality improvement and patient safety from various organizations.

• AAMC Strategic Initiatives
  https://www.aamc.org/initiatives Links to the AAMC’s strategic initiatives, including Integrating Quality and Redesigning Care Delivery, including opportunities for faculty development.

• AHRQ Quality Indicators https://www.ahrq.gov/professionals/systems/hospital/qitoolkit/index.html The Agency for Healthcare Research and Quality has developed healthcare quality indicators using inpatient hospital data.

• ASQ Quality Tools and Recourses
  http://asq.org/learn-about-quality/tools-templates.html Fishbone, flow map, control chart, FMEA, etc.

• Center for Patient Safety http://www.centerforpatientsafety.org/toolkits/ Toolkits to address common issues in the inpatient setting.

• Healthcare Quality and Patient Safety https://health.gov/hcq/ Contains computer-based video simulation training modules, such as “Partnering to Heal” about healthcare associated infections and “Pathways to Safer Opioid Use”.

• VA QUERI - Quality Enhancement Research Initiative https://www.queri.research.va.gov/implementation/quality_improvement/tool.cfm Resource providing information and recommendations on commonly used methods and tools that is searchable based on identified needs.

"Atul Gawande: How do we heal medicine?"

• ACGME http://www.acgme.org

• Agency for Healthcare Research and Quality http://www.ahrq.gov

• Choosing Wisely http://www.choosingwisely.org

• IHI Open School http://www.ihi.org/offerings/IHIOpenSchool/overview/Pages/default.aspx

• MedEd Portal http://www.mededportal.org

• National Quality Forum http://www.qualityforum.org

• Society to Improve Diagnosis in Medicine   http://www.improvediagnosis.org/

 Update on Quality at National Meeting

• Pre-meeting QI Course: At the 2017 SGIM Annual Meeting, a full-day quality improvement (QI) course was presented for the sixth consecutive year.  The course applied QI techniques to practice redesign opportunities.  Past course curricula are available in the GIM Connect community for participants or contact Nate Spell at nspell@emory.edu.

• 2017 Award for Outstanding Quality and Patient Safety Oral Presentation was presented to John Mafi, et al. for his abstract “Evaluation of a Choosing Wisely Intervention to Reduce Low Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety Net Health System.”

Revised Quality Improvement Knowledge Assessment Test (QIKAT-R) - Singh, MK et al. The Quality Improvement Knowledge Application Tool Revised (QIKAT-R). Acad. Med. 2014 [http://journals.lww.com/academicmedicine/fulltext/2014/10000/The_Quality_Improvement_Knowledge_Application_Tool.26.aspx]
      For more information including the scenarios, case prompts, and scoring rubric, contact Dr. Singh at       mks11@case.edu

Morbidity and Mortality Conference incorporating Root Cause Analysis - Tad-y DB et al. Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety. Acad. Med. 2016 [http://journals.lww.com/academicmedicine/Abstract/2016/09000/Leveraging_a_Redesigned_Morbidity_and_Mortality.23.aspx]
      For more information including the handout and format used at our institution, contact Dr. Dullet at       swdullet@health.southalabama.edu

Upcoming Events: Practice Redesign Pre-Course at the 2018 SGIM Annual Meeting

• Langley, G et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd Ed. Jossey-Bass Publishing (a Wiley Co.). 2009.  This guide offers a framework and suggestions to improve quality and productivity applicable to a variety of fields including healthcare.

• Ogrinc, G et al. Fundamentals of Healthcare Improvement: A Guide to Improving Your Patients’ Care. 2nd Ed. Joint Commissions Resources. 2012. Provides an overview of the basics of quality improvement with a focus on the interprofessional approach to solving issues.

• Wachter R. Understanding Patient Safety. 2nd Ed. Lange Publishers; 2012. Ideal for a novice clinician educator in patient safety.

• Dekker S. The Field Guide to Understanding Human Error Investigation. 3rd Ed. Ashgate Publishers; 2014. Useful for anyone leading medical error investigations or root cause analyses such as for someone leading a morbidity and mortality conference.

• Fondahn, E et al.  The Washington Manual of Patient Safety and Quality Improvement.  1st Ed.  Wolters Kluwer; 2016.  This book provides an overview of patient safety and quality improvement as well as how to apply these        principles to a variety of clinical settings.

QI/PS Education:

• Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press. 2000
  [http://nationalacademies.org/hmd/reports/1999/to-err-is-human-building-a-safer-health-system.aspx?_ga=2.214171799.140773810.1506715815-169244089.1506715815]
           This article and the statistics are credited by some as starting our modern day quality improvement          movement.

• Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press. 2001
  [http://nationalacademies.org/HMD/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx]
           This article discusses the six dimensions of quality - safe, timely, effective, efficient, equitable, and          patient-centered.

• Nasca T et al. The next GME accreditation system – rationale and benefits. N Engl J Med. 2012 [http://www.nejm.org/doi/full/10.1056/NEJMsr1200117#t=article]
           This article discusses the six core areas for CLER visits (safety, quality, transitions, duty hours,          professionalism, and supervision).

• Leape L. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Report of the Lucian Leape Institute Roundtable on Reforming Medical Education. NPSF. 2010
  [http://www.npsf.org/?page=unmetneeds]
  This article can help with the development of a quality and safety curriculum at your institution.

QI:

• Donabedian A. The quality of care. How can it be assessed? JAMA 1988
  [http://jamanetwork.com/journals/jama/fullarticle/374139]
           This landmark article describes the structure and framework for quality measures.

• McGlynn EA  et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 [McGlynn EA  et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348: 2635-2645]
           This study looked at the medical records for several thousand patients seen in the outpatient setting and determined whether or not they had received the recommended care.

PS:

• Wachter RM, Learning from our mistakes: Quality Grand Rounds, a New Case-Based Series on Medical Errors and Patient Safety. Ann Intern Med. 2002
  [http://annals.org/aim/article/715321/learning-from-our-mistakes-quality-grand-rounds-new-case-based]
           This article discusses the Quality Grand Rounds series from the Annals of Internal Medicine.

• Leape L. Error in Medicine. JAMA. 1994
  [http://jamanetwork.com/journals/jama/fullarticle/384554]
           This landmark article is one of the initial articles written on patient safety and medical error in the          healthcare industry.

• Croskberry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad. Med. 2003
  [http://journals.lww.com/academicmedicine/Fulltext/2003/08000/The_Importance_of_Cognitive_Errors_in_Diagnosis.3.aspx]
           This article focuses on cognitive errors and ways to reduce them through “cognitive debiasing.”

• Starmer AJ, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014
  [http://www.nejm.org/doi/full/10.1056/NEJMsa1405556#t=article]
           This article discusses use of the I-PASS Handoff Bundle for handoffs to reduce medical errors at several academic hospitals.

Professional Development:

• SGIM Pre-course on Quality
           Offered annually and aimed at application of basic QI approaches to common problems encountered in the          practice of medicine.

• SHM Quality and Safety Educators Academy (QSEA)
           http://shmqsea.org/          Aimed at providing medical educators of students or residents with knowledge and tools to integrate QI and PS concepts into curricula.

• Karasik AS et al. Training in quality and safety: the current landscape.  AJMQ 2014
           [http://journals.sagepub.com/doi/abs/10.1177/1062860614544194?url_ver=Z39.88-2003&          rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&]
           Details quality and safety training programs available to physicians in the US.

• Mochan E and Nash D.  Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography.  AJMQ 2014
           [http://journals.sagepub.com/doi/full/10.1177/1062860614528568]
           Describes literature to 2014 related to professional development in areas related to quality and safety, such as longitudinal mentorship, culture of safety/transparency, engagement of patients/families, safety systems, etc.

• Johns Hopkins Armstrong Institute for Patient Safety and Quality           http://www.hopkinsmedicine.org/armstrong_institute          Offers online training programs, conferences and webinars including an online Patient Safety Certificate Program

• VA Quality Scholars Fellowship Program
           (https://www.vaqs.org/)

  • Training program in quality improvement and patient safety at the United States Department for Veterans Affairs. The mission of the VA Quality Scholars program is to develop leaders, researchers, and educators who will lead the way in quality improvement healthcare.

  • Consists of eight sites across the United States, as well as an affiliate site in Toronto, Canada. Each site in the US consists of partnerships between a VA hospital and academic affiliates.

  • Includes physicians and pre- and post-doctoral nurses as fellows who participate in an interprofessional curriculum. Each site is directed by two Senior Scholars, an accomplished academic physician and doctoral-prepared nurse, and one or more other faculty experienced in mentoring and research in health care quality and patient safety.  Mentoring is a critical part of the program and faculty view each fellow as an individual with unique needs.