Silent Bias: Challenges, Obstacles, and Strategies for Leadership Development in Academic Medicine-Lessons From Oral Histories of Women Professors at the University of Kansas.

PURPOSE: Despite dramatic increases in female learners and junior faculty, a significant gap remains in female leadership in academic medicine. To assess challenges and obstacles encountered, strategies for academic success, and lessons learned for leadership development, the authors conducted an in-depth study of women full professors. METHOD: The authors used a qualitative oral history approach, interviewing 87% of the cohort of female full professors at one Midwestern medical school in 2013 using a pretested, open-ended, semistructured interview guide. Interviews were videotaped and the audio recordings transcribed. Content was sorted into categories and key themes identified within each category. RESULTS: Participants described significant challenges: being treated with "silent bias," "being ignored," and being seen as an "other." Coping strategies included downplaying, keeping a distance, employing humor, and using symbols (e.g., white coat) to carefully present themselves. Explanations for success included intelligence, meritocracy, being even-tempered, and carefully constructing femininity. The participants recommended individual skills and actions to prepare for leadership development. Virtually all women could describe an individual mentor (sponsor), usually male, who provided essential assistance for their career success. At the same time, they stressed the importance of institutional support for diversity, especially with child care. CONCLUSIONS: Attaining "full professor" status is the pinnacle of academic success. Women who successfully navigated this academic ladder describe significant external and internal challenges that require multiple strategies to overcome. Leadership development entails a combination of individual support through mentors and sponsors, self-education and reflection, and organizational structural support to promote diversity.

Improved Knowledge, Attitudes, and Behaviors After Implementation of TeamSTEPPS Training in an Academic Emergency Department: A Pilot Report.

TeamSTEPPS is a validated, formal patient safety curriculum created by the Agency for Healthcare Research and Quality (AHRQ) for the development of high-functioning multidisciplinary teams. TeamSTEPPS was implemented in an academic emergency department (ED), including all ED hospital staff as well as physicians and residents. It was hypothesized that extensive interprofessional education combined with implementation of specific tools would increase knowledge of TeamSTEPPS principles, attitudes, and behaviors. The TeamSTEPPS knowledge test and the AHRQ Hospital Survey attitude test were administered at 0, 45, and 90 days after training. Behaviors were evaluated using an observation tool that was developed to document huddle occurrence. Knowledge and attitudes significantly improved 45 days from baseline (P < .05) and were sustained by day 90. In this pilot study, the implementation of TeamSTEPPS training in a multidisciplinary team in an academic ED led to increased knowledge and improved communication attitudes. Adoption of a specific behavior, the huddle, also was observed.

Aligning academic continuing medical education with quality improvement: a model for the 21st century.

The recent health care quality improvement (QI) movement has called for significant changes to the way that health care is delivered and taught in academic medical centers (AMCs). This movement also has affected academic continuing medical education (CME). In January 2011, to better align the CME and QI efforts of AMCs, the Association of American Medical Colleges (AAMC) launched a pilot initiative called Aligning and Educating for Quality (ae4Q). The goal of this pilot was to assist 11 AMCs as they moved to a more integrated model of continuous performance improvement by aligning their quality measurement and improvement with their continuing education endeavors. In this article, the authors describe the development of the ae4Q pilot and the resulting outcomes that have led to ongoing improvements.During the 18-month pilot, AAMC consultants conducted readiness assessments and on-site visits and provided consultation services and Web-based resources based on the AMC's needs. Following these interventions at each site, they then conducted both interviews with participants and postintervention assessment surveys to measure the impact of the pilot. Findings included demonstrated increases in the alignment of CME and QI, a greater use of quality data in CME design and delivery, and a greater use of CME as an intervention for clinical improvement. Two sites also attributed measureable improved clinical outcomes to their participation in the ae4Q pilot. The AAMC has used these findings to create resources and ongoing services to support AMCs as they pursue efforts to align QI and CME.

Reduction of venous thromboembolism (VTE) in hospitalized patients: aligning continuing education with interprofessional team-based quality improvement in an academic medical center.

PROBLEM: Despite clear prophylactic guidelines and national quality emphasis, a minority of hospitalized patients receive appropriate prophylaxis for venous thromboembolism (VTE). Data from the University of Kansas Hospital (KUH) revealed an unacceptably high incidence of VTE. APPROACH: The authors aligned continuing education with quality improvement through formation of an interprofessional, multidisciplinary team to develop strategic educational and system operational plans to decrease VTE incidence. The authors reviewed 261 charts with the secondary diagnosis of VTE for identification of themes or causes of VTE to develop multipronged educational and system-based action plans. The authors reviewed a "menu" of evidence-based content delivery techniques to develop the educational plan. Multiple noneducational adjunct system strategies were also developed and implemented. OUTCOMES: After implementation of all specific action plans, the KUH VTE incidence decreased 51% from November 2010 to June 2012 (from 12.68 to 6.10 per 1,000 patients). Insertion of peripherally inserted central catheters, a common identified theme, dropped from almost 360 insertions in December of 2010 to less than 200 insertions in April 2012. NEXT STEPS: Aligning continuing education with quality improvement through an interprofessional, multidisciplinary team approach was associated with a decrease in VTE. The authors describe challenges and lessons learned to inform implementation of similar quality-improvement-driven continuing education initiatives elsewhere. Challenges included time, resources, multiple service lines, and departments with variable acceptance of data. Lessons learned included the value of leadership commitment, interprofessional team work, assessing individual data, expertise of continuing education, using multiple educational methods, and the need for overall champions.

Millennial health care: change you can believe in.

A millennium is 1,000 years. In little over a decade after the beginning of the new millennium in 2000, remarkable changes have occurred in health-care education and health-care delivery. A new millennial generation of students, trainees, junior faculty, and young practicing physicians has come of age. The numbers of women in medicine have vastly increased. Technology has impacted education with an array of educational content-delivery techniques vastly different from the usual broadcast method of teaching. New curricula have expanded to encompass teamwork with interprofessional education of the entire team. Outcomes of educational efforts now include not only knowledge transfer but also performance improvement. Delivery of health care is also dramatically different. The sentinel driver of the quality and patient safety moment, To Err Is Human, was published only 12 years ago, yet fundamental changes in expectations and measurement for health-care quality and safety have occurred to alter the health-care landscape. Financing health care has become a prime issue in the current state of the US economy. New themes in health-care delivery include teamwork and highly functioning teams to improve patient safety, the dramatic increase in palliative care and end-of-life care, and the expanded role of nursing in health-care delivery. Each issue emanating since the beginning of the millennium does not have a right vs wrong implication. This discussion is an apolitical "environmental scan" with the purpose of illuminating these dramatic changes and then outlining the implications for health-care education and health-care delivery in the coming years.

Characteristics of quality and patient safety curricula in major teaching hospitals.

The authors recently discovered 2 quality and patient safety curricula for internal medicine and general surgery residents in major teaching hospitals: an infrequent formal curriculum developed by the university and a positive informal curriculum found in the teaching hospital. A hidden curriculum was postulated. These data were gathered through applied qualitative research methodology. In this article, curricular characteristics of the formal, informal, and hidden curricula are described and analyzed. Themes evaluated were planning, delivery, evaluation, drivers, responsible entity, and resources. The data show different curricular characteristics in each theme, especially for the formal and informal curricula. Understanding curricular characteristics represents the next step in understanding the environments of resident quality and safety learning, especially in the academic hospital setting. Aligning the formal and informal curricula as well as leveraging all curricula could improve educational venues for quality and safety and institutional clinical performance, and promote a learning health care system.

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?

PURPOSE: The relationship of the quality of teaching hospitals' clinical performance to resident education in quality and patient safety is unclear. The authors studied residents' knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital's quality status, residents' curriculum, and the residents' understanding of quality. Residents' definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents' learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents' curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

The relationship between evidence-based practices and survival in patients requiring prolonged mechanical ventilation in academic medical centers.

Studies suggest variable adoption of evidence-based practice guidelines. The authors hypothesized that compliance with guidelines for patients requiring mechanical ventilation would vary among academic medical centers and that this variation might be associated with survival. A total of 1463 intensive care unit cases receiving continuous mechanical ventilation for >96 hours were reviewed. The variation in mortality based on compliance with 6 evidence-based practices was determined, and the effect of each intervention was estimated using a logistic regression model. Compliance varied widely across the participating centers. A strong association with survival was seen for 2 of the 6 practices: sedation management and glycemic control (odds ratios for death of 0.30 and 0.46, respectively, each P < .01). Spontaneous breathing trials, deep venous thrombosis prophylaxis, semi-recumbent positioning, and stress ulcer prophylaxis were not associated with survival in the model. More consistent adoption of these practices represents an opportunity for academic medical centers and was associated with enhanced survival.