Enhancing Resident Education by Embedding Improvement Specialists Into a Quality and Safety Curriculum.

Background: Quality improvement and patient safety (QIPS) curricula are critical in graduate medical education, yet barriers limit the educational experience and project outcomes. Objective: To explore the impact of QIPS curricular enhancements and integration of continuous improvement specialists (CIS) by examining the A3 document, the primary project product and surrogate for project quality. Methods: Since 2009, University of Michigan internal medicine and medicine-pediatric residents participate in a QIPS curriculum, which includes a 4-week group project. In 2016, residency leaders collaborated with CIS staff, non-clinical experts in QIPS with backgrounds in engineering and business, to improve the curriculum. Informed by a needs assessment, the intervention was implemented in 2017 and consisted of a set of enhancements including integration of CIS staff into groups as co-facilitators. In this retrospective cohort study, a blinded reviewer evaluated all available A3 documents before and after the intervention using a quantitative analysis tool. Results: All residents participated in the curriculum during the pre-intervention (July 2009 to June 2016, n=351) and post-intervention (July 2017 to June 2020, n=148) periods. A total of 23 of 84 (27%) pre-intervention and 31 of 34 (91%) post-intervention A3 documents were available for review. Scores improved significantly for 17 of 23 (74%) A3 items and for 7 of 8 (88%) sections. Mean A3 total scores increased from 29.0 to 47.0 (95% CI 12.6-23.4; P<.001) out of a possible 69.0. Conclusions: Embedding CIS experts into residency QIPS curricula is associated with improved A3 document quality.

Novel combined patient instruction and discharge summary tool improves timeliness of documentation and outpatient provider satisfaction.

BACKGROUND: Incomplete or delayed access to discharge information by outpatient providers and patients contributes to discontinuity of care and poor outcomes. OBJECTIVE: To evaluate the effect of a new electronic discharge summary tool on the timeliness of documentation and communication with outpatient providers. METHODS: In June 2012, we implemented an electronic discharge summary tool at our 145-bed university-affiliated Veterans Affairs hospital. The tool facilitates completion of a comprehensive discharge summary note that is available for patients and outpatient medical providers at the time of hospital discharge. Discharge summary note availability, outpatient provider satisfaction, and time between the decision to discharge a patient and discharge note completion were all evaluated before and after implementation of the tool. RESULTS: The percentage of discharge summary notes completed by the time of first post-discharge clinical contact improved from 43% in February 2012 to 100% in September 2012 and was maintained at 100% in 2014. A survey of 22 outpatient providers showed that 90% preferred the new summary and 86% found it comprehensive. Despite increasing required documentation, the time required to discharge a patient, from physician decision to discharge note completion, improved from 5.6 h in 2010 to 4.1 h in 2012 (p = 0.04), and to 2.8 h in 2015 (p < 0.001). CONCLUSION: The implementation of a novel discharge summary tool improved the timeliness and comprehensiveness of discharge information as needed for the delivery of appropriate, high-quality follow-up care, without adversely affecting the efficiency of the discharge process.

Chemotherapy-induced apoptosis of S-type neuroblastoma cells requires caspase-9 and is augmented by CD95/Fas stimulation.

Stromal or S-type tumor cells are a distinct lineage found in neuroblastoma tumors and have an important role in the biology of this disease. Anticancer agents induce apoptosis through death receptor- and mitochondria-initiated pathways. The object of this work was to determine the involvement of these pathways in the response to doxorubicin (Dox) and cisplatin (CDDP) in S-type neuroblastoma cells. Both drugs activated caspase-9 and caspase-3 but not caspase-8. Caspase-9-specific inhibition blocked S-type cell death induced by Dox. SH-EP1 cells transfected to express dominant negative mutant caspase-9, but not those expressing DN caspase-8, were resistant to Dox- and CDDP-induced apoptosis. The lack of caspase-8 involvement in chemotherapy-induced death was not the result of an intrinsic inability of these cells to activate this enzyme because when they were treated with tumor necrosis factor-related apoptosis-inducing ligand, caspase-8 was activated. We also found that both drugs up-regulated CD95/Fas expression but that CD95/Fas signaling was not necessary for cell killing. Experiments testing the response of chemotherapy-treated cells to agonists of the CD95/Fas receptor established that Dox and CDDP treatment sensitizes cells to CD95/Fas killing. Together, these results are consistent with a model in which caspase-9 is of central importance in the death mechanism utilized by these drugs in S-type cells. Although the death response is not dependent on CD95/Fas, concomitant stimulation of this receptor amplifies the death response in drug-treated cells.