Providing effective inpatient care for cirrhosis by improving utilization of national guidelines.

BACKGROUND: Over the past 10 years, cirrhosis incidence has increased dramatically, with a 59% increase in the need for treatment of disease complications. Cirrhosis treatment complexity and cost have increased substantially, and cirrhosis deaths are increasing by 10.5% yearly. LOCAL PROBLEM: A review of 29 cirrhosis admissions revealed that guideline criteria were only addressed 66% of the time on 10 key cirrhosis issues. After identifying gaps in care, the project aimed to improve right care for cirrhosis by 20% within 90 days by using a guideline-based checklist and chart audit process. METHODS: The quality improvement (QI) initiative used four Plan-Do-Study-Act cycles. Cycles included tests of change for the checklist, patient engagement, chart audit, and team participation. INTERVENTIONS: A guideline-based cirrhosis checklist focused on providing right care for cirrhosis patient admissions. Patient engagement was addressed with a shared decision-making tool. To monitor data, a chart audit was created. Team engagement included biweekly QI meetings with an agenda and a postmeeting survey. RESULTS: The project aim was achieved, improving cirrhosis guideline-based care by 22%, while utilization of the guideline-based checklist rose to 100%. Moreover, 96% of patients approached for shared decision making agreed to participate, and the chart audit was completed on all patients. Team engagement and satisfaction remained high throughout the cycles. CONCLUSIONS: The project team used an evidence-based approach to effectively improve inpatient care for cirrhosis. Engaging providers and patients with this approach led to high patient and team participation and improved project outcomes.

Developing the Capacity for Rapid-Cycle Improvement at a Large Freestanding Children's Hospital.

BACKGROUND: To develop the capacity for rapid-cycle improvement at the unit level, a large freestanding children's hospital designated 2 inpatient units with normal patient loads and workforce as pilot "Innovation Units" where frontline staff was trained to lead rigorous improvement portfolios. METHODS: Frontline staff received improvement training, and interdisciplinary teams brainstormed ideas for tests of change. Ideas were prioritized using an impact-effort evaluation and an assessment of how they aligned with high-level goals. A template for each test summarized the following: the opportunity for improvement, the test being conducted, dates for the tests, driver diagrams, metrics to measure effects, baseline data, results, findings, and next steps. Successful interventions were implemented and disseminated to other units. RESULTS: Multidisciplinary staff generated 150 improvement ideas and Innovation Units collectively ran >40 plan-do-study-act cycles. Of the 10 distinct improvement projects, elements of all 10 were deemed "successful" and fully implemented on the unit, and elements from 8 were spread to other units. More than 3 years later, elements of all of the successful improvements are still in practice in some form on the units, and each unit has tested >20 additional improvement ideas, using multiple plan-do-study-act cycles to refine them. CONCLUSIONS: The Innovation Unit model successfully engaged frontline staff in improvement work and established a sustainable system and framework for managing rigorous improvement portfolios at the unit level. Other hospitals and health care delivery settings may find our quality improvement approach helpful, especially because it is rooted in the microsystem of care delivery.

The Role of Organizational Context in the Creation and Sustainability of Dental Faculty Development Initiatives.

Dental faculty development programs exist for a variety of reasons: to improve teaching skills, develop and reinforce relationships among colleagues and mentors, foster career development, and support curricular initiatives and institutional priorities. These activities impact individual faculty members as well as the institutions in which they work. Each institution has a distinct culture that should be acknowledged and understood alongside conventional outcome measures. As such, this article provides an expanded view of faculty development programming, associated educational activities, and related organizational changes at the College of Dentistry, New York University (NYU) since 2005. Contextual factors include the existence of an Office of Professional Development established in 1999, an Academy of Distinguished Educators founded in 2010, and other programs for present and future educators that support the college's educational mission. Outcomes include a comparison study of one program, the creation of new courses, the sustainability and expansion of existing programs, participants' retention rate, and an increase in awards and other educational accomplishments such as publication of abstracts, oral presentations, and related activities by NYU faculty at national forums in dental education.

Long-term follow-up of a dental faculty development program.

Many, if not most, dental faculty members have not received formal training to be educators. However, the importance of faculty development programs in improving teaching skills, fostering career development, and reinforcing relationships with colleagues and mentors has increasingly been acknowledged. In 2005, the Excellence in Clinical Teaching Program at New York University College of Dentistry (NYUCD) was created to enhance the clinical teaching skills of NYUCD faculty members. As of spring 2009, fifty-nine faculty members had participated in eight separate cohorts. The program consists of five formal group sessions supplemented by readings, reflection papers, and a final project. This study examined the short- and long-term effectiveness of the program. Participants were asked to complete a short pre-program survey to self-assess their teaching abilities and, at the last session, a satisfaction survey. In fall 2011, forty-eight faculty members who completed the program from spring 2005 to fall 2009 and were actively teaching at least one session a week at NYUCD were asked to complete a follow-up survey asking about the long-term value of the program and their academic career progression since program completion. Thirty-three faculty members responded for a response rate of 69 percent. Ninety-seven percent of the respondents indicated they would recommend the program to their colleagues, 94 percent said program participation led to a greater likelihood of conferring with peers about teaching issues,79 percent had increased their teaching responsibilities, and 62 percent said that presenting the final project improved their presentation skills. In addition, the retention rate of those still teaching at the school (81 percent) exceeds national retention rate averages for dental faculty. This follow-up study suggests that participation in the Excellence in Clinical Teaching Program is associated with meaningful professional growth.

The impact of occlusal function on structural adaptation in alveolar bone of the growing pig, Sus Scrofa.

OBJECTIVES: this study investigated the effects of growth and tooth loading on the structural adaptation of the developing alveolar bone adjacent to the tooth root as the tooth erupted into function. Growth and occlusal function were expected to lead to increased alveolar bone density. Meanwhile, the supporting alveolar bone was expected to develop a dominant trabecular orientation (anisotropy) only after occlusal loading. DESIGN: minipigs with erupting and occluding mandibular first molars (M(1)'s) were used to study the effects of growth and occlusal function on developing alveolar bone structure through comparison of alveolar bone surrounding M(1)'s. A second minipig model with one side upper opponent teeth extracted prior to occlusal contact with the M(1) was raised until the non-extraction side M(1)'s developed full occlusal contact. The comparisons between extraction and non-extraction side M(1) alveolar bone were used to emphasize the impact of occlusal loading on alveolar bone structure. Specimens were scanned on a Scanco Medical µCT 20 at a 22µm voxel resolution for structural analysis. RESULTS: with growth and occlusal function a distinct alveolar bone proper tended to develop immediately adjacent to the tooth root. The cancellous bone had thicker but fewer and more separated trabeculae after growth or occlusal loading. On the other hand, occlusal function did not lead to increased alveolar structural anisotropy. CONCLUSION: during tooth eruption, growth and masticatory loads effect structural change in alveolar bone. The impact of occlusal function on cancellous bone anisotropy may need a more extensive period of time to demonstrate.

Evolution of a Rapid Hydration Protocol.

The Oncology Division of the Children's Hospital of Philadelphia (CHOP) embarked on a comprehensive project to reduce chemotherapy errors. Careful review of all systems revealed many areas for improvement. Using a unique systems improvement approach, the interdisciplinary team carried out many concurrent change projects. This article describes a project carried out by the nursing staff to improve the safety of chemotherapy administration. Nurses realized that the majority of chemotherapy infusions occurred in the evening and nighttime hours after prolonged prehydration, leading to many "handoffs" and possibilities for error. Nurses developed a novel method of prehydration, delivering a large volume of fluid in a rapid infusion. The "Rapid Hydration Protocol" greatly reduced duration of hydration without adverse effects. Rapid hydration decreased the time needed for hydration and the number of nurses involved in the first day of chemotherapy, and contributed to having chemotherapy begin earlier. The project achieved the goals of improving systems and reducing handoffs. The impact of this project, in combination with the widespread efforts of the error reduction team at CHOP contributed to significant improvements in chemotherapy safety. Nurses developed and tested this innovative hydration strategy, which continues to be very effective.

Multidisciplinary systems approach to chemotherapy safety: rebuilding processes and holding the gains.

PURPOSE: The problem of medication safety came to public attention largely through a chemotherapy error, and the high toxicity and low therapeutic index of anticancer medications make safety in their prescription and administration critical. We have undertaken a thorough revision of our systems for inpatient chemotherapy. METHODS: We participated in a multi-institutional collaborative effort of the Institute for Healthcare Improvement, and used their rapid cycle change method. Particularly powerful systems change concepts were driving out fear, "trapping" errors and learning from them, focusing on outcome rather than on input, simplifying and standardizing, using constraints and "forcing functions," reducing handoffs, and paying attention to human factors. RESULTS: Applying these concepts to our chemotherapy delivery system, we have achieved an 84% decrease in the number of chemotherapy errors that actually reach patients per 1,000 chemotherapy doses, and have sustained that improvement for 5 years. CONCLUSION: Factors contributing to our success include the rapid cycle change method, strong support from hospital administration, grassroots participation, and a tradition of interdisciplinary cooperation. Computerized direct physician order entry and cooperative group participation have had mixed effects. Continued efforts at improvement have been key to holding our gains. Although specific problems and changes may not be relevant to other organizations, the concepts and methods we used are generally applicable.