TIGER Team: Rapid Response at the University of Missouri.

By the end of the 20th century, health care organizations worldwide were recognizing the benefits of a quick response when patients were experiencing a clinical decline and the difficulty in achieving that goal. The University of Missouri STAT Nurse program, developed in 1989, was an early innovation to deliver the "right care" at the "right time" every time. Over the years, the STAT Nurse program evolved and became the core component of a Rapid Response System. Today Rapid Response at University of Missouri Health Care is called the Targeted Interventional Group Emergency Response Team, also known as the TIGER Team after the much beloved University mascot.

The Quality Improvement Knowledge Application Tool Revised (QIKAT-R).

PURPOSE: Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the "QIKAT-R." METHOD: Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: "excellent," "fair," and "poor." Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses. RESULTS: Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between "poor" and "excellent" responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale. CONCLUSIONS: The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.

Caring for our own: deploying a systemwide second victim rapid response team.

A unique rapid response system was designed to provide social, psychological, emotional, and professional support for health care providers who are "second victims"--traumatized as a result of their involvement in an unanticipated adverse event, medical error, or patient-related injury.

Linking health professional learners and health care workers on action-based improvement teams.

BACKGROUND AND METHODS: Medical students, nursing students, and other health care professionals in training were integrated with health care workers on interprofessional quality improvement (QI) teams at our academic health center. Teams received training in QI, accompanied by expert QI mentoring, with dual goals of increasing expertise in improvement while improving care. RESULTS: Eighty-six learners and health system workers participated in 12 improvement teams in 2 years. Upon completion of the training, participants expressed that the program enhanced QI and teamwork skills and increased understanding of other health care professions. At the end of the program, fourth-year medical students showed greater ability to apply QI skills, as measured by the QI Knowledge Assessment Tool than did control students who did not participate in the program (P < .0001 in 2006-2007 and P < .0005 in 2007-2008). Many teams were successful in improving care processes. CONCLUSION: The design of "learning QI by doing," accompanied by just-in-time training and ongoing expert mentoring in QI, was identified by faculty as the most important factor contributing to success. This model successfully improved application of QI skills by learners while improving care within our academic health center. Testing of the model at other academic health centers and in other training environments is warranted.

Uncovering differences among health professions trainees exposed to an interprofessional patient safety curriculum.

In response to the Institute of Medicine challenge to improve patient safety and quality of care, an office directing patient safety/quality of care at an academic medical center and faculty from health professions schools collaborated on design, delivery, and evaluation of an interprofessional student curriculum on patient safety, quality, and teamwork. Annually for 6 years, second-year medical students, senior baccalaureate nursing students, second-year masters in health administration students, and junior baccalaureate respiratory therapy students participated. A pre-/postsurvey assessing students' attitudes about quality, safety, and teamwork was developed and modified to reflect course revisions. Survey items were grouped into 1 of the 6 subscales: human fallibility, disclosure, teamwork/communication, error reporting, systems of care, and curricular time spent with other professionals. At pretest, there were significant professional group differences in all the 6 subscales. At completion, differences in 4 subscales were resolved with the exception of human fallibility (P < .001) and curricular time spent together (P < .001). Interprofessional exercises within our curriculum mediated most differences among student groups. As more interprofessional curricular experiences are designed, examining baseline group differences is essential to optimize learning outcomes.

Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility.

PURPOSE: To study the effects of a patient safety and medical fallibility curriculum on second-year medical students at the University of Missouri-Columbia School of Medicine in 2003-2004. METHOD: Students completed a knowledge, skills, and attitudes questionnaire before the curriculum, after the final learning experience, and one year later. A 95% confidence interval (CI) for paired differences assessed change over time. At one year, students also responded to items about their use of the curriculum, error reporting, and disclosure experiences. RESULTS: Fifty three of 92 students (55%) completed the questionnaire at all three assessment points. Students' eight items and the calculated knowledge score improved after the curriculum but only seven of these improvements were sustained one year. Responses to seven items did not change and five changed in an undesired direction after the curriculum and/or after one year. Seventy two students completed the self-reported behavior questions at one year. More than half reported using what they learned in the curriculum. Although 76% of students reported observing an error, 71% of these disclosed an error to their peers, 56% to a resident, and 46% to faculty. Only 7% reported an error using our electronic error reporting system. CONCLUSIONS: The curriculum led to changes in second-year medical students' knowledge, skills, and attitudes, but not all of the changes were sustained at one year, were in the desired direction, or were supported by their self-reported behaviors. The extent to which other informal or hidden curriculum experiences reversed the gains and affected the changes at one year is unknown.

Orem's self-care deficit nursing theory: pediatric asthma as exemplar.

Asthma is the most frequent reason for preventable hospital admissions among children regardless of race or socioeconomic status. Since hospitalizations are preventable, a reasonable assumption is that parents are not optimally managing their child's asthma. Using Orem's self-care deficit nursing theory, 14 conditions were uncovered in the pediatric asthma literature that influence development of competency by parents. Twelve of the 14 antecedent conditions are influenced by factors partly or completely controlled by the healthcare system. Healthcare system gaps associated with asthma symptom control have come to light through the articulation of the pediatric asthma literature and Orem's theory.

Case management for patients with heart fialure: a quality improvement intervention.

At-home case management is one strategy for improving quality of care for elderly patients with heart failure. Essential components of an effective heart failure case management intervention include frequent patient contact with the case manager and vigilant at-home monitoring of symptoms with responsive modifications to the treatment plan. It is just as important that the health care system (e.g., the acute care institution) is committed to assuring administrative support, financial backing, and dedicating clinical expert resources to achieve clinical quality improvements. In this article, the design, implementation, and outcomes of an at-home heart failure case management program are described, and challenges faced in implementing and sustaining the program are outlined.