How Successful Are Residents and Fellows at Quality Improvement?

BACKGROUND: Nationally, there is an expectation that residents and fellows participate in quality improvement (QI), preferably interprofessionally. Hospitals and educators invest time and resources in projects, but little is known about success rates or what fosters success. PURPOSE: To understand what proportion of trainee QI projects were successful and whether there were predictors of success. METHODS: We examined resident and fellow QI projects in an integrated healthcare system that supports diverse training programs in multiple hospitals over 2 years. All projects were reviewed to determine whether they represented actual QI. Projects determined as QI were considered completed or successful based on QI project sponsor self-report. Multiple characteristics were compared between successful and unsuccessful projects. RESULTS: Trainees submitted 258 proposals, of which 106 (41.1%) represented actual QI. Non-QI projects predominantly represented needs assessments or retrospective data analyses. Seventy-six percent (81/106) of study sponsors completed surveys about their projects. Less than 25% of projects (59/258) represented actual QI and were successful. Project category was predictive of success, specifically those aimed at preventive care or education. CONCLUSION: Less than a quarter of trainee QI projects represent successful QI. IMPLICATIONS: Hospitals and training programs should identify interventions to improve trainee QI experience.

Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment.

The aim of this project was to describe hospital nurses' work activity through observations, nurses' perceptions of time spent on tasks, and electronic health record time stamps. Nurses' attitudes toward technology and patients' perceptions and satisfaction with nurses' time at the bedside were also examined. Activities most frequently observed included documenting in and reviewing the electronic health record. Nurses' perceptions of time differed significantly from observations, and most patients rated their satisfaction with nursing time as excellent or good.

Parent and child perceptions of a self-regulated, home-based exercise program for children with cystic fibrosis.

BACKGROUND: Despite recognized benefits, many children with cystic fibrosis (CF) do not consistently participate in physical activities. There is little empirical literature regarding the feelings and attitudes of children with CF toward exercise programs, parental roles in exercise, or factors influencing exercise experiences during research participation. OBJECTIVES: The aim of this study is to describe the exercise experiences of children with CF and their parents during participation in a 6-month program of self-regulated, home-based exercise. METHODS: This qualitative descriptive study was nested within a randomized controlled trial of a self-regulated, home-based exercise program and used serial semistructured interviews conducted individually at 2 and 6 months with 11 purposively selected children with CF and their parent(s). RESULTS: Six boys and five girls, ages 10-16 years, and parents(nine mothers, four fathers) participated in a total of 44 interviews. Five major thematic categories describing child and parent perceptions and experience of the bicycle exercise program were identified in the transcripts: (a) motivators, (b) barriers, (c) effort/work, (d) exercise routine, and (e) sustaining exercise. Research participation, parent-family participation, health benefits, and the child's personality traits were the primary motivators. Competing activities, priorities, and responsibilities were the major barriers in implementing the exercise program as prescribed. Motivation waned, and the novelty wore off for several (approximately half) parent-child dyads, who planned to decrease or stop the exercise program after the study ended. DISCUSSION: We identified motivators and barriers to a self-regulated, home-based exercise program for children with CF that can be addressed in planning future exercise interventions to maximize the health benefits for children with CF and the feasibility and acceptability to the children and their families.

Exercise intensity self-regulation using the OMNI scale in children with cystic fibrosis.

Prescribing exercise at intensities that improve fitness is difficult in children with cystic fibrosis (CF) due to ventilatory limitations and fluctuating health status. Our aim was to determine if children with CF could regulate the intensity of cycle ergometer and treadmill exercise using target ratings of perceived exertion (RPE) derived from the Children's OMNI Scale. We examined prescription congruence (similar oxygen consumption [VO2] and heart rate [HR] for target RPE) and intensity discrimination (different VO2 and HR for different RPEs), from cycle to cycle and cycle to treadmill. Subjects were 24 children (12 male, 12 female), aged 10-17 years with varying disease severity. Each child participated in one orientation, one estimation trial (graded maximal exercise test), and two production trials (cycle and treadmill, alternating between RPE 4 and 7). At RPE 4, congruence was evident for both VO2 and HR on the treadmill. On the cycle at RPE 4, VO2 was significantly higher only in the first production trial, although HRs tended to be higher in the production trials than the estimation trial. Prescription congruence was also supported at RPE 7, with no significant differences in VO2 or HR between estimation and production trials on cycle or treadmill. Results fully supported intensity discrimination, with significant differences between VO2 and HR at RPE 4 and 7 (P < 0.0001). Children with CF appear capable of using the OMNI Scale to regulate cycle and treadmill exercise intensity. Training using this methodology has the potential to promote fitness in children with CF of varying severity.

A randomized controlled trial of a smoking cessation intervention for pregnant adolescents.

BACKGROUND: The smoking prevalence rate among pregnant adolescents has been estimated at 59-62%, and 60-80% of these adolescents continue to smoke throughout their pregnancies. OBJECTIVES: The aim of this study was to evaluate the short- and long-term effects of smoking cessation strategies tailored to the pregnant adolescent to attain and maintain abstinence. The specific aim was to examine differences in short- and long-term smoking behaviors among three groups: Teen FreshStart (TFS), Teen FreshStart Plus Buddy (TFS-B), and Usual Care (UC) control. METHODS: In this randomized controlled intervention study, a 3-group (TFS, TFS-B, and UC) by 3-occasion (baseline, 8 weeks postrandomization, and 1-year following study entry) design was used. The study included 142 pregnant adolescents who were aged 14 to 19 years. Both self-reported smoking status collected on the Smoking History Questionnaire and saliva cotinine levels were used to identify smoking behaviors. RESULTS: There were no significant differences among the three treatment groups at baseline in terms of the racial distribution, age, gestational age, age of menses initiation, number in family household, number of family members who smoked, or tobacco use. A significant difference between the UC group and the TFS-B group (p = .010) was seen in smoking behaviors measured 8 weeks following treatment initiation. At 1 year following study entry, however, there were no differences between the groups in smoking behaviors. DISCUSSION: The TFS-B intervention was more effective in attaining short-term smoking cessation in the pregnant adolescent than TFS or UC. Findings suggest that the peer-enhanced programming had a limited effect but could not sustain the participant beyond postpartum (1 year following study entry). Future studies should include relapse prevention to sustain smoking abstinence into the postpartum period.

Update on the role of exercise in cystic fibrosis.

PURPOSE OF REVIEW: The role of exercise in patients with cystic fibrosis has been recognized for as long as cystic fibrosis has been identified as a clinical syndrome, as exercise intolerance has always been a hallmark of disease progression. RECENT FINDINGS: Work published in the past year has shed new light on several aspects of this field, including physiologic responses to exercise, responses to exercise programs, and the epidemiologic and prognostic implications of activity and exercise testing. SUMMARY: Barker's work is perhaps the most compelling, as it highlights the overwhelming interest and belief in the utility of exercise testing and prescription among cystic fibrosis physicians and the contrasting paucity of programs that test their patients and prescribe exercise for them. More studies are needed to identify the form of exercise programs and tests that are most likely to be effective and to be used by cystic fibrosis centers and patients.