A Quality Improvement Approach to Ensuring Access to Specialty Care for Pediatric Patients.

Introduction: With pediatric rheumatologists in short supply, maximizing appointment availability and streamlining primary/specialty collaboration are essential. Lack of an efficient referral process impacts outcomes, quality of life, satisfaction, affordability, and resource allocation. Before this quality improvement project, our clinic had a 3- to 5-month backlog for new referrals. Methods: Using the model for improvement with numerous rapid-cycle plan-do-study-act cycles, this team restructured processes, developed a triage tool for communication across the care continuum, maximized staff roles in multiple areas, and instituted cross-disciplinary communication strategies to reduce appointment delays while significantly increasing efficiency. Results: The team succeeded in decreasing time from referral to specialty consult by 60%, decreasing no-show rates from 15% to 6%, and increasing throughput by an average of 45 more patients per month. Most new patients can now see our specialists within 23 days, meaning the children in our community have 65% shorter wait times for rheumatology services. Conclusion: The use of a triage algorithm with structured communication allows multidisciplinary care teams at both the referring and receiving providers to efficiently and accurately place patients into specialty care. This highly scalable and transferable project was accomplished with no direct financial outlay yet yielded significant returns by standardizing processes, empowering the entire care team to build skills, and improving communication.

Pediatrics Residents' Confidence and Performance Following a Longitudinal Quality Improvement Curriculum.

BACKGROUND: Quality improvement (QI) training is an integral part of residents' education. Understanding the educational value of a QI curriculum facilitates understanding of its impact. OBJECTIVE: The purpose of this study was to evaluate the effects of a longitudinal QI curriculum on pediatrics residents' confidence and competence in the acquisition and application of QI knowledge and skills. METHODS: Three successive cohorts of pediatrics residents (N = 36) participated in a longitudinal curriculum designed to increase resident confidence in QI knowledge and skills. Key components were a succession of progressive experiential projects, QI coaching, and resident team membership culminating in leadership of the project. Residents completed precurricular and postcurricular surveys and demonstrated QI competence by performance on the pediatric QI assessment scenario. RESULTS: Residents participating in the Center for Advancing Pediatric Excellence QI curriculum showed significant increases in pre-post measures of confidence in QI knowledge and skills. Coaching and team leadership were ranked by resident participants as having the most educational value among curriculum components. A pediatric QI assessment scenario, which correlated with resident-perceived confidence in acquisition of QI skills but not QI knowledge, is a tool available to test pediatrics residents' QI knowledge. CONCLUSIONS: A 3-year longitudinal, multimodal, experiential QI curriculum increased pediatrics residents' confidence in QI knowledge and skills, was feasible with faculty support, and was well-accepted by residents.

Effects of housing density and cage floor space on three strains of young adult inbred mice.

Some recommendations in the Guide for the Care and Use of Laboratory Animals (the Guide) are based on best professional judgment. Our current efforts are directed toward replacement with data-driven standards. We demonstrated earlier that young adult C57BL/6J mice could be housed with half the floor space recommended in the Guide without discernable negative effects. This report extends that work by examining optimal housing densities for young adult male and female BALB/cJ, NOD/LtJ, and FVB/NJ mice. These 8-week studies were initiated with 3-week-old BALB/cJ and NOD/LtJ mice and 3- to 5-week-old FVB/NJ mice housed in three cage types. We adjusted the number of mice per cage to house them with the floor space recommended in the Guide (approximately 12 in2 [ca. 77 cm2] per mouse) down to 5.6 in2 [ca. 36 cm2] per mouse. Early-onset aggression occurred among FVB/NJ male mice housed at all densities in cages having 51.7 in2 (ca. 333 cm2) or 112.9 in2 (ca. 728 cm2) of space. FVB/NJ male mice housed in shoebox (67.6 in2 [ca. 436 cm2]) cages did not exhibit aggression until the fifth week. Urinary testosterone output was density-dependent only for BALB/cJ male mice in shoebox cages (output decreased with increasing density) and FVB/NJ male mice. We conclude that all but FVB/NJ male mice can be housed with half the floor space specified in the Guide. The aggression noted for male FVB/NJ mice may have been due to their age span, although this did not impact negatively on the female FVB/NJ mice.

Effects of housing density and cage floor space on C57BL/6J mice.

The Guide for the Care and Use of Laboratory Animals (the Guide) is widely accepted as the housing standard by most Institutional Animal Care and Use Committees. The recommendations are based on best professional judgment rather than experimental data. Current efforts are directed toward replacing these guidelines with data-driven, species-appropriate standards. Our studies were undertaken to determine the optimum housing density for C57BL/6J mice, the most commonly used inbred mouse strain. Four-week-old mice were housed for 8 weeks at four densities (the recommended approximately 12 in2 [ca. 77.4 cm2]/mouse down to 5.6 in2 [ca. 36.1 cm2]/mouse) in three cage types with various amounts of floor space. Housing density did not affect a variety of physiologic parameters but did affect certain micro-environmental parameters, although these remained within accepted ranges. A second study was undertaken housing C57BL/6J mice with as little as 3.2 in2/mouse (ca. 20.6 cm2). The major effect was elevated ammonia concentrations that exceeded limits acceptable in the workplace at increased housing densities; however, the nasal passages and eyeballs of the mice remained microscopically normal. On the basis of these results, we conclude that C57BL/6J mice as large as 29 g may be housed with 5.6 in2 of floor space per mouse. This area is approximately half the floor space recommended in the Guide. The role of the Guide is to ensure that laboratory animals are well treated and housed in a species-appropriate manner. Our data suggest that current policies could be altered in order to provide the optimal habitation conditions matched to this species' social needs.