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Levy KL, Grzyb K, Heidemann LA, Paliani DB, Grondin C, Solomon G, Spranger E, Ellies T, Ratz D, Houchens N. Enhancing Resident Education by Embedding Improvement Specialists Into a Quality and Safety Curriculum. J Grad Med Educ 2023; 15:348-355. [PMID: 37363669 PMCID: PMC10286907 DOI: 10.4300/jgme-d-22-00456.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/19/2022] [Accepted: 02/27/2023] [Indexed: 06/28/2023] Open
Abstract
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.
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Affiliation(s)
- Kathryn L. Levy
- Kathryn L. Levy, MD, is Assistant Professor, Departments of Internal Medicine and Pediatrics, and Associate Program Director, Internal Medicine and Pediatrics Residency, University of Michigan
| | - Katie Grzyb
- Katie Grzyb, BSE, MHSA, is Continuous Improvement Specialist, Department of Internal Medicine, University of Michigan
| | - Lauren A. Heidemann
- Lauren A. Heidemann, MD, MHPE, is Associate Professor, Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System
| | - Debra Burke Paliani
- Debra Burke Paliani, MSME, is Continuous Improvement Specialist, Quality Department, University of Michigan Health System
| | - Christopher Grondin
- Christopher Grondin, MD, is Assistant Professor, Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System
| | - Gabriel Solomon
- Gabriel Solomon, MD, is Assistant Professor, Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System
| | - Elizabeth Spranger
- Elizabeth Spranger, BA, is Continuous Improvement Specialist, Department of Internal Medicine, University of Michigan
| | - Tammy Ellies
- Tammy Ellies, MBA, PMP, is Continuous Improvement Specialist, Department of Internal Medicine, University of Michigan
| | - David Ratz
- David Ratz, MS, is Statistician, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Nathan Houchens
- Nathan Houchens, MD, is Associate Professor, Department of Internal Medicine, and Assistant Program Director, Internal Medicine Residency Program, University of Michigan and Veterans Affairs Ann Arbor Healthcare System
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Lavin J, Kao LS. Building infrastructure to teach quality improvement. Semin Pediatr Surg 2023; 32:151283. [PMID: 37147216 DOI: 10.1016/j.sempedsurg.2023.151283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
With growing emphasis on healthcare quality improvement (QI) at both national and local levels, there has been increased demand for instructional programs to teach quality improvement as a discipline. Design of QI teaching programs must take into account local resources as well as the background and competing commitments of the learner. In this article, we review elements of successful quality improvement training programs including structure of didactic and experiential curricula. Special considerations for training programs at the undergraduate and graduate medical, hospital, and national/professional society level are presented.
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Affiliation(s)
- Jennifer Lavin
- Division of Pediatric Otolaryngology - Ann & Robert H. Lurie Children's Hospital of Chicago Associate Professor, Department of Otolaryngology - Head and Neck Surgery - Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Lillian S Kao
- Division of Acute Care Surgery Vice-Chair for Quality, Department of Surgery McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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Prochnow L, DiClemente L, Riley P, Tschannen D. Examining QI Knowledge Among Frontline Nurses and Nurse Leaders. J Nurs Care Qual 2023; 38:152-157. [PMID: 36214701 DOI: 10.1097/ncq.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Frontline nurses deliver direct patient care and by participating in quality improvement (QI) can have an impact on health care quality and safety. Unfortunately, nurses are not participating in QI, which may be due to a lack of QI knowledge. PURPOSE The purpose of this study was to evaluate nurses QI knowledge utilizing the revised Quality Improvement Knowledge Application Tool (QIKAT-R), with newly created nursing scenarios, among frontline nurses and nurse leaders. METHODS Using a cross-sectional design, this study evaluated nurses QI knowledge utilizing the QIKAT-R. RESULTS Overall, QI knowledge among nurses was low. The frontline nurses (n = 44) scored higher than nurse leaders (n = 11) on overall QI knowledge scores, although not significant. Frontline nurses scored higher in QI knowledge related to aim and measure, whereas nurse leaders scored higher in change. CONCLUSIONS Understanding frontline nurses QI knowledge, such as with the QIKAT-R with newly created nursing scenarios, can assist with creating targeted strategies for improving overall engagement in QI.
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Affiliation(s)
- Laura Prochnow
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
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Patel PV, Wallach T, Rosenbluth G, Heyman M, Verstraete S. Improving ondansetron use and oral rehydration instructions for pediatric acute gastroenteritis. BMJ Open Qual 2022; 11:bmjoq-2021-001616. [PMID: 35347066 PMCID: PMC8961161 DOI: 10.1136/bmjoq-2021-001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
In paediatric patients with acute gastroenteritis (AGE), ondansetron use decreases the need for intravenous fluids, reduces hospitalisations and shortens illness duration. Oral rehydration is also known to have excellent outcomes for mild to moderate dehydration secondary to AGE. Although these interventions are recommended in guidelines from international professional societies, baseline data at our clinic showed that <2% of these patients were offered ondansetron, and that few patients received appropriately detailed rehydration instructions. Therefore, we engaged residents and fellows as teachers and leaders in our university clinic’s quality improvement programme to promote evidence-based practice for paediatric AGE. Our gap analysis identified opportunities for interventions including educating paediatricians and paediatrics residents on the safety and utility of the medication. We created standardised oral rehydration after-visit instructions and implemented a trainee-led educational approach that encouraged appropriate medication use. We used a follow-up survey to uncover provider concerns and tailor future interventions. The process metrics included: proportion of paediatric patients appropriately treated with ondansetron (goal of 80%), and proportion of patients given appropriate oral rehydration instructions. The outcome metric was 7-day representation rates. To achieve sustainability, we restructured our process to have senior residents take ownership of teaching and data collection. Trainee-driven interventions increased ondansetron prescription rates to a median of 66.6%. Patients prescribed ondansetron were less likely to represent to care, although representation rate was low overall. Postintervention data suggests that prescription rates decreased without continued interventions and additional systems redesign may help sustain impact.
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Affiliation(s)
| | - Thomas Wallach
- Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Glenn Rosenbluth
- Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Mel Heyman
- Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sofia Verstraete
- Pediatrics, University of California San Francisco, San Francisco, California, USA
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Koller JP, Cochran KA, Headrick LA. Practical strategies to enhance resident engagement in clinical quality improvement. BMC MEDICAL EDUCATION 2022; 22:96. [PMID: 35164710 PMCID: PMC8842865 DOI: 10.1186/s12909-022-03134-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 01/20/2022] [Indexed: 05/19/2023]
Abstract
BACKGROUND Engaging residents in meaningful quality improvement (QI) is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. Various strategies to address these challenges for engagement have been described, but not as a unified approach. This paper describes a bundle of practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program. METHODS 62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA (Plan-Do-Study-Act) cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents, and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1 = least desired and 5 = most desired result. Data were analyzed by paired t-test. RESULTS All 62 residents participated in the program as members of ten QI teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p = 0.03), frequency of QI use (3.3 to 3.9, p = 0.001), and opinion about using QI in clinical work (3.9 to 4.0, p = 0.21). Resident assessment of QI priority in clinical work did not change. CONCLUSIONS We implemented a practical strategies bundle to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents' own practice, and real-time faculty coaching.
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Affiliation(s)
- James P Koller
- University of Missouri-Columbia School of Medicine, 101 S. Fairview Rd, Columbia, Missouri, 65203, USA.
| | - Kelly A Cochran
- University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, 64108, USA
| | - Linda A Headrick
- University of Missouri-Columbia School of Medicine, 101 S. Fairview Rd, Columbia, Missouri, 65203, USA
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Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review. Ann Surg 2021; 274:e489-e506. [PMID: 34784666 DOI: 10.1097/sla.0000000000004751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents. BACKGROUND There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery. METHODS We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully. RESULTS There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting. CONCLUSIONS The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.
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Neumeier A, Levy AE, Gottenborg E, Anstett T, Pierce RG, Tad-y D. Expanding Training in Quality Improvement and Patient Safety Through a Multispecialty Graduate Medical Education Curriculum Designed for Fellows. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:11064. [PMID: 33409360 PMCID: PMC7780740 DOI: 10.15766/mep_2374-8265.11064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/17/2020] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Although the Accreditation Council for Graduate Medical Education requires quality improvement and patient safety (QIPS) training for fellow-level trainees, this experience is often insufficient due to lack of faculty time and expertise within fellowship training programs. We developed a centralized GME curriculum targeted to an integrated, multispecialty audience of fellow-level trainees with the goal of promoting leadership and scholarship in QIPS. METHODS The University of Colorado implemented the Fellows' Quality and Safety Academy, a three-seminar curriculum in patient safety and health systems improvement. As most participants had prior training in QIPS during medical school or residency, educational strategies emphasized application of QIPS concepts through focused didactic content review paired with small-group case-based exercises and coaching of experiential project work to promote content mastery as well as practice of leadership and scholarship strategies. RESULTS Since the curriculum's inception in 2017, there have been 106 participants in the Foundations in Patient Safety seminar, 49 participants in the Adverse Events Into Quality Improvement seminar, and 48 participants in the Quality in Academics seminar. These participants represented 44 separate fellowship disciplines from both adult and pediatric subspecialties. Learners reported improved attitudes and confidence and demonstrated objective knowledge acquisition across QIPS content domains. DISCUSSION Our pedagogical approach of centralizing QIPS training and harnessing faculty expertise to teach fellow-level trainees across specialties through interdisciplinary collaboration and interactive project-based work is an effective strategy to promote development of QIPS competencies during fellowship training.
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Affiliation(s)
- Anna Neumeier
- Assistant Professor, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine
| | - Andrew E. Levy
- Assistant Professor, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine
| | - Emily Gottenborg
- Assistant Professor, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine
| | - Tyler Anstett
- Assistant Professor, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine
| | - Read G. Pierce
- Associate Professor, Division of Hospital Medicine, Department of Internal Medicine, University of Texas at Austin Dell Medical School
| | - Darlene Tad-y
- Associate Professor, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine
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Tresh A, Cohen AJ, Mmonu NA, Berdy S, Barnas K, Krombach J, Breyer BN. Resident-Driven Holistic Lean Daily Management System to Enhance Care Experience at a Safety Net Hospital. Urology 2020; 140:56-63. [PMID: 32145240 DOI: 10.1016/j.urology.2020.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/28/2019] [Accepted: 01/20/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the use of Lean in urology at Zuckerberg San Francisco General, a community safety-net and trauma hospital that serves as a major teaching site for the University of California San Francisco. METHODS We examined our process improvement activities from 2016 to 2018. Our Lean Daily Management System (DMS) includes a 15-minute team huddle ("urology Lean work") of service residents, faculty, clinic and operating room nursing staff, and anesthesia liaisons. Our DMS also includes a 5-minute preoperative huddle. Besides team-building, urology Lean work surfaces logistics, safety or equipment improvement ideas, and ensures progress and completion of initiated projects. RESULTS Over a 2-year period we developed and completed 67 projects. Projects impacted the outpatient setting (57%), followed by the operating room (22%), the Urology service (12%), and inpatient setting (9%). We completed projects in the following domains: safety (26%), quality (22%), care experience (21%), workforce care and development (13%), equity (11%), and financial stewardship (7%). Urology Lean work reduced new patient clinic access time (119-21 days) and Bacillus Calmette-Guérin in clinic treatment time (180-105 minutes). The average proportion of urology on-time surgeries was better than the overall surgery on-time surgeries (71% v 61%). CONCLUSION Urology Lean work successfully applied DMS in a service specific yet holistic approach. Urology Lean work improved resident engagement in quality and safety endeavors and served as a DMS model throughout perioperative and clinic areas.
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Affiliation(s)
- Anas Tresh
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Andrew J Cohen
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Nnenaya A Mmonu
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Sara Berdy
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | | | - Jens Krombach
- Department of Anesthesia, University of California-San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA; Department of Biostatistics and Epidemiology, University of California-San Francisco, San Francisco, CA.
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Abstract
Education in quality improvement (QI) is endorsed by the Association of American Medical Colleges across the spectrum of undergraduate, graduate, and postgraduate training. QI training is also a required component of graduate medical training per the American College of Graduate Medical Education. Despite widespread recognition of the importance of QI education and high levels of trainee involvement in QI as reported by pulmonary and critical care fellowship program directors, significant barriers to the implementation of effective and meaningful QI education during training exist. This creates an opportunity for the promotion of successfully implemented QI programs. Research demonstrates that successful QI educational programs involve the teaching of key QI concepts, participation in QI projects, protected time for QI project development, and institutional support. Using QI models such as the Plan-Do-Study-Act cycle and the Standards for Quality Improvement Reporting Excellence framework for reporting new knowledge about healthcare improvements also enhances both the educational value of the QI project and prospects for wider scholarly dissemination. In this perspective article, three examples of QI projects are discussed that serve to illustrate effective strategies of QI implementation.
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Bongiovanni T, Hansen K, Lancaster E, O’Sullivan P, Hirose K, Wick E. Adopting best practices in post-operative analgesia prescribing in a safety-net hospital: Residents as a conduit to change. Am J Surg 2020; 219:299-303. [DOI: 10.1016/j.amjsurg.2019.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 11/29/2022]
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Reardon CL, Hafer R, Langheim FJP, Lee ER, McDonald JM, Peterson MJ, Stevenson J, Walaszek A. A Quality Improvement Curriculum for Psychiatry Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10870. [PMID: 32051851 PMCID: PMC7012317 DOI: 10.15766/mep_2374-8265.10870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 09/07/2019] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Quality improvement (QI) is an increasingly important aspect of health care and residency education. There is relatively little research describing QI curricula for residents in psychiatry. Although QI curricula have been published in MedEdPORTAL, the current resource represents the first such curriculum specific to psychiatry residents. This resource aims to present a QI curriculum for psychiatry residents. METHODS The University of Wisconsin psychiatry residency program implemented a QI curriculum for our PGY 3 psychiatry residents in 2010. The initial version of the curriculum has undergone marked changes over the ensuing years, reflecting feedback received from learners and faculty instructors, as well as ongoing review of the literature, to ascertain best practices in this area of medical education. Steps taken have included faculty training, development of evaluation forms, and implementation of elements to increase accountability for successful, sustainable project development. RESULTS During the 8 completed years of this curriculum, 77 PGY 3 psychiatry residents have completed it. The Quality Improvement Knowledge Application Tool adapted for psychiatry was completed by PGY 3 residents in advance of and upon completion of the curriculum for the first 2 years of the curriculum; results demonstrated a significant improvement in scores as a measurement of QI knowledge and skills. Thirty-one of 32 resident teams (97%) have implemented a QI project. DISCUSSION Our QI curriculum for PGY 3 psychiatry residents has been successful in equipping residents with QI knowledge and having them implement QI projects.
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Affiliation(s)
- Claudia L. Reardon
- Associate Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health
| | - Roderick Hafer
- Clinical Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health
| | | | - Elliot R. Lee
- Clinical Adjunct Assistant Professor, Mendota Mental Health Institute
| | | | - Michael J. Peterson
- Associate Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health
| | - John Stevenson
- Associate Director for Research Services, University of Wisconsin Survey Center
| | - Art Walaszek
- Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health
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Goldfarb IT, Smith NA. QI Bootcamp: feasibility and acceptability of a novel approach to training residents in process improvement. Am J Obstet Gynecol 2019; 221:656-658. [PMID: 31279848 DOI: 10.1016/j.ajog.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/21/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
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