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Zhou J, Zhang F, Wang H, Yin Y, Wang Q, Yang L, Dong B, Yuan J, Liu S, Zhao L, Luo W. Quality and efficiency of a standardized e-handover system for pediatric nursing: A prospective interventional study. J Nurs Manag 2022; 30:3714-3725. [PMID: 35066952 DOI: 10.1111/jonm.13549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/24/2021] [Accepted: 01/13/2022] [Indexed: 12/30/2022]
Abstract
AIM This study examined the effect on pediatric nursing handover quality and efficiency when a standardized e-handover system was implemented. BACKGROUND Handover quality is an important aspect of nursing quality management; however, handover quality among nursing staff is poor. METHODS A prospective interventional study was carried out in a general pediatrics ward from December 2019 to November 2020. The tools included a standardized e-handover system. The intervention strategies included workflow remodeling and employee training on oral handover using the standardized e-handover system. RESULTS The omission frequency of critical handover elements decreased from 47.32% to 2.94% (p < .01), among which the omission frequencies of nine out of 16 key elements significantly decreased. Integrity also showed improvement. Specifically, the integrity of five types of critical information was significantly improved, including vital signs, signs and symptoms, laboratory test results, radiologic examination results, and treatment regimen (2.00 vs. 5.00, p < .01; 3.00 vs. 5.00, p < .01; 3.00 vs. 5.00, p < .01; 5.00 vs. 5.00, p = .009; 3.00 vs. 4.00, p < .01, respectively). Information accuracy was 100%. Workflow and efficiency significantly improved, communication duration with patient/family during work hours significantly increased (24.00 vs. 56.00, p < .01), and prehandover preparation duration significantly decreased (32.00 vs. 2.50, p < .01). Nurse handover satisfaction showed improvement (56.88 ± 15.08 vs. 74.31 ± 9.22, p < .01). CONCLUSION The standardized e-handover system effectively improved nurse handover quality, optimized workflow, increased work efficiency, and promoted teamwork. IMPLICATIONS FOR NURSING MANAGEMENT Standardized e-handover systems have great potential for ensuring the safety of pediatric patients and improving the quality of handover.
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Affiliation(s)
- Jiali Zhou
- Department of Pediatric Pulmonology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Fen Zhang
- Department of Pediatric Pulmonology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Hansong Wang
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China.,Child Health Advocacy Institute, China Hospital Development Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Yong Yin
- Department of Pediatric Pulmonology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
| | - Qian Wang
- Department of Pediatric Pulmonology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Lihua Yang
- Department of Pediatric Pulmonology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Bin Dong
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
| | - Jiajun Yuan
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
| | - Shijian Liu
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
| | - Liebin Zhao
- Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
| | - Wenyi Luo
- Shanghai Children's Medical Center, Shanghai Jiao Tong University School Of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics, Shanghai, China
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Turer RW, Arribas M, Balgord SM, Brooks S, Hopson LR, Bassin BS, Medlin R. Clinical Informatics Training During Emergency Medicine Residency: The University of Michigan Experience. AEM EDUCATION AND TRAINING 2021; 5:e10518. [PMID: 34041427 PMCID: PMC8138099 DOI: 10.1002/aet2.10518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/30/2020] [Accepted: 08/08/2020] [Indexed: 06/12/2023]
Abstract
Clinical informatics (CI) is a rich field with longstanding ties to resident education in many clinical specialties, although a historic gap persists in emergency medicine. To address this gap, we developed a CI track to facilitate advanced training for senior residents at our 4-year emergency medicine residency. We piloted an affordable project-based approach with strong ties to operational leadership at our institution and describe specific projects and their outcomes. Given the relatively low cost, departmental benefit, and unique educational value, we believe that our model is generalizable to many emergency medicine residencies. We present a pathway to defining a formal curriculum using Kern's framework.
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Affiliation(s)
- Robert W. Turer
- Departments of Emergency Medicine and Biomedical InformaticsVanderbilt University Medical CenterNashvilleTNUSA
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Miguel Arribas
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Sarah M. Balgord
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Stephanie Brooks
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Laura R. Hopson
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Benjamin S. Bassin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical Care (M‐CIRCC)Ann ArborMIUSA
- Department of Emergency MedicineDivision of Critical CareAnn ArborMIUSA
| | - Richard Medlin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
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Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process mapping in healthcare: a systematic review. BMC Health Serv Res 2021; 21:342. [PMID: 33853610 PMCID: PMC8048073 DOI: 10.1186/s12913-021-06254-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare. METHODS We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach. RESULTS The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions. CONCLUSION The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM. TRIAL REGISTRATION Prospero ID: CRD42017082140.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Laura Lennox
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
| | - James Barlow
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Liz Evans
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
| | - Julie Reed
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
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Fekieta R, Rosenberg A, Hodshon B, Feder S, Chaudhry SI, Emerson BL. Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement. Health Syst (Basingstoke) 2020; 10:239-248. [PMID: 34745587 DOI: 10.1080/20476965.2020.1768807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
During intra-hospital transfers, multiple clinicians perform coordinated tasks that leave patients vulnerable to undesirable outcomes. Communication has been established as a challenge to care transitions, but less is known about the organisational complexities within which transfers take place. We performed a qualitative assessment that included various professions to capture a multi-faceted understanding of intra-hospital transfers. Ethnographic observations and semi-structured interviews were conducted with clinicians and staff from the Medical Intensive Care Unit, Emergency Department, and general medicine units at a large, urban, academic, tertiary medical centre. Results highlight the organisational factors that stakeholders view as important for successful transfers: the development, dissemination, and application of protocols; robustness of technology; degree of teamwork; hospital capacity; and the ways in which competing hospital priorities are managed. These factors broaden our understanding of the organisational context of intra-hospital transfers and informed the development of a practical guide that can be used prior to embarking on quality improvement efforts around transitions of care.
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Affiliation(s)
- Renee Fekieta
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | | | - Beth Hodshon
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Beth L Emerson
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
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Hogan H, Hutchings A, Wulff J, Carver C, Holdsworth E, Welch J, Harrison D, Black N. Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BackgroundUnchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.ObjectiveTo determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.DesignA mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).SettingEnglish hospitals participating in the NCAA audit.ParticipantsNHS staff (approximately 300) and patients (13 million).InterventionsEducation, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.Main outcome measuresIHCA rates, survival and hospital-wide mortality.Data sourcesNCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.MethodsA literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).ResultsAcross NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.LimitationsThe organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.ConclusionsStandardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.Future workTo assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jerome Wulff
- Intensive Care National Audit & Research Centre, London, UK
| | - Catherine Carver
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Holdsworth
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - John Welch
- Critical Care Outreach, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, London, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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LEE SOOHOON, FISHER DALEA, MAH HEIDI, GOH WEIPING, PHAN PHILLIPH. A qualitative study of sign-out processes between primary and on-call residents: relationships in information exchange, responsibility and accountability. Int J Qual Health Care 2017; 29:646-653. [DOI: 10.1093/intqhc/mzx082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 06/29/2017] [Indexed: 11/12/2022] Open
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Hogan H, Carver C, Zipfel R, Hutchings A, Welch J, Harrison D, Black N. Effectiveness of ways to improve detection and rescue of deteriorating patients. Br J Hosp Med (Lond) 2017; 78:150-159. [PMID: 28277760 DOI: 10.12968/hmed.2017.78.3.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A number of interventions has been introduced to improve recognition of and response to deterioration, but evidence for improved outcomes is mixed. Future evaluations need better articulation of intervention components and outcomes, longer run-in times and consideration of the interplay between concurrent interventions.
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Affiliation(s)
- Helen Hogan
- Clinical Senior Lecturer, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH
| | - Catherine Carver
- Clinical Research Fellow, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
| | - Rebecca Zipfel
- Research Assistant, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
| | - Andrew Hutchings
- Lecturer in Statistics, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
| | - John Welch
- Consultant Nurse in Critical Care, University College London Hospital, London
| | - David Harrison
- Senior Statistician, Intensive Care National Audit and Research Centre, London
| | - Nick Black
- Professor of Health Services Research, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
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8
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Critical Access Hospital Use of TeamSTEPPS to Implement Shift-Change Handoff Communication. J Nurs Care Qual 2017; 32:77-86. [PMID: 27270844 DOI: 10.1097/ncq.0000000000000203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did. Staff involvement and being part of the "big picture" were important facilitators to change management and buy-in.
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Lazzara EH, Riss R, Patzer B, Smith DC, Chan YR, Keebler JR, Fouquet SD, Palmer EM. Directly Comparing Handoff Protocols for Pediatric Hospitalists. Hosp Pediatr 2016; 6:722-729. [PMID: 27803024 DOI: 10.1542/hpeds.2015-0251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Handoff protocols are often developed by brainstorming and consensus, and few are directly compared. We hypothesized that a handoff protocol (Flex 11) developed using a rigorous methodology would be more favorable in terms of clinicians' attitudes, behaviors, cognitions, or time-on-task when performing handoffs compared with a prevalent protocol (Situation Background Assessment Recommendation [SBAR]). METHODS Using a between-groups, randomized control trial design (Flex 11 versus SBAR) during a pilot study in a simulated environment, 20 clinicians (13 attending physicians and 7 residents) received 3 patient handoffs from a standardized physician, managed the patients, and handed off the patients to the same standardized physician. Participants completed surveys assessing their attitudes and cognitions, and behaviors and handoff duration were assessed through observations. RESULTS All data were analyzed using independent samples t tests. For attitudes, "ease of use" ratings were lower for SBAR participants than Flex 11 participants (P < .01), and "being helpful" ratings were lower for SBAR participants than Flex 11 participants (P = .02). For behaviors, results indicate no significant difference in the information acquired between the SBAR and Flex 11 protocols. However, SBAR participants gave significantly less information than Flex 11 participants (P < .01). For cognitions, SBAR and Flex 11 participants reported similar workload except for frustration. For handoff duration, there were no significant differences between the protocols (P = .36). CONCLUSIONS The results suggest that Flex 11 is an efficient, beneficial tool in a simulated environment with pediatric clinicians. Future studies should evaluate this protocol in the inpatient setting.
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Affiliation(s)
- Elizabeth H Lazzara
- Department of Human Factors, Embry-Riddle Aeronautical University, Daytona Beach, Florida;
| | - Robert Riss
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, Kansas City, Missouri
| | - Brady Patzer
- Department of Psychology, Wichita State University, Wichita, Kansas; and
| | - Dustin C Smith
- Department of Psychology, Wichita State University, Wichita, Kansas; and
| | - Y Raymond Chan
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, Kansas City, Missouri
| | - Joseph R Keebler
- Department of Human Factors, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | | | - Evan M Palmer
- Department of Psychology, San Jose State University, San Jose, California
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Vidyarthi AR, Coffey M. Paperless handover: are we ready? BMJ Qual Saf 2015; 25:299-301. [DOI: 10.1136/bmjqs-2015-005027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 11/03/2022]
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11
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Rachlin S, Schonberger A, Nocera N, Acharya J, Shah N, Henkel J. Continuous Certification Within Residency: An Educational Model. Acad Radiol 2015; 22:1294-8. [PMID: 26314498 DOI: 10.1016/j.acra.2015.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 11/18/2022]
Abstract
Given that maintaining compliance with Maintenance of Certification is necessary for maintaining licensure to practice as a radiologist and provide quality patient care, it is important for radiology residents to practice fulfilling each part of the program during their training not only to prepare for success after graduation but also to adequately learn best practices from the beginning of their professional careers. This article discusses ways to implement continuous certification (called Continuous Residency Certification) as an educational model within the residency training program.
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Affiliation(s)
- Susan Rachlin
- Department of Radiology, New York Medical College, 40 Sunshine Cottage Road, Valhalla, New York.
| | | | | | - Jay Acharya
- Department of Radiology, Westchester Medical Center
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Doers ME, Beniwal-Patel P, Kuester J, Fletcher KE. Feedback to Achieve Improved Sign-out Technique. Am J Med Qual 2014; 30:353-8. [DOI: 10.1177/1062860614535237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Jessica Kuester
- Medical College of Wisconsin, Milwaukee, WI
- Clement J. Zablocki VA Medical Center, Milwaukee, WI
| | - Kathlyn E. Fletcher
- Medical College of Wisconsin, Milwaukee, WI
- Clement J. Zablocki VA Medical Center, Milwaukee, WI
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