According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Since publication of the Society for Healthcare Epidemiology of America position paper on Clostridium difficile infection in 1995, significant changes have occurred in the epidemiology and treatment of this infection. C. difficile remains the most important cause of healthcareassociated diarrhea and is increasingly important as a community pathogen. A more virulent strain of C. difficile has been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.

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Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

Methods  This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969–2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003–2009.

Results  The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

Conclusions  Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

Medical Education 2010: 44: 50–63

A critical review of simulation-based medical education research: 2003-2009

Evaluating the quality of medical care.

Purpose This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP). Method This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

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Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence

BACKGROUND
Interdisciplinary rounds (IDR) provide a means to assemble hospital team members and improve collaboration. Little is known about teamwork during IDR.


OBJECTIVE
To evaluate and characterize teamwork during IDR.


DESIGN
Cross-sectional observational study.


SETTING
Six medical units which had implemented structured interdisciplinary rounds (SIDR).


MEASUREMENTS
We adapted the Observational Teamwork Assessment for Surgery (OTAS) tool, a behaviorally anchored rating scale shown to be reliable and valid in surgical settings. OTAS provides scores ranging from 0 to 6 (0 = problematic behavior; 6 = exemplary behavior) across 5 domains (communication, coordination, cooperation/backup behavior, leadership, and monitoring/situational awareness) and for prespecified subteams. Two researchers conducted direct observations using the adapted OTAS tool.


RESULTS
We conducted 7-8 independent observations for each unit (total = 44) and 20 joint observations. Inter-rater reliability was excellent at the unit level (Spearman's rho = 0.75), and good across domains (rho = 0.53-0.68) and subteams (rho = 0.53-0.76) with the exception of the physician subteam, for which it was poor (rho = 0.35). Though teamwork scores were generally high, we found differences across units, with a median (interquartile range [IQR]) 4.5 (3.9-4.9) for the lowest and 5.4 (5.3-5.5) for the highest performing unit (P < 0.01). Domain scores differed, with leadership receiving the lowest (median [IQR] = 5.0 [4.6-5.3]), and cooperation/backup behavior and monitoring/situational awareness receiving highest scores (median [IQR] = 5.4 [5.0-5.5] and 5.4 [5.0-5.7]). Differences across subteams were of borderline significance (P = 0.05).


CONCLUSIONS
The adapted OTAS instrument demonstrated acceptable reliability for assessing teamwork during SIDR across units, domains, and most subteams. Variation in performance suggests a need to improve consistency of teamwork and emphasizes the importance of leadership.

ORIGINAL RESEARCH Assessment of Teamwork During Structured Interdisciplinary Rounds on Medical Units

BACKGROUND

Hospital medical groups use various staffing models that may systematically affect care continuity during the admission process.



OBJECTIVE

To compare the effect of 2 hospitalist admission service models (“general” and “admitter-rounder”) on patient disposition and length of stay.



DESIGN

Retrospective observational cohort study with difference-in-difference analysis.



SETTING

Large tertiary academic medical center in the United States.



PARTICIPANTS

Patients (n = 19,270) admitted from the emergency department to hospital medicine and medicine teaching services from July 2010 to June 2013.



INTERVENTIONS

Admissions to hospital medicine staffed by 2 different service models, compared to teaching service admissions.



MEASUREMENTS

Incidence of transfer to critical care within the first 24 hours of hospitalization, hospital and emergency department length of stay, and hospital readmission rates ≤30 days postdischarge.



RESULTS

The change of hospitalist services to an admitter-rounder model was associated with no significant change in transfer to critical care or hospital length of stay compared to the teaching service (difference-in-difference P = 0.32 and P = 0.87, respectively). The admitter-rounder model was associated with decreased readmissions compared to the teaching service on difference-in-difference analysis (odds ratio difference: −0.21, P = 0.01). Adoption of the hospitalist admitter-rounder model was associated with an increased emergency department length of stay compared to the teaching service (difference of +0.49 hours, P < 0.001).



CONCLUSIONS

Rates of transfer to intensive care and overall hospital length of stay between the hospitalist admission models did not differ significantly. The hospitalist admitter-rounder admission service structure was associated with extended emergency department length of stay and a decrease in readmissions. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine

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Association of hospital admission service structure with early transfer to critical care, hospital readmission, and length of stay

Blue-tinged toes

e17667 Background: Neutropenic Fever (NF) is a prevalent complication of myelosuppressive chemotherapy with significant morbidity, mortality, and cost Despite clear treatment guidelines by the Inf

Compliance in guideline-based management of febrile neutropenia.

Teamwork is tightly linked to patient safety for hospitalized patients. Barriers to teamwork in hospital settings abound, including large team sizes and dynamic team membership because of the need to provide care 24 hours a day, 7 days a week. Team members are often dispersed across clinical service areas and care for multiple patients at the same time. Compounding the potential for these structural barriers to impede teamwork, professionals seldom receive any formal training to enhance teamwork skills, and students and trainees have relatively few interactions during their formative years with individuals outside of their own profession. In this issue of the Journal of Hospital Medicine, Tofil et al. describe the effect of a novel interprofessional training program to improve teamwork among medical and nursing students at the University of Alabama. The curriculum included 4, 1-hour simulation sessions and resulted in improved ratings of self-efficacy with communication and teamwork attitudes. The authors report that the curriculum has continued and expanded to include other health professionals. Beyond the short-term results, the curriculum developed by Tofil and colleagues may have lasting effects on individual participants. Students, exposed to one another during a particularly impressionable period of their professional development, may develop better appreciation for the priorities, responsibilities, needs, and expertise of others. The experience may inoculate them from adopting unfavorable behaviors and attitudes that are common among practicing clinicians and comprise the “hidden” curriculum, which often undermines the goals of the formal curriculum. An early, positive experience with other team members may be especially important for medical students, as physicians tend to be relatively unaware of deficiencies in interprofessional collaboration. Though undoubtedly valuable to the learners and contributing to our collective knowledge on the subject, the study by Tofil and colleagues includes limitations common to teamwork training curricula. To make the potential of teamwork training a reality in improving patient outcomes, we must first revisit some key teamwork concepts and principles of curriculum development. Baker and colleagues define a team as consisting of 2 or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal. For a team to be successful, individual team members must have specific knowledge, skills, and attitudes (ie, competencies). For team training curricula to be successful, existing frameworks like TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) should be used to define learning objectives. Because teamwork is largely behavioral and affective, simulation is the most appropriate instruction method. Simulation involves deliberate practice and expert feedback so that learners can iteratively enhance teamwork skills. Other instructional methods (eg, didactics, video observation and debriefing, brief role play without feedback) are too weak to be effective. Importantly, Tofil and colleagues used an accepted teamwork framework to develop learning objectives, simulation as the instructional method, and an interprofessional team (ie, a physician, nurse, and an adult learning professional with simulation expertise) to perform simulation debriefings. However, for team training to achieve its full potential, leaders of future efforts need to aim for higher level outcomes. Positive reactions are encouraging, but what we really want to know is that learners truly adopted new skills and attitudes, applied them in real-world clinical settings, and that patients benefited from them. These are high but achievable goals and absolutely necessary to advance the credibility of team training. Relatively few studies have evaluated the impact of team training on patient outcomes, and the available evidence is equivocal. The intensity and duration of deliberate practice during simulation exercises must be sufficient to change ingrained behaviors and to ensure transfer of enhanced skills to the clinical setting if our goal is to improve patient outcomes. Leaders of future efforts must also develop innovative simulation exercises that reflect the real-life challenges and contexts for medical teamwork including dispersion of team members, challenges of communication in hierarchical teams, and competing demands under increasing time pressure. Simulated communication events could include a nurse deciding whether and how to contact a physician not immediately present (and vice versa). Sessions should include *Address for correspondence and reprint requests: Kevin J. O’Leary, MD, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611; Telephone: 312-926-5924; Fax: 312-926-4588; E-mail: keoleary@nmh.org

/pdf/making-the-potential-benefit-of-teamwork-training-a-reality-1tzzpum0g7.pdf

Kevin J. O'Leary

Papers

ORIGINAL RESEARCH Assessment of Teamwork During Structured Interdisciplinary Rounds on Medical Units

Association of hospital admission service structure with early transfer to critical care, hospital readmission, and length of stay

Blue-tinged toes

Compliance in guideline-based management of febrile neutropenia.

Making the potential benefit of teamwork training a reality.