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

AIMS
To improve the timeliness and quality of discharge for patients by creating the role of the Attending Nurse.


BACKGROUND
Discharge time affects hospital throughput and patient satisfaction. Bedside nurses and hospitalists have competing priorities that can hinder performing timely, high quality discharges.


METHODS
This retrospective analysis evaluated the effect of an Attending Nurse paired with a hospital medicine physician on discharge time and quality. A total of 8329 patient discharges were eligible for the study and propensity score matching yielded 2715 matched pairs.


RESULTS
In the post- intervention matched cohort, the percentage of patients discharged before 2pm increased from 34.4% to 45.9% (p <0.01) and the median discharge time moved 48 minutes earlier. In the unmatched cohort, patient satisfaction with the discharge process improved on several questions. While length of stay was not affected, the 30-day readmission rate did increase from 8.9% to 10.7% (p=0.02).


CONCLUSION
With the new Attending Nurse role, we positively impacted throughput by shifting discharge times earlier in the day while improving patient satisfaction Length of stay stayed the same but the 30-day readmission rate increased.


IMPLICATIONS FOR NURSING MANAGEMENT
Our multidisciplinary approach to the problem of late discharge times led to the creation of a new role. This role made ownership of discharge tasks clear and reduced competing priorities, freeing up nurses and hospitalists to perform other care related responsibilities without holding up discharges.

Effect of an Attending Nurse on Timeliness of Discharge, Patient Satisfaction, and Readmission.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs). We agree that a 7-on/7-off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7-on/7-off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work-life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect. We respectfully disagree with Dr. Kerman’s concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under-reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2-stage method to identify and confirm AEs. In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs. A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This timeconsuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems. With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs. We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist. We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity. Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre-post evaluation of a hospitalist staffing model specifically designed to improve continuity. In the CICLE model, physicians work in a 4-day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P 5 0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS. Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and Received: April 20, 2015; Accepted: April 22, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2405 Published online in Wiley Online Library (Wileyonlinelibrary.com).

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The authors reply "The effect of hospitalist continuity on adverse events".

Learning by Doing: Improving and Adapting in Quality Improvement Education.

Abstract Background Healthcare organizations made major adjustments to deliver care during the COVID pandemic, yet little is known about how these adjustments shaped ongoing quality and safety improvement efforts. We aimed to understand how COVID affected four U.S. hospitals’ prospective implementation efforts in an ongoing quality improvement initiative, the RE designing S yst E ms to Improve T eamwork and Quality for Hospitalized Patients (RESET) project, which implemented complementary interventions to redesign systems of care for medical patients. Methods We conducted individual semi-structured interviews with 40 healthcare professionals to determine how COVID influenced RESET implementation. We used conventional qualitative content analysis to inductively code transcripts and identify themes in MAXQDA 2020. Results We identified three overarching themes and nine sub-themes. The three themes were (1) COVID exacerbated existing problems and created new ones. (2) RESET and other quality improvement efforts were not the priority during the pandemic. (3) Fidelity of RESET implementation regressed. Conclusion COVID had a profound impact on the implementation of a multifaceted intervention to improve quality and teamwork in four hospitals. Notably, COVID led to a diversion of attention and effort away from quality improvement efforts, like RESET, and sites varied in their ability to renew efforts over time. Our findings help explain how COVID adversely affected hospitals’ quality improvement efforts throughout the pandemic and support the need for research to identify elements important for fostering hospital resilience. 

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Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study

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Factors Associated with Use of Inpatient Telehealth for Hospitalized COVID-19 Patients: an Observational Study of 4 Hospitals in a Single Health System

Kevin J. O'Leary

Papers

Effect of an Attending Nurse on Timeliness of Discharge, Patient Satisfaction, and Readmission.

The authors reply "The effect of hospitalist continuity on adverse events".

Learning by Doing: Improving and Adapting in Quality Improvement Education.

Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study

Factors Associated with Use of Inpatient Telehealth for Hospitalized COVID-19 Patients: an Observational Study of 4 Hospitals in a Single Health System