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.

/pdf/clinical-practice-guidelines-for-clostridium-difficile-meg93r15my.pdf

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

Teamwork in Hospital Medicine

Objective To determine the efficacy of a program to limit the use of the IV push route for opioids on the experience of pain by inpatients and on associated safety events. Design Retrospective cohort study. Setting Two inpatient general medicine floor units at an urban tertiary care academic medical center. Subjects 4752 inpatient opioid recipients. Methods Patients on one unit were exposed to a multidisciplinary intervention to limit prescription of opioids via the IV push route, with the other unit used as a control unit. The primary study outcome was mean numeric pain score per patient during the hospital stay. Secondary measures included hospital length of stay and post-discharge patient satisfaction. Fidelity measures included percentage of patient population exposed to each opioid administration route and amount of opioid administered per route. Safety measures included patient disposition, transfer to intensive care, and incidence of naloxone administration. Results The intervention was successful in decreasing both percentage of patients exposed to IV push opioids and amount of opioid administered via the IV push route, but no associated changes in other study outcomes were identified. Conclusions For treatment of acute pain in medical inpatients, no evidence of benefit or harm was identified in relation to increase or decrease in use of the IV push opioid route.

The Effect of Reducing Intravenous Push Opioid Use on Hospital Medicine Patients' Pain Experience during Hospitalization.

The authers reply

/pdf/an-intensive-intervention-to-reduce-readmissions-for-2lcnp5cw.pdf

An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial

Collaboration is important in services, but may lead to interruptions. Professionals exercise discretion on whether to preempt individual tasks to switch to collaborative tasks. Task switching can introduce setup times, often mental and unobservable, when resuming the preempted task and thus can increase workload.We analyze and quantify how collaboration, through interruptions and setup times, affects workload. We introduce an episodal workflow model that captures the interruption dynamics — each switch and the episode of work it preempts — present in settings where collaboration and multitasking is paramount. We then deploy the model in a field study of hospital medicine physicians — “hospitalists.” A hospitalist’s patient-care routine includes visiting patients and consulting with other caregivers to guide patient diagnosis and treatment.A rigorous empirical analysis is presented using a dataset assembled from direct observation of physician activity and pager-log data. We estimate that a hospitalist incurs a total setup time of 5min per patient per day, which represents a significant 20% of the workload: caring for 14 patients per day, a hospitalist spends more than one hour each day on setups. Switches causally lead to longer documentation time in general but the magnitude of the effect depends on the trigger: when the switch is triggered by the hospitalist the setup time is smaller.

Kevin J. O'Leary

Papers

Teamwork in Hospital Medicine

The Effect of Reducing Intravenous Push Opioid Use on Hospital Medicine Patients' Pain Experience during Hospitalization.

The authers reply

An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial

Collaboration, Interruptions and Changeover Times: Model and Empirical Study of Hospitalist Processing Times