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Journal Club  
     


Current References

Friday, May 22, DHLPMR Journal Club

Alexander, Jefrey A, and Hearld, Larry R.What Can We Learn From Quality Improvement Research?: A Critical Review of Research Methods
Med Care Res Rev 66(3):235-271, 2009.

Ogrinc G, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
Qual Saf Health Care 17(Supp 1):i13-i32, 2008.

Karen Homa selected this month's article by Alexander and Hearld (attached), and she also includes a recently published article concerning the SQUIRE guidelines. Karen invited lead authors of the latter article---Greg Ogrinc and Sue Mooney---to join the discussion if available.

The selected article is a recent review of the research methods used to study QI. As you read the review think about the SQUIRE framework for publishing QI work.

  1. What parts of Alexander and Hearld's review map to the SQUIRE framework?
  2. Were there any parts of the SQUIRE guidelines missed or not examined in their review?
  3. Did Alexander and Hearld reveal any contradictions in their article?

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About the Journal Club

Why?

  • Critical review of the literature
  • Connection with our current work
  • Good reading
  • Good conversation
  • Good communication
  • Identify gaps - develop research opportunities
  • Help each other learn
  • Learn more about each other
  • Challenge each other in a safe, respectful environment
  • Have the opportunity to critique our own presentations, manuscripts

What? (Domains)

  • Safety
  • Health professional education
  • Service redesign
  • Organizational behavior, culture
  • Innovation and diffusion
  • Regulation and accreditation
  • Policy
  • Microsystems
  • Health services research
  • QI research
  • Translational research

Who?

DHLPMR residents, coaches, and program management group, VA Quality Scholars, any other interested staff, residents, or students.

Which articles will we read?

We will be inviting people to suggest articles - we will come to you, or you can come to us if you see something that you think would be good. We encourage you suggest a couple questions for people to have in mind as they read the article(s). Tina Foster and Jim Heimarck will coordinate this process. We would especially welcome suggestions from literature that you read that others in the group may not, such as specialty-specific journals, or journals which are not "medical." Additionally, although we will focus on only a couple articles a month, this is a good place for us to share information about what we've been reading.

When/Where?

The Journal Club meets on the first Friday of every month from 12:15 to 1:15 pm in the Video Conference Room on the 3rd floor of the Novell Bldg, Lebanon. Residents and staff from each of our institutional sites (DHMC and Concord Hospital) participate via V-tel connection. You can attend in the V-tel conference room on Level 2 (left at bottom of stairwell coming from main rotunda) at DHMC, or in the Fourth Floor conference room at Concord Hospital.

At the beginning of each academic year, responsibility for the monthly article selection(s) and 2-3 thought-provoking questions will be assigned to residents and staff members who will submit them (electronically, preferably) to Jim Heimarck for distribution two weeks in advance of the meeting. The reference(s), and related questions will be distributed to regular attendees of the Journal Club and posted on this web site.

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Past Journal Club References

Friday, April 24, DHLPMR Journal Club

Haynes, Alan B, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
NEJM 360:491-9, 2009.

Steve Liu selected this month's readings on the topic of surgical checklists; the first is the attached NEJM article on surgical checklists and the second is Atul Gawande's New Yorker commentary on this subject. Questions for the JC discussion are:

  1. Checklists, in the traditional sense, are used to ensure that simple (yes or no answers) tasks are completed. Do you think that the tasks that were addressed either in the ICU study or the surgical checklist are simple, complicated, or complex?
  2. There were dramatic improvements in the outcome measures both in the ICU and the surgical study. Do you think the results that were seen were primarily from completion of the tasks in the checklist or could they be due to changes in the context or setting in which the checklists were implemented? In other words, do you think the use of the checklists changed the culture and professionals who participated in the study? As we have seen in multiple practicum projects, is this a case where a seemingly "simple" intervention leads to complex changes in the context/setting in which it was implemented?
  3. What is the future of checklists in medicine? What other settings could they be useful in?
  4. Atul Gawande believes that the "test pilot" culture of medicine currently prevents more widespread adoption of checklists and standardization. What do you think are the barriers to more widespread adoption/implementation of checklists? In your own practice and practicum work, could you envision a balance between standardization and provider autonomy? What are the tasks that could be amenable to a checklist and what tasks should be left for providers and patients to address on their own?

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Friday, March 27, DHLPMR Journal Club

Regan-Smith, Martha, et al. Teaching Residents Chronic Disease Management Using the Flinders Model
J Cancer Educ 21(2):60-62, 2006.

Battersby, Malcolm, et al. SA HealthPlus: A Controlled Trial of a Statewide Application of a Generic Model of Chronic Illness Care
Millbank Quarterly 85(1):37-67, 2007.

Martha Regan-Smith selected the attached articles and will lead the discussion concerning the Flinders Model for Chronic Disease Management. She offers these questions to consider........

  1. How does this model change the patient's role in his/her own care?
  2. How does this model change the provider's role in his/her care?
  3. How does this contribute to Wagner's Chronic Disease Care model?

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Friday, February 9, DHLPMR Journal Club

Meyer, Brett C., et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study
Lancet Neurol 2008;7:787-95.

Tracie Caller selected the attached article and offers these questions to consider........

  1. How do you think telemedicine can affect both quality and cost/value of health care?
  2. Telemedicine involves integration of microsystems within multiple institutions. What are the challenges faced in this process?
  3. How might you implement such a system in your own institution, and how would you know it was working (or not working)?

Friday, January 9, DHLPMR Journal Club

Hahn, Karissa, et al. Diabetes Flow Sheet Use Associated with Guidelines Adherence Ann Fam Med 2008;6(3):235-238.

Chris Allen selected the attached article and offers these questions to consider...

  1. Why do you think that flow sheet use had less effect on outcomes than it has in other areas such as ICU care?
  2. Why do you think that flow sheets were used in such a small percentage of the sampled primary care patients with DM?
  3. In your opinion, will flow sheets prove to be a valuable tool for improving diabetic patient care?
  4. Do you think that results of this study (lack of improvement in outcome targets) are more a consequence of the primary care setting/system or of the nature of the disease?

Friday, December 5, DHLPMR Journal Club

Feinmann, Jane Patient Safety: Cutting Out Human Error BMJ 2008;337:a2370.

Weick, KE and Sutcliffe, KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. California Management Review 45(2):73-84, 2003.

Martha Regan-Smith selected the above articles and offers these questions to consider...

  1. How do these papers give you a new perspective on your improvement work?
  2. Identify cultural blind spots in/around your improvement project.
  3. What "easy explanation" for less than the best care have you heard?
  4. How do these papers relate to Dr. Edwards' Leadership Lessons Series presentation?

November 7, 2008 Journal Club:

Ames, Daniel R. and Flynn, Francis J. What Breaks a Leader: The Curvilinear Relationship Between Assertiveness and Leadership J Personality & Soc Psych 2007;92(2):307-324.

Sharon Alroy-Preis selected the article and states, "Please tell everyone that I'm sorry it's a little long (~15 pages....) but this is a subject I struggle with and would like to hear others' opinion and experience"

Her questions to consider:

1. Have you found your balance in this topic?

2. If yes - how did you find it? think of situations that helped you clarify how to maintain the balance

3. If not - do you feel you are "over" or "under" and what can be done to improve the balance?

October 3, 2008 Journal Club:

Wachter RM, Flanders SA, Fee C, et al. Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measure Ann Int Med 2008;49:29-32.

Hayward RA. Performance Measurement in Search of a Path. NEJM 2008;356:9.

Steve Liu offers 2 articles for discussion.....one is an article from the Annals of Internal Medicine on antibiotic timing for CAP and the other is an editorial to another related article from the NEJM.

Here are questions for discussion:

1. What are some difficulties that you have encountered in developing performance measures for the population in your practicum or CLAR work? How do you differentiate clinical guidelines from performance measures?

2. Have you encountered or can you envision any unintendend consequences of measuring performance in your LPMR work or in other improvement interventions that you have seen in your home department? What are some ways to minimize the effects of these unintended consequences?

3. How can the use of the simple, complicated and complex typology help in discriminating between measures that should be "all-or-none" (with a goal of 100%) and those that should be measured with "bands" of performance (with goals between 60-80%)?

September 5, 2008 Journal Club:

Scott JG, Cohen D, DiCicco-Bloom B, et al. Understanding Healing Relationships in Primary Care. Ann Fam Med 2008;6(4):315-322.

Meza JP, Fahoome GF. The Development of an Instrument for Measuring Healing. Ann Fam Med 2008;6(4):355-360.

Pippa Shulman selected the attached articles and poses these questions for your consideration as you read:

1) Is healing an important measure? does it contribute to overall satisfaction or can we measure outcomes to validate healing as important? Does a healing relationship improve outcomes or just the relationship between physician and patient?

2) Would it be possible to measure trust or hope in the patient/physician encounter?


August 1, 2008 Journal Club:

Davidoff F. Improving peer review: Who's responsible? BMJ 2004;328:657-658.

Jefferson T, Wager E, Davidoff F. Measuring the Quality of Editorial Peer Review JAMA 2002;287(21):2786-2790.

Manish Mishra selected the attached article and asks that you think of this article's message in relation to the "peer reviewed journals" in which our papers appear, and the medical writing course presented in our Friday didactics sessions. Manish has invited Tom Mead (medical library background), David Stevens (who conducts our medical writing course), and Frank Davidoff (co-author of this article) to join the conversation, if available.


July 11, 2008 Journal Club:

Liu SK, Homa KA, Butterly JR, Kirkland KB, Batalden PB. Improving the simple, complicated, and complex realities of community-acquired pneumonia.

Glouberman S, Zimmerman B. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, July 2002.

Paul Batalden and Steve Liu will lead this discussion about these two articles. You are asked to consider a patient encounter you've had in the last month and come prepared to discuss the simple, complex, and complicated aspects of that encounter.


June 13, 2008 Journal Club:

Kass N, Pronovost PJ, Sugarman J, Goeschel CA, Lubomski LH, Faden R. Controversy and Quality Improvement: Lingering Questions About Ethics, Oversight, and Patient Safety Research. The Joint Commission Journal on Quality and Patient Safety 2008;34(6):349-53.

Kisha Weiser selected the attached article and includes the additional note: "this is the reference to which the article frequently refers: Pronovost P et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:27252732. Erratum in: N Engl J Med 2007;356:2660." Her questions for you to consider as you read are:

  1. Many of us are going to be going to institutions with less experienced IRBs and less experience in QI work. What regulatory oversight needs to be in place, if any?

  2. Collecting data, especially when the data is not flattering poses some medicolegal risk. Of course, not collecting data does not protect either. How might a QI oversight committee provide some medicolegal protection?

  3. What would a robust QI oversight committee look like? What would its function be?


May 2, 2008 Journal Club:

Nease DE, Nutting PA, Dickinson WP, Bonham AJ, Graham DG, Gallagher KM, Main DS. Inducing Sustainable Improvement in Depression Care in Primary Care Practices. The Joint Commission Journal on Quality and Patient Safety 2008;34(5):247-55.

Mao Fontanilla will be leading the dialogue and offers the following questions for your consideration:

  1. What was (were) the process change intervention(s) in this study?

  2. What is the underlying assumption behind a modified improvement collaborative approach and why is it thought to be applicable for complex adaptive systems?

  3. What outcomes were measured? Were they appropriate and relevant?

  4. Was there a role for tracking clinical outcomes? Would it have been relevant?

  5. Were the case studies at the end of the study helpful? If so, how?

  6. What can we learn from this improvement initiative? Is there anything that we can use for our individual practicum projects?


April 11, 2008 Journal Club:

Martin DR, O'Brien JL, Heyworth JA, Meyer NR. Point Counterpoint: The Function of Contradictions on an Interdisciplinary Health Care Team. Qual Health Res 2008;18:369.

Karen Homa has selected this article and will lead the dialogue; she writes...."This qualitative study explores contradictions and how revealing these can create opportunities for improvement/collaboration. I believe contradictions can be revealed during changes made in a system. So read through this article and lets talk about how contradictions (what are they) might be operating in your QI work. Looking forward to the discussion."


March 7, 2008 Journal Club:

Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review - a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy 2005;10(1):21-34.

Greenhalgh T, Kristjansson E, Robinson V. Realist review to understand the efficacy of school feeding programmes. BMJ 2007;335;858-861.

The attached readings introduce a concept to be explored more actively in the months ahead. Paul Batalden has invited one of the authors to a day-and-a-half discussion of the subject in early April, and suggested the concept be discussed at our Journal Club in advance of that visit. Hank Kutz agreed to lead this discussion and notes that you'll have some extensive reading. He offers the following:

"There are 2 articles for Journal club on March 7th covering the topic of the 'realist review.' Please read the longer of the two articles for discussion, focusing more on concepts a 'realist review' entails than the specifics of how to conduct one. The shorter article is an example of a review as it relates to school feeding programs.

Questions to ponder while reading:

  1. What are the fundamental differences between the "realist review" and the SQUIRE guidelines in conveying context of improvement work? Are they mutually exclusive?

  2. What is the underlying core "theory" behind your improvement work? (practicum, CLAR...etc.)

  3. What are the underlying assumptions tied to the core theory of your improvement?

  4. What ties your improvement project to the particular context in which you are working the most: 1) the core theory behind your improvement strategy or 2) your assumptions surrounding that theory?

  5. For those of you like me whose brain now hurts...just a general introduction and discussion of the key points "realist review" will likely fill up more time than we have!


February 1, 2008 Journal Club:

Wachter RM, Foster NE, Dudley RA. Medicare's Decision to Withhold Payment for Hospital Errors: The Devil Is in the Details. The Joint Commission Journal on Quality and Patient Safety 2008;34(2):116-23.

This month's article was selected by Andrew Chi, who offers the following questions for you to consider while reading the article:

  1. What do you think of Medicare's new policy, theoretically, financially, and practically?

  2. How might Medicare's new policy affect your practice of medicine and the kind of care your patients will receive? Can you give specifics?

  3. What do you think about the proposed non-reimbursable events/conditions on Tables 2-4? Which do you agree with, and which do you disagree with?

  4. In summary, what are the problems and/or benefits that you foresee with this big Medicare change?


January 4, 2008 Journal Club:

Gawande A. The Checklist; If something so simple can transform intensive care, what else can it do? The New Yorker, December 10, 2007.

Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA, Hunt E. Creating High Reliability in Health Care Organizations. Health Services Research 41:4, Part II (August 2006).

This month's article was selected by Sarah Greer, who invites you to join this conversation.


December 7, 2007 Journal Club:

Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Practices. J Qual Patient Safety 2005;31(8):438-46.

This month's article was selected by Lora Council, who invites you to join this conversation; she notes the "intent is for us to continue our discussion from last journal club as to how quality improvement can best be done in the context of a complex system." Questions to consider as you read:

  1. Would any part of your project benefit from improving the quality of relationships between agents rather than working to improve the individual agent?

  2. In what ways have you acted as a facilitator? How is facilitating your project creating sustainability?

  3. Leading change in a complex system requires different leadership skills than straightforward CQI. Have you used any RAP type skills as a leader of your change? Would developing RAP leadership skills enhance your current project?


November 2, 2007 Journal Club:

Burke W, Psaty BM. Personalized Medicine in the Era of Genomics. JAMA 2007;298(14):1682-4.

Dr. Fontanilla, who will lead the DHLPMR Journal Club discussion on Nov 2, offers these questions to consider for our dialogue:

  1. What does "personalized medicine" mean to you? Do you practice "personalized medicine"?

  2. "Genomics-based knowledge and tools promise the ability to approach each patient as the biological individual he or she is." Can you give examples of how genomics is being applied in your specialty? What is your experience with genetic testing?

  3. What are the "drivers" of the genomics movement?

  4. What are the benefits of genetic testing? In what situations would you advocate for genetic testing?

  5. What are the possible negative effects of genetic testing?

  6. Is risk-based prevention preferable to population-wide measures in the context of limited public health resources?


October 5, 2007 Journal Club:

Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of Teaching Quality Improvement to Clinicians: A Systematic Review. JAMA 2007;298(9):1023-37.

Batalden P, Davidoff F. Teaching Quality Improvement: The Devil Is in the Details. JAMA 2007;298(9):1059-61.

Auden McClure, who selected the articles and will lead Friday's discussion, notes that "the journal club will focus primarily on Paul's JAMA article and a discussion around teaching QI. Paul's article references the 32 page Boonyasai systematic review and so it is provided as background."


September 7, 2007 Journal Club:

Auerbach AD, Landefeld CS, Shojania KG. The Tension between Needing to Improve Care and Knowing How to Do It. N Engl J Med 2007;357(6):608-13.

Beth Prairie selected this month's article and will lead our discussion, and she offers a few questions to consider (below) as you read the article. She also asks you to consider the following:

"This article raises important, potentially contentious issues in a major journal about the work we are all currently engaged in. These points are being discussed in a variety of forums around the country. I think we are in a particularly good position to write, and potentially publish, a letter to the editor about this piece. Please give some serious thought prior to journal club about what you would say in a letter to the editor regarding this article. I plan to take notes from our conversation and draft a letter for review by the group with the intent of submission."

Questions to consider:

  1. What do you think is the purpose of this piece?

  2. Take each argument (see Table 1 for summary) - If you had to pick a side for each, where would you fall?

  3. Do you agree with the author's assertion that ..."quality improvement is on common ground with the rest of biomedicine"? (p. 612) Why or why not?


August 3, 2007 Journal Club:

McDonald R, Harrison S, Checkland K, Campbell SM, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ 2007;334.

Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of Primary Care in England with the Introduction of Pay for Performance. N Engl J Med 357;2.

This month's journal club will pick up on the Pay-for-Performance theme we spoke about last year. Lisa Pastel, who selected these articles-- as well as last year's articles on the same subject -- also provides the letter to the editor that we prepared a year ago. At that time we expressed concern about the assumption that financial incentives are needed to improve care as well as concern about the unintended consequences of Pay-for-Performance. These two articles (one from the BMJ, the other from NEJM) directly address both of these issues.

Lisa invites you to give thought to the effect structured programs such as Pay-for-Performace might have on your field, your practicum, and our patients.

  • Is this the right direction for us to continue in?

  • Will this actually improve the quality of care in a sustainable way?

  • Are there areas in medicine where this kind of intervention would not work?

  • Is this the right way to provide the best care to our patients?


July 6, 2007 Journal Club:

Glouberman S, Zimmerman B. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, July 2002.

The article for discussion is attached and is already familiar to some involved with our residency program. This paper begins by distinguishing simple, complicated and complex problems, and provides a framework for understanding healthcare systems in which we work.


June 1, 2007 Journal Club:

Randolph G, Fried B, Loeding L, Margolis P, Lannon C. Organizational Characteristics and Preventive Service Delivery in Private Practices: A Peek Inside the "Black Box" of Private Practices Caring for Children. Pediatrics 2005;115;1704-1711.

The attached article was selected by Auden McClure, who will also lead our Friday discussion.


May 4, 2007 Journal Club:

Ockene JK, Edgerton EA, Teutsch SM, Marion LN, Miller T, Genevro JL, Loveland-Cherry CJ, Fielding JE, Briss PA. Integrating evidence-based clinical and community strategies to improve health. Am J Prev Med 2007;32(3):244-52.

The attached article was selected by Kristin Anderson, who provides these questions to consider as you read it:

  1. The article suggests that system integration through better pathways is the key to better outcomes for patients. Do you have specific examples from your own projects as examples where better connections can be made between microsystem/mesosystems/macrosystems? What are the barriers?

  2. On page 248, the authors suggest that system breakdown occurs where macro/mesosystems are not available to support clinicians. Who do you think has the responsibility to improve those connections?

  3. On page 250, the authors address the fact that there are cases where program implementation is difficult when there is a lack of evidence. Do we have an ethical responsibility to act without evidence?

  4. The authors use computer linked systems for referrals as an example of how linkages between systems can occur. Building on our discussion about leadership in April, are there specific examples where we can act to improve those connections? How do/should we prioritize areas of concern?


April 6, 2007 Journal Club:

Flin R, Yule S. Leadership for safety: industrial experience. Qual Saf Health Care 2004;13;45-51.

This month's discussion will be led by Chris Cook, who has selected the attached article for discussion. The theme of this discussion will focus on our (residents') vision of our future in leadership roles regarding patient safety as the second years move on to new positions and the first years transition to executing the practicum.:

Questions to consider as you read this article:

  1. In the next two years where do you see yourself (supervisor, middle manager, senior leader) with respect to patient safety or quality activities? Are there situation specific examples?

  2. If your role changes depending on situation how do you anticipate shifting your mental focus?

  3. Generic strategies to assist leaders in fostering safety are discussed. Can you give specific examples of things that might encourage patient safety?

  4. For the senior leaders in the group, how have you tried to instill a culture of safety?


March 6, 2007 Journal Club:

Goldmann D. System Failure versus Personal Accountability - The Case for Clean Hands. N Engl J Med 355;2: July 13, 2006.

This month's discussion will be led by Gavin Cotter, who apologizes for the short lead time to read the article and provides the following comment:

"It is an article that created alot of discussion within the Infection Control Group, yet is applicable to each of our LPMR quality improvement projects. Be prepared to talk about your project. We can learn a lot from each others experiences."

Questions to consider prior to Journal Club:

  1. What does accountability mean to you?

  2. Consider your own project: Who is accountable? What are the consequences for a "violation?"

  3. This article presents the required elements for Hand Hygiene: a model for system responsibility to personal accountability. How would you make a similar case for your own project?


February 6, 2007 Journal Club:

George B, Sims P, McLean AN, Mayer D. Discovering Your Authentic Leadership. Harvard Business Review February 2007.

This month's discussion will be led by Sally Ward, who provides the following comment:

This article allows each of us to consider our own path to being an 'authentic leader'. A set of questions on p. 134 should be read and considered before reading the paper.


January 2, 2007 Journal Club:

Brennan Ramirez LK, Hoehner CM, Brownson RC, Cook R, Orleans CT, Hollander M, Barker DC, Bors P, Ewing R, Killingsworth R, Petersmarck K, Schmid T, Wilkinson W. Indicators of Activity-Friendly Communities: An Evidence-Based Consensus Process. Am J Prev Med 2006;31(6):515-524.

This month's discussion will be led by Brian Shiner, who provides the following comment:

In order to mix it up a little bit and avoid making people read something psychiatry-specific, I chose something glitzy out of this month's American Journal of Preventive Medicine. The commentary on page 530 is helpful.

I was interested in this article for two reasons:

  1. Governmental Public Health Project: I am working with a health-promotion project in Keene for persons with severe mental illness. Issues like transportation frequently come up when participants stop going to the gym, gain weight back, etc.

  2. Field Visits from ECS 154: I think this gives a nice lens for thinking about whether a community is health-promoting. I had a hard time thinking about this during our field visits this fall.

Questions:

  1. Given our large referral region at DHMC and the diversity of places that our patients come from, how do we make relevant recommendations about physical activity?

  2. Can you think of one town where your patients come from that meets all the indicator domains? Is there a town that meets none of them? Does this apply to rural communities?

  3. Is this "actionable" information? As we think about the patients coming to our microsystems (Jason's diabetes project and Auden's obesity project come to mind), do we need to consider this, or is this beyond the scope of our influence? (i.e. Why worry about this if we can't even remember to check HgbA1Cs or wash our hands?)


December 1, 2006 Journal Club:

Gawande A. Casualties of War - Military Care for the Wounded from Iraq and Afghanistan. N Engl J Med 2006:351(24);2471-75.

Hogan MP, Pace DE, Hapgood J, Boone DC. Use of Human Patient Simulation and the Situation Awareness Global Assessment Technique in Practical Trauma Skills Assessment. J Trauma 2006;61:1047-1052.

This month's discussion will be led by Sarah Greer, who has provided two articles and the following description:

The article by Atul Gawande is an interesting description of the war in Iraq and discussion of measurement. One of the training tools that we are adopting from our military colleagues is the use of simulation. The second paper is a recent study by a group in Newfoundland on simulation in trauma with a discussion about validation of assessment tools.


November 3, 2006 Journal Club:

McDonald R, Waring J, Harrison S. Rules, safety and the narrativisation of identity: a hospital operating theatre case study. Sociology of Health & Illness 2006;28(2):178-202.

Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks MM. A prospective study of patient safety in the operating room. Surgery 2006;139:159-73.

This month's discussion will be led by Beth Prairie, who has provided two articles for discussion. She will draft a "letter to the editor" in response to the Christian, et al article; this draft will be distributed in advance of the meeting. Beth also provided some questions for you to ponder as you read:

Re: McDonald article

  1. Do you believe in the concept of a "safety culture"?

  2. What do you think the implications of this research are in terms of limiting physician autonomy? In terms of changing the "craftsman" attitude?

  3. What do you think about the causes and/or motivations behind not following written rules and policies? Do you think the methods used in this paper around narrative identity are helpful in understanding those motivations?

  4. What do you think about the differences between the manager and physician narratives? What useful information could be gleaned from that when thinking about implementing safety protocols?

  5. What do you think about the tension in the physician narrative around the importance of routine and of being able to work "on the edge" and the need to be flexible? How does this influence implementation of protocols and guidelines?

Re: Christian article

  1. What do you think of their methodology?

  2. Do you think it's significant that the two areas they discovered as persistently problematic were communication/information flow and workload coordination? Why?

  3. What are some approaches to alleviating these 2 problem areas?

  4. How do think the findings in this article relate to those in the McDonald article?


October 6, 2006 Journal Club:

Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M. Pay-for-Performance Programs in Family Practices in the United Kingdom. N Engl J Med 2006;355(4):375-84.

Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does Pay-for-Performance Improve the Quality of Health Care? Ann Intern Med 2006;145(4):265-272.

This month's discussion will be led by Lisa Pastel, who suggests two articles for discussion. She will be preparing a "letter to the editor" for consideration during the discussion, in response to the NEJM article. Additionally, she offers the following commentary and questions to consider as you read the articles:

"Pay-for-Performance - What is the evidence?"

We will be looking at 2 recent articles regarding pay-for-performance, one in the UK and the other a systematic review of P4P programs. Our journal club will be attended by Dr. John Butterly from Cardiology who is involved with early efforts in pay-for-performance at DHMC. Below are some questions to consider as we resume the previous format writing a letter to the editor.

  1. Does pay-for-performance improve quality of care?

  2. Where should pay-for-performance focus - on the outcomes, the process, the individual, the group, prevention, acute, or chronic conditions? Where is it most likely to be most effective?

  3. What are the drawbacks to pay-for-performance? What are the benefits of pay-for-performance?

  4. Is pay-for-performance cost-effective?


September 1, 2006 Journal Club:

Amalberti R, Auroy Y, Berwick D, Barach P. Five System Barriers to Achieving Ultrasafe Health Care. Ann Intern Med 2005;142:756-764.

This month's discussion will be led by Ken Deem and Martha Regan-Smith. The article was recommended by Paul Batalden after it produced a thoughtful dialogue, at a recent Summer Symposium, about barriers to improved safety in health care organizations.

This month we will temporarily return to our format of considering a series of questions to focus the discussion. Ken's and Martha's questions are:

  1. The article addresses 5 "high-level organizational dimensions" in managing risk and safety. Who is in a position to utilize these concepts to improve the health care industry?

  2. Why can't health care limit production to improve safety?

  3. How could physician autonomy be limited? Who would enforce restrictions on autonomy?

  4. What "ethically compelling numerators" exist in your own practice? How does your choice of denominator change the perception of risk?

  5. Are there sectors of medicine incapable of becoming "ultrasafe"? What are the ethical implications of a two-tiered system of medicine with different levels of inherent risk?


August 4, 2006 Journal Club:

Eric Howell, MD, from Johns Hopkins' Bayview Campus, who is speaking earlier in the day at the Medicine Grand Rounds on the issue of transitions of care between hospitalists & primary care, will join the Leadership Preventive Medicine Journal Club to continue dialogue about issues surrounding "Readmissions & Hand-offs" in the context of the attached articles.

Jason Aaron, LPM resident in his Practicum Year, has arranged this Journal Club discussion as a continuation of the morning Grand Rounds presentation, and it should provide a great learning opportunity.

As part of the journal club format, Jason will be drafting a letter to the editor of the first article on diabetes-related readmissions and will gather input from the diverse attendees to revise his letter based upon the institutional perspective on the issue. The discussion will not be limited to diabetes of course, it will be more broad. Questions to consider are:

  1. Can we predict readmissions among chronic illnesses?

  2. If so, how?

  3. What is the most effective practice for preventing readmissions (obviously the national trend is toward using multidisciplinary teams incorporating specialized or advance-practice nurses)?

  4. How short is too short for length of stay? Do we cross this line?

  5. Is it reasonable to expect better (given the 2nd article's evidence showing no improvement in readmission rates for CHF during the 1990's)?


July 7, 2006 Journal Club:

Schafer S, Gillette H, Hedberg K, Cieslak P. A Community-wide Pertussis Outbreak: An Argument for Universal Booster Vaccination. Arch Intern Med 2006;166:1317-1321.

This month's discussion will be led by Travis Harker and Julie Sorensen, with credit to Jason Aaron who suggested this timely article for the DHMC community.

This month we will try a new approach to the Journal Club dialogue. In place of questions for the reader to consider, the discussion leader(s) will draft a "letter to the editor" re: the article under consideration, and the discussion will center on both the article and the letter. The discussion leaders will attempt to provide their draft "letter to the editor" before the meeting. Hopefully, a number of these letters from the DHLPMR Journal Club will be published documents.

We thank Travis and Julie for their leadership with this new style of Journal Club review, and you can expect more discussion about this format during the upcoming Journal Club.


June 2, 2006 Journal Club:

Stevenson KM, Dahl JL, Berry PH, Beck SL, Griffie J. Institutionalizing effective pain management practices: Practice change programs to improve the quality of pain management in small health care organizations. J Pain Symptom Manage 2006;31:248--261.

This month's article was selected by Brian Boulay, who will lead the discussion. He provides the following questions to consider as you read:

  1. The scope of this project is much larger than that of a microsystem. The authors sought to adapt evidence-based care in multiple settings. What are the challenges that come with expanding the scope of quality improvement efforts beyond the microsystem?

  2. The authors claim that this initiative was designed to go further than education, and would install institutional structures to improve pain assessment and treatment. To what degree would you say they achieved this goal?

  3. Does the article discuss the various settings in enough depth to let you know what factors contributed to success? What information would you have wanted?

  4. What do you think of the measures in this project? Would you have constructed different measures?

  5. Does this project appear sustainable? What factors may influence the sustainability of the performance gains?


May 5, 2006 Journal Club:

Durbin CG. Team model: Advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med 2006; 34[Suppl.]:S12-S17).

This month's article was selected by Chris Cook, who will lead the discussion, and he provides the following questions to consider as you read:

  1. Are teams routinely employed in your practice environment? If so how are they developed?

  2. How has the team fostered a sense of "ownership" for patient care?

  3. What barriers have you experienced moving from a sole provider model to a team model of care?

  4. How has your local practice addressed barriers to team formation similiar to those discussed in the article or unique to its microsystem?


April 7, 2006 Journal Club:

Bernat JL, Peterson LM. Patient-Centered Informed Consent in Surgical Practice. Arch Surg 2006;141:86-92.

This month's article was selected by Ken Deem, who is pleased to report that Dr. Lynn Peterson, one of the co-authors of this month's article, will be joining the Journal Club discussion. In this article, Bernat and Peterson review the "doctrine" of informed consent and discuss some of the challenges faced when informed consent is seen as a process rather than a signature on a form.

As you read this article, please consider the following questions:

  1. Informed consent is "reconceptualized" as a process with related situations, issues and controversies. What processes are identified? Are specific steps for each process considered? What are they? Can you map one of these processes based upon information provided in the article?

  2. Imagine a balanced set of measures for one process related to informed consent. What measures are identified in this article?

  3. The article concludes with several suggestions for improving informed consent. Does the article help the reader frame these improvement initiatives within their local setting? How might the processes, measures, and improvement initiatives discussed be adapted to lead local improvement efforts?

  4. The DHMC consent form is also available for your review. How does this form support or oppose the concept of informed consent as a process at DHMC?


March 7, 2006 Journal Club:

Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful Strategies for Improving Operating Room Efficiency at Academic Institutions. Anesth Analg 1998;86:896-906.

This month's discussion will be led by Erica Boulay, who selected the article and posed the following questions to ponder as you read the article:

  1. Was the description of the improvement effort sufficient to permit another hospital to duplicate it?

  2. Do you think that the measures chosen by the authors were balanced? If not, what else would you want to know?

  3. What do you think about the types of figures that they chose to display the data? Were they effective? If not, what would you do?

  4. What do you think about the results and degree of impact of the improvement project?

  5. Did you identify any sources of bias? If so, how might this affect interpretation of their results?

  6. Did they provide information about their plans to maintain the changes or what their next steps might be?


February 7, 2006 Journal Club:

Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases: Implications for Pay for Performance. JAMA 2005;294:716-724.

This month's discussion will be led by Lora Council, who selected the article and posed the following questions to ponder as you read the article:

  1. After reading the article, do you agree that "clinical practice guidelines do not provide an appropriate, evidence based approach for assessing quality of care in older adults with several comorbid diseases?"

  2. What are the unintended consequences of basing pay for performance on CPG recommendations?

  3. Given that CPGs may improve quality by supporting a rational clinical approach and decreasing variation, can they be used as a quality assessment tool?

  4. What other quality assessment tools could be used to assess the care of the hypothetical patient in this article? How can you measure quality in complex patients?


January 3, 2006 Journal Club:

Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Crit Care Med 2005;33(10):2184-93.

This month's discussion will be led by David Kelley, who selected the article and posed the following questions to consider as you read the article:

The expressed goals of this meta-analysis were to assess the magnitude of effect of ventilator-associated pneumonias (VAP) on three pt parameters: mortality, length of stay & costs.

  1. In your opinion, were the authors successful in their quest?
    • What characteristics of the meta-analysis supported their conclusions?
    • What characteristics of the meta-analysis seemed to weaken their assertions?

  2. "Statistically Significant Heterogeneity": does this present characteristic of the included set of articles in the meta-analysis cause concern for you? Why?
    • What 2 broad categories contribute to heterogeneity in a meta-analysis?
    • A Forest plot can visually demonstrate the magnitudes of effect & variance between articles in a meta-analysis. Should the authors have included a Forest plot? Could this type of plot have allowed the reader to ascertain whether the significant inter-article variance resulted from a small number of outliers or gross incongruence?

  3. Do you feel that the large number of study types strengthened or undermined the authors' assertions? Why?
    • Could the study selection paradigm been modified to yield a stronger, more congruent collection of studies?
    • Would this increase in congruence necessarily conveyed more validity to the authors' assertions?

  4. If you had unlimited resources at your disposal, how would you attack the question on the above three pt parameters?
    • In the reality of restricted resources, how would you change your plan of attack from #4?
    • Do you consider them worth the expenditure of resources to address?


December 2, 2005 Journal Club:

Dong M, Giles WH, Felitti VJ, Dube SR, Williams JE, Chapman DP, Anda RF. Insights Into Causal Pathways for Ischemic Heart Disease: Adverse Childhood Experiences Study. Circulation, 2004;110:1761-1766.

This month's discussion will be led by Jason Aaron, who selected the article, and Jeff Fetter from the Med-Psych program who finds this subject to be an area of interest. Please consider their questions as you read the article:

  1. What are the implications of the ACE Model (Adverse Childhood Experiences)?

  2. What is the danger of ignoring the role of ACE in managing chronic illness (assuming this association is valid)?

  3. How often do your patients self-medicate with things like food, alcohol, nicotine?

  4. How have your patients' lifestyle choices led to the illness you treat (whether it's lung cancer, COPD, irritable bowel, HIV, teen age pregnancy)?

  5. Name one way in which your patients may be "choosing" their illness (i.e. what is the advantage of being ill in the their particular case)? Example: an obese woman may be ignored by men that remind her of a former abuser.

  6. Do you find it strange that this research would arise out of an HMO like Kaiser Permanente? Is that sufficient for classifying it as an important Preventive Medicine topic?


November 4, 2005 Journal Club:

Wall RJ, Ely EW, Elasy TA, Dittus RS, Foss J, Wilkerson KS, Speroff T. Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Qual Saf Health Care, 2005;14;295-302.

This month's discussion will be led by Gavin Cotter and Kathy Kirkland, who selected the article and questions. Please consider their questions as you read the article:

  1. Comment on the process undertaken to define the clinical microsystem (i.e. flow diagram/Interdisciplinary team). Was it complete in your opinion? If no, then what other approaches would you undertake?

  2. With any transformation of change support of leadership is a great advantage. Do you feel adequate support from leadership was given in this article? What do you think of Risk Managements initial input?

  3. Comment on the measurement of change: "real time process measurement." Do you feel the use of the alternative Shewart-type statistical control methodology was effective? Why?

  4. Comment on the team's cycles of continuous quality improvement (CQI).

  5. Note the "key concepts for sustainability." Do you think this list is complete? If no, then what would you add?

  6. Reflect on your present project (CLAR/Practicum): Did you apply a similar approach?


October 7, 2005 Journal Club:

Katzelnick DJ, Von Korff M, Chung H, Provost LP, Wagner EH. Applying Depression-Specific Change Concepts in a Collaborative Breakthrough Series. Journal on Quality and Patient Safety, 31;7:July 2005.

This month's discussion will be led by Brian Shiner, who has teamed with Tom Oxman in selecting the article and questions. Please consider their questions as you read the article:

  1. This large implementation and dissemination study lacked a control group. Does this prevent the results from being clinically useful?

  2. What clinical diseases that you deal with in your own practices could be improved with this model? What are the potential drawbacks?

  3. Is working the PDSA cycle necessary to implement evidence-based practice in diverse clinics? What are alternatives? Why not just follow the information in the McArthur depression kit?

  4. Why do you think some of the teams did not succeed?


September 2, 2005 Journal Club:

Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. California Management Review, vol. 45, no. 2, Winter 2003.

This month's discussion will be led by Kisha Weiser, who has teamed with Steve Liu in article selection and question formulation. Please consider their questions as you read the article:

  1. Presumably, we are all limited (and freed) by our culture. How would you begin to recognize or expose sets of underlying assumptions and practices within your own culture, to which you are "entrapped"?

  2. In the BRI example, the article focuses primarily on the fixed assumption that poor outcomes were related to difficulty of case mix. I would argue there were several other assumptions/norms that limited BRIs ability to recognize the severity of the problem. What other assumptions did you notice?

  3. In your department, and related to your CLAR, what assumptions have you seen? How will these affect learning/change in your department and make CLAR work more difficult? How do these assumptions, that you too have assumed/learned, affect YOUR ability to learn/change/think creatively about your CLAR?

  4. Seeing these assumptions- how do you work around them? Do you challenge them? ignore them? find a new project? How might you use this culture to your advantage, to gain buy in or support?


August 5, 2005 Journal Club:

Kotter JP. Leading Change: Why Transformation Efforts Fail. Harvard Business Review, March-April 1995.

This month's article is offered by Concord Hospital's Bill Gunn. Please consider the following questions as you read the article:

  1. The author studied transforming actions in major corporations... which of these observations, if any, apply to the change process in healthcare microsystems?

  2. A "Useful Rule of Thumb" is offered in the top right column on p. 63. Does this bear any resemblance to the PRB presentations?

  3. For the LPM 2 residents, based on your CLAR experience and initial work on the Leadership Practicum, which "errors" in leading change do you think most critically effect the outcome?

  4. As you read the transforming "errors", do any memories emerge of personal successes, or failures, in instituting a change? Any in your work experience that might offer an educational lesson? Share a success or failure story related to one of the described "errors", and how the situation might have had a different outcome.


July 1, 2005 Journal Club:

Glouberman S, Zimmerman B. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, July 2002.

This month's article was selected by Paul Batalden, who provided the following questions to stimulate your thinking about change in organizations:

  1. What are examples of these three different types of systems in direct patient care? How might you know if you have labeled them correctly?

  2. So, if you really want to change a COMPLICATED patient care system you know very well, what should you do?

  3. Ditto, but what if the system is COMPLEX...??

  4. In the last two weeks, what propositions for changing, improving health care have you heard? What type of system do think the speaker was thinking of? How accurate was the change prescription?


June 3, 2005 Journal Club:

Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton CG. Evidence of a Dose-Response Relationship Between "truth" Antismoking Ads and Youth Smoking Prevalence. Am J Public Health. 2005;95:425-31.

This month's article was selected by Sharon McDonnell and she provides the following introduction and questions to stimulate your preparation:

The article provides one of the first evaluations of the large scale social marketing campaign made possible by the Master Settlement Agreement between tobacco companies, 46 state Attorneys General, and the American Legacy foundation.

  1. Please read the attached article prior to the session.

  2. During the session we will:

      a. watch a few examples of TV advertising developed and shown by "truth".

      b. Describe relevant background on how the advertising campaign was designed and how this can be contrasted with the more typical "public service announcements" used in public health promotion.

  3. Consider "societal level" or health determinant-based public health interventions such as the "truth" anti-smoking campaign and compare these with other, perhaps more familiar, public health interventions. The comparisons might include cost, efficiency, effectiveness, and what others?

  4. We will not be focusing on the specifics of the relatively complex study design and analysis of the paper. That said, however, if money were no object how would you design this evaluation to answer the questions about the effectiveness of this or similar campaigns that might be even more convincing?

  5. The campaign has been criticized for its high cost. In lieu of the results of this evaluation what do you think about the cost effectiveness?


May 6, 2005 Journal Club:

Relman AS. Medicine and the Free Market: The Health of Nations. The New Republic. 03/07/05.

This month's article was selected by John Trummel and he offers the following questions for your consideration:

  1. Do you buy the argument that healthcare is not a business? If so, what implications does this have for our present system of healthcare?

  2. Do you think that competition in the healthcare market has led to improved quality of care? For example, the concept of "disease management" was developed both to improve care and cut costs. And there are advantages to the "gatekeeper" model of healthcare. Is the author too quick to dismiss the entire system?

  3. The author argues that a competitive healthcare market has caused the quality of medical care to suffer. Do you agree? Was the IOM report, "Crossing the Quality Chasm," negligent because it didn't address the flaws in the system? (Remember: every system is perfectly designed to get the results it produces.)

  4. What's wrong with the idea of "consumer-driven healthcare"? Shouldn't we be giving the consumers what they want? Won't this improve quality? Isn't it somewhat paternalistic to believe that informed consumers can't make a rational choice about their care?

  5. Do you think a majority of doctors will really care about eroding professionalism and quality of care to stand up to the entrenched interests and demand a reform of the system? What do you think of Dr. Relman's proposal for an ideal healthcare system? Is it realistic? What are the advantages and disadvantages? What would Dr. Weeks think?


April 1, 2005 Journal Club:

Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units. N Engl J Med. 2004;351(18):1838-48.

This month's article was selected by Julie Sorensen, and she offers the following questions for your consideration:

  1. Comment on the study design. Any weaknesses in the design? Would something like the Intervention Schedule be possible in your institution?

  2. What are the implications of this study for academic hospitals? Do the results apply to less acute settings such as the medical floor? Do they apply to more senior physicians?

  3. If you feel that prolonged physician duty shifts may be harmful for patients, do you think physicians and hospitals can or will respond appropriately without outside intervention? In other words, the government has had to make regulations for airline pilots and truck drivers to prevent them from endangering the public by working too long; will this kind of intervention be necessary for the medical community?

  4. How could reduced work hours impact on physicians' readiness to practice independently after training?

  5. Studies showing that humans subjected to acute and chronic sleep deprivation are more likely to make errors have been done before. In fact, this article published in NEJM would not be considered for publication in the human factors literature (according to George Blike, DHMC patient safety officer). Why did this study, and others recently published, need to be done? Is there any reason to think that physicians are different from other humans in their ability to function after sleep deprivation? What does this say about the medical community?


March 1, 2005 Journal Club:

Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from US hospitals. Qual Saf Health Care. 2004;13;26-31.

This month's article was selected by Steve Liu, and he offers the following questions for your consideration:

  1. Public reporting of quality measures has become increasingly important to this institution through the quality measures web site (http://www.dhmc.org/qualitymeasures). Nationally, it is also taking on more importance as CMS begins to report quality measures for 4000 hospitals on their web site (http://www.cms.hhs.gov/quality/hospital/) and could begin to base reimbursement on these measures. Do you think that this method of feedback to institutions through the internet and "pay-for-performance" initiatives can promote improvement efforts within our hospital and nationally?

  2. Does feedback have to be provider specific or can institution wide data also promote change? Do you feel that provider specific data feedback can be punitive? If the institution begins to be judged and reimbursed based on certain performance measures - what would you think of the possibility that provider's salaries could be based on their performance on certain quality measures?

  3. If provider specific data was available, would you be willing to share that data with your colleagues? With your patients?

  4. What are some ways in which you could integrate timely, valid, and credible feedback into the health care systems in which you work?


February 1, 2005 Journal Club:

Shojania KG, Grimshaw JM. Evidence-Based Quality Improvement: The State Of The Science. Health Affairs. 2005;24(1):138-50.

This month's article was selected by Sally Ward, and she offers the following questions for participant consideration:

  1. The article states that the paradigm of EBM should be applied to research in the area of quality improvement (QI) and argues that randomized designs are even more essential to QI than to clinical medicine. Do you agree with the author's argument?

  2. The author explains that one of the obstacles to obtaining meaningful outcomes is the lack of consistency in definitions used in the literature. Do you think this is unique to QI research? How would you suggest making this happen?

  3. On page 148, the author argues that "we need empirically derived models to inform the decision to select specific implementation strategies, based on clinical features of the quality target, organizational or social context, and relevant attitudes and beliefs of providers and patients." What does this mean to you?


January 4, 2005 Journal Club:

Murray M, Tantau C. Same-Day Appointments: Exploding the Access Paradigm. FPM. September 2000.

O'Hare CD, Corlett J. The Outcomes of Open-Access Scheduling. FPM. February 2004.

This month's articles were selected by Travis Harker, and he offers the following thought-provoking questions for participants:

  1. The O'Hare article argues that open access scheduling has dramatically improved their system of care delivery in many ways that both doctors and patients care about. How would you approach promoting this idea in your system of care? What would be barriers? Would it work in your specialty?

  2. Can this model of scheduling work in all environments? Low socio-economic status communities? Specialty practices?

  3. If this model doesn't fit your specialty, what can be done to facilitate access for patients when it is timely for them?


December 3, 2004 Journal Club:

Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ. 2004;329;1017.

This month's article, "What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review", was selected by Matt Cole, and he offers the following thought-provoking questions for participants:

  1. The authors systematically reviewed the effects of standalone (Table 1) versus clinically integrated teaching methods (Table 2). Is this a fair comparison, given that none of the studies compared the two teaching methods to each other? Recall some of your experiences of both methods during your training? Which did you prefer? Why?

  2. The authors conclude that although both teaching methods can improve knowledge, standalone teaching is ineffective in bringing about changes in skills, attitudes, and behavior. Drawing from your own experiences, do you agree with this conclusion? Can you think of any examples that contradict their conclusion?

  3. How can we encourage more individuals to bring 'teaching out of classrooms?'

  4. What key elements of the existing 'culture of medicine' must be considered, in order to reach out to those individuals not convinced of the value in an integrated method of teaching?


November 5, 2004 Journal Club:

Armstrong EG, Mackey M, Spear SJ. Medical Education as a Process Management Problem. Acad Med. 2004;79(8):721-8.

Brian Boulay selected this month's article and will lead the discussion. His questions for consideration are:

  1. Reflect on your experience in medical school. Is it consistent with the case study and the authors' arguments against the current system? Did you perceive any problem at the time?

  2. The authors take great pains to defend their analogy between medical education and manufacturing. Is this analogy realistic or problematic?

  3. How can residents adjust their efforts to maximize our contribution to the education of medical students?

  4. What obstacles exist to implementing the changes the authors propose (the pathway rule, connection rule, and work activity rule)? How might these obstacles be overcome?

  5. How comprehensive is this proposed change? Does it ignore any larger context in which medical education occurs?


October 1, 2004 Journal Club:

Elgerg S. Quality Improvement in Family Practice: A Recipe for Change. Am J Med Quality. 2004;19(2):83-7.

Kristin Anderson selected this month's article (attached) and will lead the discussion. Her questions for consideration are:

  1. With respect to the Q1 level, What does "culture of medicine" mean for you? Do you think it limits the quality of care that you deliver?

  2. Based on the Q2 level, how do you think guidelines in medicine work now and how do you see them working in the future? Do you think state law is an appropriate way to ensure quality?

  3. How do we provide an environment for ourselves and other practitioners to make changes at the Q3/Q4 level? What are the barriers to the factors in the quality compass that are outlined? How significant is employee satisfaction to you?

  4. In what ways can we encourage people to take their own steps toward quality improvement?

  5. This article was written in regards to Quality Improvement in the Family Practice setting. For those of you in other specialties, can you think of any fundamental differences in an approach to Quality Improvement in your specific clinical settings?


September 3, 2004 Journal Club:

Ogrinc G, Headrick LA, Mutha S, Coleman MT, O'Donnell J, Miles PV. A Framework for Teaching Medical Students and Residents about Practice-based Learning and Improvement, Synthesized from a Literature Review. Acad Med. 2003;78:748-56.

Jared Barton selected this month's article (attached) and will lead the discussion. His questions for discussion are:

  1. Is the Dreyfus level of Professional Development and Knowledge Performance useful for developing the construct by which the panel categorized its recommendations?

  2. How practical would it be for a residency program director to implement the recommendations of the panel?

      a. Is the article clear and understandable?

      b. Are the recommendations well defined?

      c. Could these recommendations be incorporated into a residency program without significant difficulty?

      d. What would it take to install these recommendations into your previous (non-DHLPMR) residency?


August 6, 2004 Journal Club:

Thom DH, Ribisl KM, Stewart AL, Luke DA, et al. Further Validation and Reliability Testing of the Trust in Physician Scale. Med Care. May 1999;37(5):510-7.

Thom DH et al. Physician Behaviors that Predict Patient Trust. J Family Practice. April 2001;50(4):323-8.

Thom DH, Hall MA, Pawlson LG. Measuring Patients' Trust In Physicians When Assessing Quality Of Care. Health Affairs. Jul/Aug 2004;23(4):124.

Questions to think about:

  1. What is your response to the concept of measuring patient trust in providers?

  2. How might you approach measuring trust in a given microsystem? Would you measure only patients' trust? others'? How might you respond to the results?

  3. Is trust within your organization important? How do you assess your level of trust in your microsystem or larger organization? How does your level of trust affect your actions?

  4. What about trust at the "community" level? For example, a health department that wanted to ascertain if "trust" in providers was a problem in their community? Is there trust in the microsystems and larger organizations that provide care?


July 9, 2004 Journal Club:

Drucker PF. What Makes an Effective Executive. Harvard Business Review. June 2004:58-63.

Paul Batalden and Jim Heimarck collaborated on selecting the article, and offer the following questions for participants:

  1. Drucker describes 8 common practices of a successful leader. Do they make sense to you? Have you observed them in action in individuals leading an organization (whether large or small)? Describe a situation in your experience that portrays effective use of these practices. Have you observed other practices of effective managers that you think should be added to the list?

  2. Managers are described as "doers; they execute" in the section entitled "Write an Action Plan". In the same section the action plan is described as a "statement of intentions". Why? How do we reconcile the image of decision-making, action-oriented, results-driven, and authoritative leader with the possible image of uncertainty, changeableness, and/or "waffling"?

  3. What is the role of "failure" for the effective leader?

  4. Why are "problems" opportunities?

  5. How does "authority" accrue to the effective leader?


June 4, 2004 Journal Club:

Burke JP. Infection Control - A Problem for Patient Safety. N Engl J Med. 2003;348(7):651-6.

Gawande A. Notes of a Surgeon: On Washing Hands. N Engl J Med. 2004;350(13):1283-6.

Klass P. Perspective: Index Case. N Engl J Med. 2004;350(20):2023-6.

Carolyn Murray selected the articles for June and her questions for the group are:

  1. How do current systems of care in your clinical practice relate specifically to infection risks to your patients? (examples: antibiotic prescribing patterns, correctly timed surgical antibiotic prophylaxis, hand washing "culture")

  2. Perri Klass refers to our "die with your boots on ethos" as one reason she never considered "not" seeing patients when she was ill. Keeping in mind the SARS outbreak in Toronto, how do we consider these patient and co-worker risks in terms of re-defining "professionalism"?

  3. Health care worker compliance with influenza vaccination is only 30-40 percent nation wide. Mandatory vaccination for health care workers is being considered in some health care facilities. Do you think this is appropriate?


May 7, 2004 Journal Club:

Zuger A. Dissatisfaction with Medical Practice. N Engl J Med. 2004;350(1):69-75.

The article was selected by Steve Liu, and discussion will consider these questions:

  1. Knowing that there are regional and specialty variations in physician satisfaction, what is your opinion of the local satisfaction at DHMC and Concord?

  2. What do you feel are the primary sources of physician dissatisfaction in your practice? And are there possible solutions that you have developed to reduce or cope with the dissatisfaction?

  3. How can we demand more of physicians (demand higher quality and fewer errors) without increasing the workload and dissatisfaction? Do you believe that identifying the problem of medical errors has "magnified feelings of insecurity" among physicians?

  4. Do you feel that physician satisfaction is a public health issue? Have you seen or experienced episodes where patient safety or care was compromised?

  5. Should prospective medical students undergo an "informed consent" prior to entering medical school? How should we educate and fully inform prospective students about the future careers that they about to enter?


March 2, 2004 Journal Club:

Merenstein, D. A piece of my mind: Winners and losers. JAMA. 2004;291(1):15-16.

Perron L, Moore L, et al. PSA screening and prostate cancer mortality. CMAJ. 2002;166(5):586-91.

Vis AN. Does PSA screening reduce prostate cancer mortality?. CMAJ. 2002;166(5):600-01.

Discussion will consider these questions:

  1. Is the shared-decision making model advisable for young physicians given the risk of this experience?

  2. Other than defaulting to doing unneccesary testing, what could have this third year resident and his residency done to prevent this outcome? What can other residencies learn?

  3. When "doing what is right" is at odds with "covering your back", what should providers do?

  4. What opportunities does this experience create for providers in the future?


February 3, 2004 Journal Club:

Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289:1969-75.

Collins BA, Hawks JW, Davis R. From Theory to Practice: Identifying Authentic Opinion Leaders to Improve Care. Managed Care. July 2000.


January 2, 2004 Journal Club:

Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of Medical Errors in Morbidity and Mortality Conferences. JAMA. 2003;290:2838-42.


December 2003 Journal Club:

Souba WW. The New Leader: New Demands in a Changing, Turbulent Environment. J Am Coll Surg. 197;1:July 2003.

Souba WW. Academic Medicine and the Search for Meaning and Purpose. Academic Medicine. 77;2:February 2002.


November 7, 2003 Journal Club:

Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs, and Issues. Ann Intern Med. 2003;139(1):31-39.

Primer on Dissecting a Medical Imperative. Effective Clinical Practice. November/December 2000;3:6.

Norton R. Unintended Consequences. The Concise Encyclopedia of Economics.

Questions:

  1. At the VA we have a computer physician order entry system - reputably one of the best in the country. In our experience however, we have seen a decline in certain types of error (transcription error, handwriting error), but we continue to have significant problems with medication error. We have been examining medication error at the time of discharge and have found new, unanticipated errors including: loss of patients outpatient medication list after transfer to inpatient and therefore inability to confirm discharge list with previous outpatient list, problems with "cut & paste" etc. I found NO literature on how to deal with unintended consequences - how would you begin to systematically address or pre-emptively address unintended consequences? What does one do about these unintended consequences anyway?

  2. I found almost no discussion of medical literature on Unintended Consequences. This concept however is much more familiar in the economic realm... When/How do we begin to consider potential unintended effects in QI projects?


September 5, 2003 Journal Club:
There are three articles and an editorial for this session.

Ferguson TB, Peterson ED, Coombs LP et al. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial. JAMA. 2003;290:49-56.

Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775780.

Moss F, Thompson R. Editorial: A new structure for quality improvement reports. Quality in Health Care. 1999;8:76.

Lenfant C. Clinical Research to Clinical Practice - Lost in Translation? N Engl J Med. 349;9:August 28,2003.

Questions for the JAMA article and QSHC editorial:

  1. What makes the JAMA article a quality improvement study? Is it?
  2. Would it meet the criteria suggested by the Editors in Quality in Health Care? If so, why? If not, why?

Questions for the Academic Medicine article:

  1. How could this be made useful to practicing physicians interested in decreasing their diagnostic errors?
  2. How could practitioner practice be assessed for diagnostic errors?
  3. What difference could it make and would such difference be monitored?


July 11, 2003 Journal Club:

McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45.

Barabasi AL, Bonabeau E. Scale-free networks. Sci Am. 2003;288(5):60-9.

Paul's slide depicts 5 knowledge domains, all of which are important to consider when thinking about how to improve health care and the health of populations:

  1. Scientific Evidence
  2. Understanding Context
  3. Balanced Measurement
  4. Linking Science and Context
  5. Improvement

Can we think about which of these domains are addressed in the articles we read for Journal Club? What are the questions we want to ask about the literature that addresses these domains? Most of us are familiar with the kinds of questions we ask about scientific evidence. I have attached Paul's list of questions to "ask and be clear about" when trying to improve care in a particular setting. Are there other questions related to the concepts covered above? Are there ways to begin thinking about how these five domains should be approached, and how they relate to each other?


June 13, 2003 Journal Club:

van Schoor NM, Smit JH, Twisk JWR, Bouter LM, Lips P. Prevention of Hip Fractures by External Hip Protectors: A Randomized Controlled Trial. JAMA. 2003;289(15):1957-1962.

Meyer G, Warnke A, Bender R, Muhlhauser I. Effect on hip fractures of increased use of hip protectors in nursing homes: cluster randomised controlled trial. BMJ. 2003;326(76).

Questions to ponder:

  1. These two articles conflict in their assessment of the effectiveness of hip protectors. What issues should be considered when deciding whether to use this intervention? Address if you are the hospital administrator, and if you are leading a fall reduction team.

  2. What is the impact of studying one fall and injury reduction strategy in isolation?

  3. What needs to be done to resolve the dilemma of these conflicting results?


May 2, 2003 Journal Club:

Donald M. Berwick. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975.

Mills PD, Weeks WB, Surott-Kimberly BC. A Multihospital Safety Improvement Effort and the Dissemination of New Knowledge. Joint Commission on Quality and Safety 2003;29(3):124-133.

Berwick's article provides an excellent summary of some of the literature and synthesizes seven key "rules" for fostering innovation. Weeks reports on the results of a VA collaborative effort and the local diffusion of improvement.

Consider the following:

  1. Are the rules for disseminating innovation practical? Are they helpful in addition to other tools for improvement?

  2. What were the greatest barriers to diffusion of innovation for the teams as reported in the Weeks article? What other barriers might there be?

  3. How could the 7 rules have helped the teams in the QuIC collaborative? Which rules might be most helpful in a collaborative environment?

  4. Which rules could be most helpful when you're leading an improvement team in your local setting?


February 7, 2003 Journal Club:

David Meltzer et al. Effects of Physician Experience on Costs and Outcomes on an Academic General Medicine Service: Results of a Trial of Hospitalists. Ann Intern Med. 2002;137:866-874.

Andrew C. Auerbach et al. Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes. Ann Intern Med. 2002;137:859-865.

These two studies published in the Annals last year evaluate the cost and outcomes of care provided by hospitalists.

Consider the following:

  1. Are these quality improvement studies? Why or why not?

  2. What is a hospitalist? Can you tell from the methods section of these papers?

  3. Auerbach is a retrospective cohort study. What do you think of their secondary analysis using the propensity score? Could this be applied to other, non-randomized studies?

  4. The Leapfrog group has endorsed intensivists as a method of improving the quality of care. They would like your opinion on hospitalists - yes or no?


January 3, 2003 Journal Club:

Tobin & Norris. "Mental health and general practice: improving linkages using a total quality management approach."

Related questions for reflection:

  1. Reflect on your own experiences in the integration (or lack thereof) between primary care and mental health services in caring for patients with severe and chronic mental illness.

  2. Consider the pros/cons of provider-focused vs. patient-focused measurement when evaluating efforts to improve systems integration.

Joubert. "PQM - Psychiatry Quality Management."

Following the current revolution of computerizing medical records, Joubert offers a glimpse into the potential future of integrating CQI into the electronic record. As current and future leaders in quality healthcare, we will be the targeted consumers of such software. How can we best evaluate these systems? Specifically:

  1. What do you think about continual PDSA of "our" IT systems vs. purchasing "their" package?

  2. How does a detailed QI/record system for one specialty or service affect interdisciplinary work? Would it contribute to the segregation of services as discussed in Tobin & Norris? If not, in what settings would you consider using this new type of clinical software?


November 2002 Journal Club:

Ellison P. Anesthesiology, Volume 84(4): April 1996; pages 965-975.

Dovey, Phillips and Green. "A preliminary taxonomy of medical errors in family practice." Quality Safety Health Care, 2002; 11:233-238.

Related questions for reflection:

  1. As you read the transcript of Pierce's speech do you see that culture emerging? Or being purposefully developed? If so to either of these what are key points to its development?

  2. Pierce spends some time on the 20/20 piece on "Deep Sleep." Do you think/feel that was a catalyst for more safety consciousness in the anesthesia community? If so, do you think the IOM to Err is Human report could have the same effect on the general public and medicine in general? Or will the IOM report have a short term impact?

  3. What are your thoughts on the Taxonomy of errors in family medicine article? Could this be a springboard and a framework for outpatient based error analysis?

  4. If so, is the message diluted with this published in this journal (aimed at safety) versus a mainstream FP journal?

  5. How would you advise we spread the word about this work and frame work?


October 4, 2002:

Hofer and Hayward. "Are Bad Outcomes from Questionable Clinical Decisions Preventable Medical Errors? A Case of Cascade Iatrogenesis." Annals of Internal Medicine, 137(5): 327-333.

Related questions for reflection:

  1. How should we think about the questions related to post hoc establishment of causality in root cause analysis?

  2. How do the questions posed by this article related to the concepts of action plans and the use of PDCA cycles?

Halm, Lee, and Chassin. "Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature." Annals of Internal Medicine, 137(6): 511-520.

Related questions for reflection:

  1. How might we think about designing methodologies that would better help us tease out relationships between volumes and outcomes?

  2. How do we get context and processes into the design of such studies?


September 6, 2002:

Leape et al. "What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety." JAMA, July 24/31, vol 288(4), 501-507.

Shojania et al. "Safe but Sound: Patient Safety Meets Evidence-Based Medicine." JAMA, July 24/31, 288(4): 508-513.

Related questions for reflection:

  1. Do we need different "types" of evidence for patient safety research?

  2. What are the challenges of evaluating systems-level interventions?

  3. Are there dangers in using "practices based on inference (linkage), accepted practices in other industries, and common sense" as evidence?

Reilly et al. "Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department." JAMA, July 17, vol 288(3), 342-350.

Related questions for reflection:

  1. Is this research or QI?

  2. What separates the two?

  3. If this is QI, why was it accepted in a prominent journal?

  4. What strategies can we use to make our QI projects and QI research appealing to leading journals?

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