The Clinical Learning Environment Review (CLER) program identified that resident involvement in interprofessional (IP) quality improvement and patient safety (QIPS) efforts was lacking and called for improvement. Interviews with residents, faculty, and staff were held to determine the status of IP QIPS in their hospital. Benefits (e.g., learning about other professions), facilitators, and barriers to resident involvement and a positive clinical learning environment were identified.

Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.

It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.

Engaging residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into graduate medical education curriculum focusing on organizational elements such as culture, interprofessional learning, and faculty development.

This qualitative study of a large-scale quality improvement effort to reduce readmissions and adverse events after discharge identified numerous barriers to implementing the project as well as several facilitators of success. Intensive mentoring by project champions appeared to be a key factor in success of the program.

This retrospective study found that providing resident and fellow physicians with a financial incentive to meet inpatient quality improvement goals led to enhanced patient safety processes, such as hospital-to-home transitions and timely completion of discharge summaries. These findings highlight a need for broader implementation of trainee incentives as part of quality improvement.

Efforts to improve patient safety were initially built on the establishment of a no-blame philosophy, but recently experts have called for a just culture that balances systems-based thinking with personal accountability. This study surveyed physicians, nurses, medical students, and inpatients regarding attitudes toward public reporting and penalties for violations of basic safety protocols. The authors used scenarios involving hand hygiene, fall risk assessment, and preoperative time-outs since they are backed by strong evidence, easy to perform, and linked to important and common patient harms. Respondents endorsed feedback and penalties for clinicians that failed to follow these evidence-based practices. Health care professionals tended to favor punitive measures such as fines, suspensions, and firing, over public reporting. This may provide some insight into the power of public reporting to motivate change. An AHRQ WebM&M perspective discusses the organizational implementation of a just culture.

Hospitals that participated in Project BOOST, a national quality improvement collaborative for preventing readmissions, appeared to have slightly lower 30-day readmission rates.

This study found that dictating discharge summaries was a task residents commonly completed after hours. With greater work hour restrictions on the horizon, strategies to manage indirect patient care activities may include using them as opportunities to teach system-based practice improvement.

This commentary describes a structured communication strategy that targets discussions at time of admission, change in clinical condition, and time of discharge, to reduce communication failures and improve patient safety.

None of the providers directly involved in caring for hospitalized elderly patients—nurses, physicians, or case managers—were able to accurately predict the likelihood that these patients would be readmitted within 30 days of discharge.

A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors, including selected never events and hospital-acquired infections. The impact of the policy was debated, including the ability of providers and systems to accurately identify conditions present on admission. This study involved an educational intervention to assess the policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the intervention group, who received education about the new policy as part of the study, were less likely than participants who received no such education to select the most clinically appropriate response. While all the trainees acknowledged responsibility to understand CMS documentation rules and felt poorly trained to do so, their responses to the vignettes raised concern about the potential harm and unintended consequences caused by unnecessary testing and procedures that may result from the policy. The implications of the CMS policy are further discussed in an AHRQ WebM&M perspective.

This study discovered that while nurses and physicians use patient whiteboards differently, they all value its potential for improving teamwork, communication, and patient care. The authors provide a series of recommendations for those adopting whiteboards and advocate for their use as a patient-centered tool.

After the implementation of duty hours regulations, approximately one-quarter of internal medicine residents reported spending less time teaching. Interestingly, residents who taught less were also less likely to report emotional exhaustion, and were more likely to report satisfaction with the quality of care they provided.

This article describes the development and implementation of a tool for retrospective case review by hospitalists.

A teamwork training intervention that involved internal medicine residents, pharmacists, and nurses as well as nonclinical staff was successfully implemented at an academic hospital. The intervention focused on developing teamwork skills and communication techniques, based on interactive discussions between providers of different disciplines.

Reducing duty hours for physicians in training should, in theory, improve patient safety by reducing physician fatigue. Indeed, prior research documents a link between increased fatigue and self-reported errors and percutaneous injuries among residents. But do increased work hours directly lead to fatigue? This survey of interns in cognitive specialties (including internal medicine, pediatrics, and psychiatry) at an academic medical center found that the major determinants of fatigue were increased stress level and poorer quality of sleep—not the absolute number of hours worked. Working more than 80 hours per week (the maximum, according to current regulations) was not associated with increased stress or fatigue. This study adds to a growing body of research that questions the relationship between work hours and housestaff fatigue. A recent editorial called for evidence-based duty hours regulations, taking into account not only hours worked per week but overall housestaff workload and other system factors contributing to stress and fatigue.

Residency programs have been required to limit duty hours for housestaff since 2003. The effect of this policy change on errors remains controversial, although at least one prior study demonstrated fewer errors when housestaff worked shorter shifts. In this survey of internal medicine residents, the number of hours worked was not associated with a perceived risk of committing medical errors. Administrative workload and overall work stress were more closely associated with suboptimal care. The results suggest that, in order to reduce errors committed by residents, both the number of hours worked and the nature of residents' work should be addressed.

Increased workload for nurses is associated with worsened patient outcomes, but similar studies of human factors affecting physicians have focused on the effects of shift duration and other organizational characteristics. This study from an academic medical center examined the effects of increased housestaff workload, defined as the number of new patient admissions and the overall team census, on inpatient mortality, length of stay, and costs. More admissions on the on-call day were associated with increases in all three primary outcomes. In contrast, an increase in overall team census was associated with decreased length of stay and lower costs. Although these findings are preliminary, the study adds important data to the ongoing debate on balancing patient safety and resident education.