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Liberation in the Exam Room: Racial Justice and Equity in Health Care

Institute for Healthcare Improvement -

This tool is intended to be used as a starting guideline for individuals in the health care delivery context as they work to identify key areas of focus on racial justice and health equity, serving as a resource to begin conversations with teams within the organization toward developing a deeper understanding of structural racism and its impact on achieving health equity.

Creating Age-Friendly Health Systems: How to Meet the Needs of a Growing Population of Older Adults

Institute for Healthcare Improvement -

This article explains an emerging care model for older adults focused on the “4Ms” of Age-Friendly Health Systems — What Matters, Mobility, Medications, and the Mentation of older adults — that is in the testing phase at five health systems, as part of the Creating Age-Friendly Health Systems initiative led by IHI.

A Simple Way to Involve Frontline Clinicians in Managing Costs

Institute for Healthcare Improvement -

This article describes the building blocks of a value-management system in health care. The approach that IHI co-developed includes a simplified method to understand quality, cost, and workforce capacity on a weekly basis; a visual management system to present and analyze this data regularly; and daily, point-of-care communication to support continuous improvement.

Determining the optimal place and time for procedural education

Quality and Safety in Health Care Journal -

Just-in-time performance support as an educational process

In an apprenticeship model, for a trainee who is developing their skills, situating them in the workplace has distinct advantages. Starting from legitimate peripheral participation, the developing clinician is moulded by social interaction and collaboration while they learn from the spectrum of patients that make up a given clinical population.1 The goal is lasting behavioural and cognitive changes in the trainee as they take up the mantle of ‘expert clinician’.

However, to take on legitimate roles in the clinical workplace, a trainee requires direct just-in-time support, or ‘scaffolding’, in the form of supervision. Their preceptors provide enough support to ensure that safe and successful patient management can be accomplished. This is analogous to training wheels for someone learning to ride a bicycle—a scaffolding mechanism that enables a relative novice to perform the activity from start to finish when they...

Just-in-time simulation-based training

Quality and Safety in Health Care Journal -

Simulation-based training and assessment in healthcare are now commonplace in the majority of industrialised nations. The role of standardised patients, high-fidelity and low-fidelity manikins, synthetic, animal and virtual reality platforms, and simulation suites, are accepted, and integrated into training curricula in medical and nursing schools, and residency programmes. Despite this widespread use, only a handful of studies have assessed the impact of simulation-based education on patient and health system outcomes, and these studies have their focus on procedural skills such as central line insertion or laparoscopic surgery.1 2 Furthermore, the emphasis of such studies has been on simulation-based education as a tool to impact early learners, with minimal consideration of its use for independent practitioners such as attending physicians and experienced nurses.

An emerging area of simulation-based education is just-in-time training, or as it was termed by Niles et al in 2009, ‘rolling refreshers’, which...

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents

Quality and Safety in Health Care Journal -


Open communication between healthcare professionals about care concerns, also known as ‘speaking up’, is essential to patient safety.


Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats.


Anonymous, cross-sectional survey.


Six US academic medical centres, 2013–2014.


1800 medical and surgical interns and residents (47% responded).


Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales.


Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50).


Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay

Quality and Safety in Health Care Journal -


A subset of high-risk procedures present significant safety threats due to their (1) infrequent occurrence, (2) execution under time constraints and (3) immediate necessity for patient survival. A Just-in-Time (JIT) intervention could provide real-time bedside guidance to improve high-risk procedural performance and address procedural deficits associated with skill decay.


To evaluate the impact of a novel JIT intervention on transvenous pacemaker (TVP) placement during a simulated patient event.


This was a prospective, randomised controlled study to determine the effect of a JIT intervention on performance of TVP placement. Subjects included board-certified emergency medicine physicians from two hospitals. The JIT intervention consisted of a portable, bedside computer-based procedural adjunct. The primary outcome was performance during a simulated patient encounter requiring TVP placement, as assessed by trained raters using a technical skills checklist. Secondary outcomes included global performance ratings, time to TVP placement, number of critical omissions and System Usability Scale scores (intervention only).


Groups were similar at baseline across all outcomes. Compared with the control group, the intervention group demonstrated statistically significant improvement in the technical checklist score (11.45 vs 23.44, p<0.001, Cohen’s d effect size 4.64), the global rating scale (2.27 vs 4.54, p<0.001, Cohen’s d effect size 3.76), and a statistically significant reduction in critical omissions (2.23 vs 0.68, p<0.001, Cohen’s d effect size –1.86). The difference in time to procedural completion was not statistically significant between conditions (11.15 min vs 12.80 min, p=0.12, Cohen’s d effect size 0.65). System Usability Scale scores demonstrated excellent usability.


A JIT intervention improved procedure perfromance, suggesting a role for JIT interventions in rarely performed procedures.

Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer

Quality and Safety in Health Care Journal -


Relatively little attention has been devoted to the role of communication between physicians as a mechanism for individual and organisational learning about diagnostic delays. This study’s objective was to elicit physicians’ perceptions about and experiences with communication among physicians regarding diagnostic delays in cancer.

Design, setting, participants

Qualitative analysis based on seven focus groups. Fifty-one physicians affiliated with three New York-based academic medical centres participated, with six to nine subjects per group. We used content analysis to identify commonalities among primary care physicians and specialists (ie, medical and surgical oncologists).

Primary outcome measure

Perceptions and experiences with physician-to-physician communication about delays in cancer diagnosis.


Our analysis identified five major themes: openness to communication, benefits of communication, fears about giving and receiving feedback, infrastructure barriers to communication and overcoming barriers to communication. Subjects valued communication about cancer diagnostic delays, but they had many concerns and fears about providing and receiving feedback in practice. Subjects expressed reluctance to communicate if there was insufficient information to attribute responsibility, if it would have no direct benefit or if it would jeopardise their existing relationships. They supported sensitive approaches to conveying information, as they feared eliciting or being subject to feelings of incompetence or shame. Subjects also cited organisational barriers. They offered suggestions that might facilitate communication about delays.


Addressing the barriers to communication among physicians about diagnostic delays is needed to promote a culture of learning across specialties and institutions. Supporting open and honest discussions about diagnostic delays may help build safer health systems.


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