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BACKGROUND: Residency programs involve trainees in quality improvement (QI) projects to evaluate competency in systems-based practice and practice-based learning and improvement. Valid approaches to assess QI proposals are lacking. OBJECTIVE:We developed an instrument for assessing resident QI proposals-the Quality Improvement Proposal Assessment Tool (QIPAT-7)-and determined its validity and reliability.DESIGN: QIPAT-7 content was initially obtained from a national panel of QI experts. Through an iterative process, the instrument was refined, pilot-tested, and revised.PARTICIPANTS: Seven raters used the instrument to assess 45 resident QI proposals. MEASUREMENTS:Principal factor analysis was used to explore the dimensionality of instrument scores. Cronbach's alpha and intraclass correlations were calculated to determine internal consistency and interrater reliability, respectively. RESULTS: QIPAT-7 items comprised a single factor (eigenvalue=3.4) suggesting a single assessment dimension. Interrater reliability for each item (range 0.79 to 0.93) and internal consistency reliability among the items (Cronbach's alpha=0.87) were high. CONCLUSIONS:This method for assessing resident physician QI proposals is supported by content and internal structure validity evidence. QIPAT-7 is a useful tool for assessing resident QI proposals. Future research should determine the reliability of QIPAT-7 scores in other residency and fellowship training programs. Correlations should also be made between assessment scores and criteria for QI proposal success such as implementation of QI proposals, resident scholarly productivity, and improved patient outcomes.KEY WORDS: quality improvement; systems-based practice; practicebased learning and improvement; assessment; evaluation study; validation study. INTRODUCTIONThe Accreditation Council for Graduate Medical Education (ACGME) released its Outcome Project in 1999 requiring residents and fellows to demonstrate competency in systemsbased practice (SBP) and practice-based learning and improvement (PBLI).1 Involvement of trainees in quality improvement (QI) efforts has been proposed as a means of addressing these two competencies. Indeed, resident physicians are in an excellent position to identify health care systems improvements, 2-4 yet they often lack the skills to identify the best interventions for improvement and the time and mentorship necessary to implement them. Consequently, many internal medicine residencies have developed QI curricula. We searched the literature for examples of health systems and QI curricula and their assessment. 3,5-10 Some published curricula involve seminar and lecture formats that are typically evaluated using pre-and posttests of knowledge. 5,7,8,10 Other curricula incorporate independent-study QI proposals and/or QI projects.3,5-10However, reports of QI project assessments, and QI proposals in particular, are uncommon. Like any thoughtful research or business endeavor, a good QI project begins with a written proposal that explains the problem, hypoth...

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BACKGROUND:We learned from a focus group that many patients find discharge to be one of the least satisfying elements of the hospital experience. Patients cited insufficient communication about the day and time of the impending discharge as a cause of dissatisfaction.OBJECTIVE:In partnership with the Institute for Healthcare Improvement, Improvement Action Network collaborative, we tested the practicality of an in‐room “discharge appointment” (DA) display.SETTING AND PATIENTS:Eight inpatient care units in 2 hospitals at an academic medical center (Mayo Clinic, Rochester, MN).INTERVENTION:DA displayed on a specially designed bedside dry‐erase board.MEASUREMENTS:The primary outcome was the proportion of discharged patients who had been given a DA, including same‐day DAs. Secondary outcomes were (1) the proportion of DAs scheduled before the actual dismissal day and (2) the timeliness of the actual departure compared with the DA.RESULTS:During the 4‐month period, 2046 patients were discharged. Of those, 1256 patients (61%) were given a posted DA, of which 576 (46%) were scheduled at least a day in advance and 752 (60%) departed from the care unit within 30 minutes of the appointed time.CONCLUSIONS:With a program for in‐room display of a DA in various hospital units, more than half the patients had a DA set, and most of the DA patients departed on time. Further investigation is needed to determine the effect of DAs on patient and provider satisfaction. Journal of Hospital Medicine 2007;2:13–16. © 2007 Society of Hospital Medicine.

BACKGROUND: Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood. STUDY DESIGN AND METHODS:This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015. RESULTS:We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 10 9 /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events. CONCLUSION: Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.A llogeneic blood transfusion is the most common procedure performed in the United States, 1 but many transfusion episodes are inconsistent with evidence-based guidelines. With increased recognition of the potential for patient harm and excessive health care costs associated with inappropriate transfusion practices, many institutions have attempted to reduce non-evidencebased transfusion episodes. Formal, multidisciplinary programs for patient blood management (PBM), designed with the primary objective of optimizing patients' blood health, 2-11 have also been associated with reduced blood product use. In ABBREVIATIONS: HSCT = hematopoietic stem cell transplantation; ICU = intensive care unit; IQR = interquartile range; PBM = patient blood management.From the

The US Military Health System (MHS), which is responsible for providing care to active and retired members of the military and their dependents, faces challenges in delivering cost-effective, high-quality primary care while maintaining a provider workforce capable of meeting both peacetime and wartime needs. The MHS has implemented workforce management strategies to address these challenges, including "medical home" teams for primary care and other strategies that expand the roles of nonphysician providers such as physician assistants, nurse practitioners, and medical technicians. Because these workforce strategies have been implemented relatively recently, there is limited evidence of their effectiveness. If they prove successful, they could serve as a model for the civilian sector. However, because the MHS model features a broad mix of provider types, changes to civilian scope-of-practice regulations for nonphysician providers would be necessary before the civilian provider mix could replicate that of the MHS.

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to the editor: The studies by Samaha et al. 1 and Foster et al. 2 (May 22 issue) are intended to expand our knowledge about low-carbohydrate diets. One potential long-term concern about the low-carbohydrate diet is its relatively high protein load and the effect this has on kidneys. This issue is especially important in persons with diabetes, who are more likely than others to have an underlying nephropathy. As a matter of fact, the population studied by Samaha et al. 1 consisted of obese patients and among whom the prevalence of diabetes was high. For this reason, we are very interested in the data on the serum creatinine level at the conclusion of the study. Unfortunately, the study had a high dropout rate; nevertheless, data on renal function from the subjects who completed the study might shed light on this important issue. In addition, the death of one subject with diabetes in the low-carbohydrate group (whose death was thought to be due to poor compliance with drug therapy) should be kept in mind when the results of this study are interpreted.