Publications by authors named "Greg Ogrinc"

69 Publications

Different approaches to making and testing change in healthcare.

BMJ 2021 08 17;374:n1010. Epub 2021 Aug 17.

VA Outcomes Group, Department of Veterans Affairs, White River Junction, VT, USA.

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http://dx.doi.org/10.1136/bmj.n1010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369383PMC
August 2021

Measuring and publishing quality improvement.

Authors:
Greg Ogrinc

Reg Anesth Pain Med 2021 08 24;46(8):643-649. Epub 2021 May 24.

American Board of Medical Specialties, Chicago, Illinois, USA

Misalignment of measures, measurement and analysis with the goals and methods of quality improvement efforts in healthcare may create confusion and decrease effectiveness. In healthcare, measurement is used for accountability, research, and quality improvement, so distinguishing between these is an important first step. Using a case vignette, this paper focuses on using measurement for improvement to gain insight into the dynamic nature of healthcare systems and to assess the impact of interventions. This involves an understanding of the variation in the data over time. Statistical process control (SPC) charting is an effective and powerful analysis tool for this. SPC provides ongoing assessment of system functioning and enables an improvement team to assess the impact of its own interventions and external forces on the system. Once improvement work is completed, the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines is a valuable tool to describe the rationale, context, and study of the interventions. SQUIRE can be used to plan improvement work as well as structure a manuscript for publication in peer-reviewed journals.
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http://dx.doi.org/10.1136/rapm-2020-102201DOI Listing
August 2021

The state of nutrition in medical education in the United States.

Nutr Rev 2020 09;78(9):764-780

Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Despite the significant impact diet has on health, there is minimal nutrition training for medical students. This review summarizes published nutrition learning experiences in US medical schools and makes recommendations accordingly. Of 902 articles, 29 met inclusion criteria, describing 30 learning experiences. Nutrition learning experiences were described as integrated curricula or courses (n = 10, 33%), sessions (n = 17, 57%), or electives (n = 3, 10%). There was heterogeneity in the teaching and assessment methods utilized. The most common was lecture (n = 21, 70%), often assessed through pre- and/or postsurveys (n = 19, 79%). Six studies (26%) provided experience outcomes through objective measures, such as exam or standardized patient experience scores, after the nutrition learning experience. This review revealed sparse and inconsistent data on nutrition learning experiences. However, based on the extant literature, medical schools should build formal nutrition objectives, identify faculty and physician leadership in nutrition education, utilize preexisting resources, and create nutrition learning experiences that can be applied to clinical practice.
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http://dx.doi.org/10.1093/nutrit/nuz100DOI Listing
September 2020

Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?

Acad Med 2020 07;95(7):1006-1013

R. Englander is associate dean, undergraduate medical education, and professor, pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota. E. Holmboe is chief, research, milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. P. Batalden is emeritus professor, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. R.M. Caron is professor, Department of Health Management and Policy, College of Health and Human Services, University of New Hampshire, Durham, New Hampshire. C.F. Durham is professor and director, interprofessional education and practice, and director, education-innovation-simulation learning environment, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. T. Foster is professor of obstetrics and gynecology and of community and family medicine, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. G. Ogrinc is senior associate dean for medical education and professor of medicine, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. N. Ercan-Fang is associate director for medical education for primary and specialty care services, co-director, the VA longitudinal integrated clerkship, and associate professor of medicine, Minneapolis VA Health Care System and the University of Minnesota Medical School, Minneapolis, Minnesota. M. Batalden is interim chief quality officer, Cambridge Health Alliance, and assistant professor of medicine, Harvard Medical School, Boston, Massachusetts.

In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.
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http://dx.doi.org/10.1097/ACM.0000000000003137DOI Listing
July 2020

Building the Bridge to Quality: An Urgent Call to Integrate Quality Improvement and Patient Safety Education With Clinical Care.

Acad Med 2020 01;95(1):59-68

B.M. Wong is associate professor of medicine, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, and associate director, Centre for Quality Improvement and Patient Safety (C-QuIPS), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. K.D. Baum is professor of medicine and adjunct professor, School of Public Health, and associate chief medical officer, University of Minnesota, Minneapolis, Minnesota. L.A. Headrick is professor emerita of medicine, University of Missouri School of Medicine, Columbia, Missouri. E.S. Holmboe is senior vice president for milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. F. Moss is dean, Royal Society of Medicine, and academic lead for collaboration, learning and partnerships, North West London Collaboration for Leadership in Applied Health Research and Care, London, United Kingdom. G. Ogrinc is professor of medicine, Dartmouth Institute, and senior associate dean for medical education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. K.G. Shojania is professor and vice chair of quality and innovation, Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, and director, Centre for Quality Improvement and Patient Safety (C-QuIPS), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. E. Vaux is consultant nephrologist, Royal Berkshire National Health Service Foundation Trust, Reading, and vice president of education and training, Royal College of Physicians, London, United Kingdom. E.J. Warm is professor of medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6088-2434. J.R. Frank is associate professor, Department of Emergency Medicine, University of Ottawa, and director, Specialty Education, Strategy and Standards, Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.
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http://dx.doi.org/10.1097/ACM.0000000000002937DOI Listing
January 2020

What Do I Do When Something Goes Wrong? Teaching Medical Students to Identify, Understand, and Engage in Reporting Medical Errors.

Acad Med 2019 12;94(12):1910-1915

H.F. Ryder is associate professor, Department of Medicine and Medical Education, and professor, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; ORCID: https://orcid.org/0000-0003-3120-1166. J.T. Huntington is assistant professor, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. A. West was health scientist, White River Junction VA Medical Center, White River Junction, Vermont, and staff member, Veterans Affairs Office of Rural Health, Eastern Region, until his retirement in 2017. G. Ogrinc is senior associate dean, Medical Education, professor, Department of Medicine, and professor, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Problem: Identifying and processing medical errors are overlooked components of undergraduate medical education. Organizations and leaders advocate teaching medical students about patient safety and medical error, yet few feasible examples demonstrate how this teaching should occur. To provide students with familiarity in identifying, reporting, and analyzing medical errors, the authors developed the interactive patient safety reporting curriculum (PSRC), requiring clinical students to engage intellectually and emotionally with personally experienced events in which the safety of one of their patients was compromised.

Approach: In 2015, the authors incorporated the PSRC into the third-year internal medicine clerkship. Students completed a structured written report, analyzing a patient safety incident they experienced. The report focused on severity of outcome, root cause(s) analysis, system-based prevention, and personal reflection. The report was bookended by 2 interactive, case-based sessions led by faculty with expertise in patient safety, quality improvement, and medical errors.

Outcomes: Students accurately analyzed the severity of the outcome, and their reports directly led to 2 formal root cause analyses and 4 system-based improvements.

Next Steps: The time- and resource-efficient PSRC allows students to apply patient safety knowledge to a medical error they experienced in a way that can directly affect care delivery. This model-interactive learning sessions coupled with engaging in a personally experienced case-can be implemented in various settings. Educators seeking to use student-experienced events for learning should not discount the emotional effects of those events on medical students.
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http://dx.doi.org/10.1097/ACM.0000000000002872DOI Listing
December 2019

Health Systems Science: The "Broccoli" of Undergraduate Medical Education.

Acad Med 2019 10;94(10):1425-1432

J.D. Gonzalo is associate professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: https://orcid.org/0000-0003-1253-2963. G. Ogrinc is professor of medicine, Dartmouth Institute for Health Policy and Clinical Practice, and senior associate dean for medical education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Health system leaders are calling for reform of medical education programs to meet evolving needs of health systems. U.S. medical schools have initiated innovative curricula related to health systems science (HSS), which includes competencies in value-based care, population health, system improvement, interprofessional collaboration, and systems thinking. Successful implementation of HSS curricula is challenging because of the necessity for new curricular methods, assessments, and educators and for resource allocation. Perhaps most notable of these challenges, however, is students' mixed receptivity. Although many students are fully engaged, others are dissatisfied with curricular time dedicated to competencies not perceived as high yield. HSS learning can be viewed as "broccoli"-students may realize it is good for them in the long term, but it may not be palatable in the moment. Further analysis is necessary for accelerating change both locally and nationally.With over 11 years of experience in global HSS curricular reform in 2 medical schools and informed by the curricular implementation "performance gap," the authors explore student receptivity challenges, including marginalization of HSS coursework, infancy of the HSS field, relative nascence of curricula and educators, heterogeneity of pedagogies, tensions in students' perceptions of their professional role, and culture of HSS integration. The authors call for the reexamination of 5 issues influencing HSS receptivity: student recruitment processes, faculty development, building an HSS academic "home," evaluation metrics, and transparent collaboration between medical schools. To fulfill the social obligation of meeting patients' needs, educators must seek a shared understanding of underlying challenges of HSS innovations.
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http://dx.doi.org/10.1097/ACM.0000000000002815DOI Listing
October 2019

SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education): Publication Guidelines for Educational Improvement.

Acad Med 2019 10;94(10):1461-1470

G. Ogrinc is senior associate dean for medical education and professor of medicine and of the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. G.E. Armstrong is associate professor, University of Colorado College of Nursing, Aurora, Colorado. M.A. Dolansky is associate professor, Case Western Reserve University, Frances Payne Bolton School of Nursing, and Department of Veterans Affairs Louis Stokes Medical Center, Cleveland, Ohio. M.K. Singh is assistant dean, Health Systems Science, and associate professor of medicine, Case Western Reserve University School of Medicine and Department of Veterans Affairs Louis Stokes Medical Center, Cleveland, Ohio. L. Davies is associate professor, Section of Otolaryngology-Head & Neck Surgery and Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, and associate professor, Department of Veterans Affairs Medical Center, White River Junction, Vermont.

The SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence) guidelines were published in 2015 to increase the completeness, precision, and transparency of published reports about efforts to improve the safety, value, and quality of health care. The principles and methods applied in work to improve health care are often applied in educational improvement as well. In 2016, a group was convened to develop an extension to SQUIRE that would meet the needs of the education community. This article describes the development of the SQUIRE-EDU extension over a three-year period and its key components. SQUIRE-EDU was developed using an international, interprofessional advisory group and face-to-face meeting to draft initial guidelines; pilot testing of a draft version with nine authors; and further revisions from the advisory panel with a public comment period. SQUIRE-EDU emphasizes three key components that define what is necessary in systematic efforts to improve the quality and value of health professions education. These are a description of the local educational gap; consideration of the impacts of educational improvement to patients, families, communities, and the health care system; and the fidelity of the iterations of the intervention. SQUIRE-EDU is intended for the many and complex range of methods used to improve education and education systems. These guidelines are projected to increase and standardize the sharing and spread of iterative innovations that have the potential to advance pedagogy and occur in specific contexts in health professions education.
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http://dx.doi.org/10.1097/ACM.0000000000002750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760810PMC
October 2019

A 4-Year Integrated Nutrition Curriculum for Medical Student Education.

Med Sci Educ 2019 Mar 12;29(1):23-28. Epub 2018 Oct 12.

Geisel School of Medicine at Dartmouth, Lebanon, NH 03756 USA.

While poor diet is the one of the primary contributors to death and disability in the USA, formal nutrition education in medical schools across the nation remains sparse. As it stands, few medical schools have formally incorporated nutrition education, and fewer still have integrated nutrition into the entire length of their 4-year curriculum. We describe how a new, formally integrated, 4-year nutrition curriculum was developed and is being implemented in a US medical school, and how this program will evolve as part of a twenty-first century medical school education.
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http://dx.doi.org/10.1007/s40670-018-00629-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360248PMC
March 2019

Learning to Overcome Hierarchical Pressures to Achieve Safer Patient Care: An Interprofessional Simulation for Nursing, Medical, and Physician Assistant Students.

Nurse Educ 2017 Sep-Oct;42(5S Suppl 1):S27-S31

Author Affiliations: Professor and Dean, School of Nursing and Health Professions, Colby-Sawyer College, New London (Dr Reeves); Assistant Professor and Associate Director of Didactic Education, Masters of Physician Assistant Program, Franklin Pierce University, Lebanon (Dr Denault); Hospitalist, Dartmouth-Hitchcock Medical Center, Lebanon (Dr Huntington); Assistant Professor of Medicine (Dr Huntington) and Senior Associate Dean for Medical Education, Interim, and Associate Chief of Staff for Education (Dr Ogrinc), Geisel School of Medicine at Dartmouth, Hanover; Professor and Director, Master of Physician Assistant Studies, Franklin Pierce University, Lebanon (Dr Southard); and Assistant Professor and Simulation & Learning Specialist, Colby-Sawyer College, New London (Ms Vebell), New Hampshire.

To positively impact patient safety, the Institute of Medicine, as well as the Quality and Safety Education for Nurses initiative, has recommended clinician training in structured communication techniques. Such techniques are particularly useful in overcoming hierarchical barriers in health care settings. This article describes an interprofessional simulation program to teach structured communication techniques to preprofessional nursing, medical, and physician assistant students. The teaching and evaluation plans are described to aid replication.
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http://dx.doi.org/10.1097/NNE.0000000000000427DOI Listing
November 2017

Science of health care delivery as a first step to advance undergraduate medical education: A multi-institutional collaboration.

Healthc (Amst) 2017 Sep 23;5(3):98-104. Epub 2017 Mar 23.

Academic Outreach and Advancing a Healthier Wisconsin Endowment, Medical College of Wisconsin, United States.

Physicians must possess knowledge and skills to address the gaps facing the US health care system. Educators advocate for reform in undergraduate medical education (UME) to align competencies with the Triple Aim. In 2014, five medical schools and one state university began collaborating on these curricular gaps. The authors report a framework for the Science of Health Care Delivery (SHCD) using six domains and highlight curricular examples from each school. They describe three challenges and strategies for success in implementing SHCD curricula. This collaboration highlights the importance of multi-institutional partnerships to accelerate innovation and adaptation of curricula.
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http://dx.doi.org/10.1016/j.hjdsi.2017.01.003DOI Listing
September 2017

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents.

J Grad Med Educ 2016 Oct;8(4):563-568

Background : Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work.

Objective : We sought to determine the clinical and educational impact of an integrated QI curriculum.

Methods : This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention.

Results : The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0-27) increased from 13.3 at baseline to 15.3 at end point ( < .01), as did the self-efficacy composite score ( < .05). Satisfaction with the curriculum was rated highly by all participants.

Conclusions : Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.
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http://dx.doi.org/10.4300/JGME-D-15-00412.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058590PMC
October 2016

Co-Creating Quality in Health Care Through Learning and Dissemination.

J Contin Educ Health Prof 2016 ;36 Suppl 1:S16-8

Dr. Holmboe: ACGME, Chicago, IL. Dr. Foster: Associate Professor, Departments of Obstetrics-Gynecology and Community and Family Medicine, Dartmouth-Hitchcock Medical Center and The Dartmouth Institute, Lebanon, NH. Dr. Ogrinc: Senior Associate Dean for Medical Education, Geisel School of Medicine at Dartmouth, Associate Chief of Staff for Education, White River Junction, VA.

For most of the 20th century the predominant focus of medical education across the professional continuum was the dissemination and acquisition of medical knowledge and procedural skills. Today it is now clear that new areas of focus, such as interprofessional teamwork, care coordination, quality improvement, system science, health information technology, patient safety, assessment of clinical practice, and effective use of clinical decision supports are essential to 21st century medical practice. These areas of need helped to spawn an intense interest in competency-based models of professional education at the turn of this century. However, many of today's practicing health professionals were never educated in these newer competencies during their own training. Co-production and co-creation of learning among interprofessional health care professionals across the continuum can help close the gap in acquiring needed competencies for health care today and tomorrow. Co-learning may be a particularly effective strategy to help organizations achieve the triple aim of better population health, better health care, and lower costs. Structured frameworks, such as the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, provide guidance in the design, planning, and dissemination of interventions designed to improve care through co-production and co-learning strategies.
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http://dx.doi.org/10.1097/CEH.0000000000000076DOI Listing
February 2018

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

BMJ Qual Saf 2016 12 13;25(12):e7. Epub 2016 Apr 13.

Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden.

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.
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http://dx.doi.org/10.1136/bmjqs-2015-004480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256235PMC
December 2016

Between the guidelines: SQUIRE 2.0 and advances in healthcare improvement practice and reporting.

BMJ Qual Saf 2016 08 1;25(8):559-61. Epub 2016 Mar 1.

White River Junction VA Medical Center, White River Junction, Vermont, USA Department of Medicine and The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.

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http://dx.doi.org/10.1136/bmjqs-2015-005039DOI Listing
August 2016

Exemplary Care and Learning Sites: A Model for Achieving Continual Improvement in Care and Learning in the Clinical Setting.

Acad Med 2016 Mar;91(3):354-9

L.A. Headrick is senior associate dean for education and Helen Mae Spiese Professor in Medicine, University of Missouri School of Medicine, Columbia, Missouri. G. Ogrinc is senior associate dean for medical education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, and associate chief of staff for education, White River Junction VA Hospital, White River Junction, Vermont. K.G. Hoffman is associate dean for curriculum and assessment, School of Medicine, and associate professor, Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri. K.M. Stevenson is clinical assistant professor, School of Physical Therapy, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, and adjunct lecturer and PhD candidate, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden. M. Shalaby was internal medicine residency program director, Lehigh Valley Health Network, Allentown, Pennsylvania, at the time of writing. He is now program director of the internal medicine-primary care residency and associate professor of clinical medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. A.S. Beard is internal medicine hospitalist, Minneapolis VA Healthcare System, and assistant professor of medicine, University of Minnesota Medical School, Minneapolis, Minnesota. K.E. Thörne is child and youth psychiatrist and head of clinical education, Region Jönköping County, Jönköping, Sweden. She is also a PhD candidate in medical education, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden, and Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden. M.T. Coleman is Marie Lahasky Chair and Professor, Department of Family Medicine, and teaching scholar, Louisiana State University Health Sciences Center, New Orleans, Louisiana. K.D. Baum is associate chair for

Problem: Current models of health care quality improvement do not explicitly describe the role of health professions education. The authors propose the Exemplary Care and Learning Site (ECLS) model as an approach to achieving continual improvement in care and learning in the clinical setting.

Approach: From 2008-2012, an iterative, interactive process was used to develop the ECLS model and its core elements--patients and families informing process changes; trainees engaging both in care and the improvement of care; leaders knowing, valuing, and practicing improvement; data transforming into useful information; and health professionals competently engaging both in care improvement and teaching about care improvement. In 2012-2013, a three-part feasibility test of the model, including a site self-assessment, an independent review of each site's ratings, and implementation case stories, was conducted at six clinical teaching sites (in the United States and Sweden).

Outcomes: Site leaders reported the ECLS model provided a systematic approach toward improving patient (and population) outcomes, system performance, and professional development. Most sites found it challenging to incorporate the patients and families element. The trainee element was strong at four sites. The leadership and data elements were self-assessed as the most fully developed. The health professionals element exhibited the greatest variability across sites.

Next Steps: The next test of the model should be prospective, linked to clinical and educational outcomes, to evaluate whether it helps care delivery teams, educators, and patients and families take action to achieve better patient (and population) outcomes, system performance, and professional development.
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http://dx.doi.org/10.1097/ACM.0000000000001072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885596PMC
March 2016

[SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process].

Medwave 2015 Nov 20;15(10):e6318. Epub 2015 Nov 20.

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA; Institute for Healthcare Improvement, Cambridge, Massachusetts, USA.

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multi-dimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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http://dx.doi.org/10.5867/medwave.2015.10.6318DOI Listing
November 2015

Squire 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

Am J Crit Care 2015 Nov;24(6):466-73

Greg Ogrinc is senior associate dean for medical education, Geisel School of Medicine at Dartmouth, associate chief of staff for education, White River Junction VA, and associate professor of community and family medicine, medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Louise Davies is senior scholar, Quality Scholars Program, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and associate professor of surgery, Geisel School of Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire. Daisy Goodman is fellow, VA Quality Scholars Fellowship Program and instructor of obstetrics and gynecology and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Paul Batalden is active emeritus professor, pediatrics and community and family medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire. Frank Davidoff is editor emeritus, Annals of Internal Medicine, and adjunct professor at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. David Stevens is adjunct professor, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; editor emeritus, BMJ Quality and Safety, London, England; and senior fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of 3 key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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November 2015

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines from a Detailed Consensus Process.

Perm J 2015 ;19(4):65-70

Adjunct Professor at The Dartmouth Institute for Health Policy and Clinical Practice in Hanover, NH; and an Editor Emeritus of BMJ Quality and Safety in London, United Kingdom; and Senior Fellow of the Institute for Healthcare Improvement in Cambridge, MA.

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015, using 1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group; 2) two face-to-face consensus meetings to develop interim drafts; and 3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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http://dx.doi.org/10.7812/TPP/15-141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4625997PMC
August 2016

Standards for QUality Improvement Reporting Excellence 2.0: revised publication guidelines from a detailed consensus process.

J Surg Res 2016 Feb 28;200(2):676-82. Epub 2015 Sep 28.

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Institute for Healthcare Improvement, Cambridge, Massachusetts.

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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http://dx.doi.org/10.1016/j.jss.2015.09.015DOI Listing
February 2016

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process.

J Contin Educ Nurs 2015 Nov;46(11):501-7

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).
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http://dx.doi.org/10.3928/00220124-20151020-02DOI Listing
November 2015

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

Am J Med Qual 2015 Nov-Dec;30(6):543-9

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH Institute for Healthcare Improvement, Cambridge, MA.

In the past several years, the science of health care improvement has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes 3 key components of systematic efforts to improve the quality, value, and safety of health care: formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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http://dx.doi.org/10.1177/1062860615605176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4620592PMC
January 2017

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

Can J Diabetes 2015 Oct;39(5):434-9

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA; Institute for Healthcare Improvement, Cambridge, Massachusetts, USA.

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using 1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group; 2) 2 face-to-face consensus meetings to develop interim drafts and 3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of 3 key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).
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http://dx.doi.org/10.1016/j.jcjd.2015.08.001DOI Listing
October 2015

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process.

J Nurs Care Qual 2016 Jan-Mar;31(1):1-8

Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Drs Ogrinc, Davies, Goodman, and Batalden); Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire (Drs Ogrinc, Davies, Goodman, Batalden, Davidoff, and Stevens); Department of Veterans Affairs Medical Center, White River Junction, Vermont (Drs Ogrinc, Davies, and Goodman); and Institute for Healthcare Improvement, Cambridge, Massachusetts (Dr Stevens). Dr Davidoff is Editor Emeritus of Annals of Internal Medicine. Dr Stevens is Editor Emeritus of BMJ Quality & Safety.

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http://dx.doi.org/10.1097/NCQ.0000000000000153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411027PMC
November 2016

SQUIRE 2.0-Standards for Quality Improvement Reporting Excellence-Revised Publication Guidelines from a Detailed Consensus Process.

J Am Coll Surg 2016 Mar 15;222(3):317-23. Epub 2015 Sep 15.

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; BMJ Quality and Safety, London, UK; Institute for Healthcare Improvement, Cambridge, MA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2015.07.456DOI Listing
March 2016

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

BMJ Qual Saf 2016 12 14;25(12):986-992. Epub 2015 Sep 14.

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA.

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasises the reporting of three key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognising that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).
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http://dx.doi.org/10.1136/bmjqs-2015-004411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256233PMC
December 2016

Findings from a novel approach to publication guideline revision: user road testing of a draft version of SQUIRE 2.0.

BMJ Qual Saf 2016 Apr 11;25(4):265-72. Epub 2015 Aug 11.

Department of Education, Department of Veterans Affairs Medical Center, White River Junction, Vermont, USA.

Background: The Standards for Quality Improvement Reporting Excellence (SQUIRE) Guideline was published in 2008 (SQUIRE 1.0) and was the first publication guideline specifically designed to advance the science of healthcare improvement. Advances in the discipline of improvement prompted us to revise it. We adopted a novel approach to the revision by asking end-users to 'road test' a draft version of SQUIRE 2.0. The aim was to determine whether they understood and implemented the guidelines as intended by the developers.

Methods: Forty-four participants were assigned a manuscript section (ie, introduction, methods, results, discussion) and asked to use the draft Guidelines to guide their writing process. They indicated the text that corresponded to each SQUIRE item used and submitted it along with a confidential survey. The survey examined usability of the Guidelines using Likert-scaled questions and participants' interpretation of key concepts in SQUIRE using open-ended questions. On the submitted text, we evaluated concordance between participants' item usage/interpretation and the developers' intended application. For the survey, the Likert-scaled responses were summarised using descriptive statistics and the open-ended questions were analysed by content analysis.

Results: Consistent with the SQUIRE Guidelines' recommendation that not every item be included, less than one-third (n=14) of participants applied every item in their section in full. Of the 85 instances when an item was partially used or was omitted, only 7 (8.2%) of these instances were due to participants not understanding the item. Usage of Guideline items was highest for items most similar to standard scientific reporting (ie, 'Specific aim of the improvement' (introduction), 'Description of the improvement' (methods) and 'Implications for further studies' (discussion)) and lowest (<20% of the time) for those unique to healthcare improvement (ie, 'Assessment methods for context factors that contributed to success or failure' and 'Costs and strategic trade-offs'). Items unique to healthcare improvement, specifically 'Evolution of the improvement', 'Context elements that influenced the improvement', 'The logic on which the improvement was based', 'Process and outcome measures', demonstrated poor concordance between participants' interpretation and developers' intended application.

Conclusions: User testing of a draft version of SQUIRE 2.0 revealed which items have poor concordance between developer intent and author usage, which will inform final editing of the Guideline and development of supporting supplementary materials. It also identified the items that require special attention when teaching about scholarly writing in healthcare improvement.
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http://dx.doi.org/10.1136/bmjqs-2015-004117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4819644PMC
April 2016

The SQUIRE Guidelines: an evaluation from the field, 5 years post release.

BMJ Qual Saf 2015 Dec 18;24(12):769-75. Epub 2015 Jun 18.

The Geisel School of Medicine at Dartmouth, Hanover, NH, USA Department of Veterans Affairs Medical Center, White River Junction, VT, USA.

Background: The Standards for Quality Improvement Reporting Excellence (SQUIRE) Guidelines were published in 2008 to increase the completeness, precision and accuracy of published reports of systematic efforts to improve the quality, value and safety of healthcare. Since that time, the field has expanded. We asked people from the field to evaluate the Guidelines, a novel approach to a first step in revision.

Methods: Evaluative design using focus groups and semi-structured interviews with 29 end users and an advisory group of 18 thinkers in the field. Sampling of end users was purposive to achieve variation in work setting, geographic location, area of expertise, manuscript writing experience, healthcare improvement and research experience.

Results: Study participants reported that SQUIRE was useful in planning a healthcare improvement project, but not as helpful during writing because of redundancies, uncertainty about what was important to include and lack of clarity in items. The concept "planning the study of the intervention" (item 10) was hard for many participants to understand. Participants varied in their interpretation of the meaning of item 10b "the concept of the mechanism by which changes were expected to occur". Participants disagreed about whether iterations of an intervention should be reported. Level of experience in writing, knowledge of the science of improvement and the evolving meaning of some terms in the field are hypothesised as the reasons for these findings.

Conclusions: The original SQUIRE Guidelines help with planning healthcare improvement work, but are perceived as complicated and unclear during writing. Key goals of the revision will be to clarify items where conflict was identified and outline the key components necessary for complete reporting of improvement work.
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http://dx.doi.org/10.1136/bmjqs-2015-004116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4680161PMC
December 2015
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