Publications by authors named "Mamta K Singh"

23 Publications

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Using Kern's Six-Step Approach to Integrate Health Systems Science Curricula into Medical Education.

Acad Med 2021 May 4. Epub 2021 May 4.

M.K. Singh is professor of medicine, Jerome Kowal, MD Designated Professor for Geriatric Health Education, Veterans Affairs Northeast Ohio Healthcare System, and former assistant dean, Health Systems Science, Case Western Reserve University School of Medicine, Cleveland, Ohio; ORCID: https://orcid.org/0000-0001-8235-4272. H.L. Gullett is associate professor and Charles Kent Smith, MD and Patricia Hughes Moore, MD Professor in Medical Student Education in Family Medicine, Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, Ohio; ORCID: https://orcid.org/0000-0002-3984-517X. P.A. Thomas was, when this was written, professor of medicine, Amasa B. Ford Professor of Geriatrics, and vice dean, Medical Education, Case Western Reserve University School of Medicine, Cleveland, Ohio; she is currently professor of medicine emerita, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: https://orcid.org/0000-0003-4528-9891.

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted six-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the six-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.
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http://dx.doi.org/10.1097/ACM.0000000000004141DOI Listing
May 2021

The interprofessional VA quality scholars program: Promoting predoctoral nursing scientists and their career trajectories.

Nurs Outlook 2021 Mar-Apr;69(2):221-227. Epub 2020 Sep 24.

Senior Faculty Scholar, VA Quality Scholars Program, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH.

Background: The VA Quality Scholars (VAQS) program is an interprofessional fellowship that provides a unique opportunity for predoctoral nurse scientists to embed their work in quality improvement learning "laboratories" to inform their scholarship, science, and research.

Purpose: To describe the VAQS program in relation to promoting nursing science and predoctoral nurse scientist (PhD) career trajectories, and to propose policy implications.

Method: Data were collected on all predoctoral (PhD, DNP) nurses who entered and completed the VAQS program nationally.

Findings: A total of 17 predoctoral nurses (11 PhD and 6 DNP) have completed the VAQS program. Ten predoctoral PhD nurses (91%) completed their degree while in the program. Nine predoctoral PhD nurses (82%) entered a postdoctoral fellowship, and many obtained positions as faculty at research-intensive universities postfellowship.

Discussion: The knowledge, skills, and experiences gained by predoctoral nurse scientists from the VAQS's program contribute to their nursing research and professional career growth.
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http://dx.doi.org/10.1016/j.outlook.2020.08.003DOI Listing
April 2021

Improving access in a VA primary care clinic using an innovative Panel Retention Tool: a quality improvement report.

BMJ Qual Saf 2020 11 10;29(11):947-955. Epub 2020 Jun 10.

Department of Internal Medicine, Louis Stokes VA Medical Center, Cleveland, Ohio, USA.

Background: Loss to follow-up is an under-recognised problem in primary care. Continuity with a primary care provider improves morbidity and mortality in the Veterans Health Administration. We sought to reduce the percentage of patients lost to follow-up at the Northeast Ohio Veterans Affairs Healthcare System from October 2017 to March 2019.

Methods: The Panel Retention Tool (PRT) was developed and tested with primary care teams using multiple Plan, Do, Study and Act cycles to identify and schedule lost to follow-up patients. Baseline data on loss to follow-up, defined as the percentage of panelled patients not seen in primary care in the past year, was collected over 6 months during tool development. Outcomes were tracked from implementation through spread and sustainment (12 months) across 14 primary care clinics.

Results: Of the 96 170 panelled patients at the beginning of the study period, 2715 (2.8%) were found to be inactive and removed from provider panels, improving panel reliability. Among the remaining, 1856 (1.9%) patients without scheduled follow-up were scheduled for future care, and 1239 (1.3%) without recent prior care completed encounters during the study period. The percentage of patients lost to follow-up decreased from 10.1% (lower control limit (LCL) 9.8%-upper control limit (UCL) 10.4%) at baseline to 6.4% (LCL 6.2%-UCL 6.7%) postintervention and patients without planned future care decreased from 21.7% (LCL 21.3%-UCL 22.1%) to 17.1% (LCL 16.7%-UCL 17.5%).

Conclusions: The PRT allowed primary care teams in an integrated health system to identify and schedule lost to follow-up patients. Ease of use, adaptability and encouraging outcomes facilitated spread. This has the potential to contribute to more appropriate utilisation of healthcare resources and improved access to primary care.
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http://dx.doi.org/10.1136/bmjqs-2019-010398DOI Listing
November 2020

Development and Validation of the Systems Thinking Scale.

J Gen Intern Med 2020 08 27;35(8):2314-2320. Epub 2020 Apr 27.

Office of Curricular Affairs, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Purpose: Systems thinking is the ability to recognize and synthesize patterns, interactions, and interdependencies in a set of activities and is a key component in quality and safety. A measure of systems thinking is needed to advance our understanding of the mechanisms that contribute to improvement efforts. The purpose of this study was to develop and conduct psychometric testing of a systems thinking scale (STS).

Methods: The development of the STS included obtaining national quality and safety experts' conceptual domains of systems thinking and the generation of a provisional set of items. Further psychometric analyses were conducted with interprofessional healthcare faculty (N = 342) and students (N = 224) engaged in quality improvement initiatives and education.

Results: Of the 26 items identified in the development phase, factor analyses indicated three factors: (1) system thinking (20 items), (2) personal effort (2 items), and (3) reliance on authority (4 items). The six items from factors 2 and 3 were omitted due to low factor loadings. Test-retest reliability of the 20-item STS was performed on 36 healthcare professionals and a correlation of 0.74 was found. Internal consistency testing on a sample of 342 healthcare professionals using Cronbach's alpha showed a coefficient of 0.89. Discriminant validity was confirmed with three groups of healthcare professions students (N = 102) who received high, low, or no dose levels of systems thinking education in the context of process improvement.

Conclusions: The 20-item STS is a valid and reliable instrument that is easy to administer and takes less than 10 min to complete. Further research using the STS has the potential to advance the science and education of quality improvement in two main ways: (1) increase understanding of a critical mechanism by which quality improvement processes achieve results, and (2) evaluate the effectiveness of our education to improve systems thinking.
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http://dx.doi.org/10.1007/s11606-020-05830-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403244PMC
August 2020

Integrating a Reflective Learning Activity to Ensure Quality Improvement Project Success.

Nurs Educ Perspect 2020 Sep/Oct;41(5):E42-E44

About the Authors Christine Horvat Davey, PhD, RN, BSPS, is VA Quality Scholar, Cleveland VA Medical Center, and a research associate, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Mary A. Dolansky, PhD, RN, is an associate professor and director, QSEN Institute, Cleveland VA Medical Center, and a senior faculty scholar, VA Quality Scholars Program, Frances Payne Bolton School of Nursing, Case Western Reserve University. Andrew T. Harris, MD, is a primary care physician, Cleveland VA Medical Center. Mamta K. Singh, MD, MA, is director, Center of Excellence in Primary Care, Cleveland VA Medical Center, and assistant dean for systems science, School of Medicine, Case Western Reserve University. The authors acknowledge the Veteran's Affairs Quality Scholar Program and the Cleveland Veteran's Affairs Transforming Outpatient Care Center of Excellence. For more information, contact Christine Horvat Davey at

This article describes a brief learning activity that provided reflective time to identify barriers, facilitators, and action steps to ensure quality improvement (QI) project success. Learners from our program participated in an interactive 90-minute session that used Liberating Structures to reflect on current barriers to implementation of their QI projects. Analysis of the individual reflective cards identified 10 barriers to QI success. Facilitators were grouped into 16 themes. Action steps were placed into six categories. Integration of reflection promotes important identification of QI project barriers, facilitators, and the creation of action steps.
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http://dx.doi.org/10.1097/01.NEP.0000000000000610DOI Listing
September 2020

Association of a Multisite Interprofessional Education Initiative With Quality of Primary Care.

JAMA Netw Open 2019 11 1;2(11):e1915943. Epub 2019 Nov 1.

Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon.

Importance: Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality.

Objective: To estimate the association of a multisite IPE initiative with quality of care.

Design, Setting, And Participants: This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019.

Main Outcomes And Measures: Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie, <9% or unmeasured), and annual renal test; among patients 65 years and older, outcomes included prescription of high-risk medications; among patients with hypertension, outcomes included hypertension control (ie, blood pressure, <140/90 mm Hg); and among all patients, outcomes included timely mental health referrals, primary care mental health integrated visits, and hospitalizations for ambulatory care-sensitive conditions.

Results: A total of 44 527 patients contributed 107 686 patient-years; 49 279 (45.8%) were CoEPCE resident patient-years (mean [SD] patient age, 59.3 [15.2] years; 26 206 [53.2%] white; 8073 [16.4%] women; mean [SD] patient Elixhauser comorbidity score, 12.9 [15.1]), and 58 407 (54.2%) were non-CoEPCE resident patient-years (mean [SD] patient age, 61.8 [15.3] years; 43 912 [75.2%] white; 4915 [8.4%] women; mean [SD] patient Elixhauser comorbidity score, 13.8 [15.7]). Compared with resident clinicians who did not participate in the CoEPCE initiative, CoEPCE training was associated with improvements in the proportion of patients with diabetes with poor hemoglobin A1c control (-4.6 percentage points; 95% CI, -7.5 to -1.8 percentage points; P < .001), annual renal testing among patients with diabetes (3.2 percentage points; 95% CI, 0.6 to 5.7 percentage points; P = .02), prescription of high-risk medications among patients 65 years and older (-2.3 percentage points; 95% CI, -4.0 to -0.6 percentage points; P = .01), and timely mental health referrals (1.6 percentage points; 95% CI, 0.6 to 2.6 percentage points; P = .002). Fewer patients cared for by CoEPCE resident clinicians had a hospitalization for an ambulatory care-sensitive condition compared with patients cared for by non-CoEPCE resident clinicians in non-CoEPCE clinics (-0.4 percentage points; 95% CI, -0.9 to 0.0 percentage points; P = .01). Sensitivity analyses with alternative comparison groups yielded similar results.

Conclusions And Relevance: In this study, the CoEPCE initiative was associated with modest improvements in quality of care. Implementation of IPE was associated with improvements in patient outcomes and may potentiate delivery system reform efforts.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.15943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902823PMC
November 2019

In Response to "Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?"

J Gen Intern Med 2020 03 19;35(3):937-938. Epub 2019 Nov 19.

Division of General Internal Medicine, Case Western Reserve University, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-019-05346-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080894PMC
March 2020

Creating change, challenging structure: graduate and faculty perspectives on the implementation of an interprofessional education program in veterans affairs primary care.

J Interprof Care 2020 Nov-Dec;34(6):756-762. Epub 2019 Nov 7.

Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.

Interprofessional clinical education programs have the potential to impact participants' professional expectations and practices related to team-based care. In this qualitative study, research team members interviewed 38 graduates and 19 faculty members from such an interprofessional training program, the Department of Veterans Affairs (VA) Centers of Excellence in Primary Care Education (CoEPCE). Semi-structured interviews with participants enquired about skills gained, impact on career expectations, and barriers to implementing interprofessional skills in the post-training workplace. Data were coded and analyzed using a hybrid inductive/deductive approach. Participants perceived that the program was successful in creating new norms of flattened team hierarchies, broadening graduates' understanding of role interaction, and teaching interactional skills involving teamwork. Participants reported organizational and systemic barriers to changing existing primary care practice. Interprofessional clinical education programs may help new professionals recognize and act on opportunities for improvement in existing practice. Healthcare employers must recognize changed expectations and provide opportunities for interprofessional collaboration to attract graduates from such programs.
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http://dx.doi.org/10.1080/13561820.2019.1676706DOI Listing
November 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

The Dyad Model for Interprofessional Academic Patient Aligned Care Teams.

Fed Pract 2019 Feb;36(2):88-93

is the Assistant Professor, Department of Behavioral Sciences Philip R. Lee Institute for Health Policy Studies, University of California in San Francisco. is a Training Administrator; A is the Nurse Practitioner Associate Director; and are Faculty; was previously the Evaluation Associate Director; was previously Interprofessional Associate Director; was previously Faculty; and was previously Director; all at the Center of Excellence in Primary Care Education at the Louis Stokes Cleveland Veterans Affairs Medical Center in Ohio. Mary Dolansky is an Associate Professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University, Simran Singh is an Assistant Professor, and Mamta Singh is the Assistant Dean for Health Systems Science, both at Case Western Reserve University School of Medicine.

Combining interprofessional education, clinical or workplace learning, and physician resident teachers in the ambulatory setting, the dyad model enhances teamwork skills and increases nurse practitioner students' clinical competence.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411364PMC
February 2019

Assessing Residents' Veteran-Centered Care Skills in the Clinical Setting.

J Grad Med Educ 2018 Jun;10(3):279-284

Background : Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient.

Objective : We assessed residents' ability to recognize and address mental health issues that affect US military veterans.

Methods : Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results.

Results : Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum.

Conclusions : This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma.
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http://dx.doi.org/10.4300/JGME-D-17-00700.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008020PMC
June 2018

Starting With Lucy: Focusing on Human Similarities Rather Than Differences to Address Health Care Disparities.

Acad Med 2017 09;92(9):1259-1263

L. Clementz is training administrator, Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio. M. McNamara is associate professor of medicine, Case Western Reserve University School of Medicine, physician associate director, Center of Excellence in Primary Care Education, and medicine associate director, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio. N.M. Burt is curator and head, Human Health and Evolutionary Medicine, Cleveland Museum of Natural History, Cleveland, Ohio. M. Sparks is assistant nursing director, Center of Excellence in Primary Care Education, and nurse practitioner, Primary Care Clinic, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio. M.K. Singh is associate professor of medicine and assistant dean of health systems science education, Case Western Reserve University School of Medicine, and physician director, Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio.

Problem: Multicultural or cultural competence education to address health care disparities using the traditional categorical approach can lead to inadvertent adverse consequences. Nontraditional approaches that address these drawbacks while promoting humanistic care are needed.

Approach: In September 2014, the Cleveland VA Medical Center's Center of Excellence in Primary Care Education Transforming Outpatient Care (CoEPCE-TOPC) collaborated with the Cleveland Museum of Natural History (CMNH) to develop the Original Identity program, which uses a biocultural anthropologic framework to help learners recognize and address unconscious bias and starts with a discussion of humans' shared origins. The program comprises a two-hour initial learning session at the CMNH (consisting of an educational tour in a museum exhibit, a didactic and discussion section, and patient case studies) and a one-hour wrap-up session at the Louis Stokes Cleveland VA Medical Center.

Outcomes: The authors delivered the complete Original Identity program four times between March and November 2015, with 30 CoEPCE-TOPC learners participating. Learners' mean ratings (n = 29; response rate: 97%) for the three initial learning session questions were consistently high (4.2-4.6) using a five-point scale. Comments to an open-ended question and during the audio-recorded wrap-up sessions also addressed the program objectives and key elements (e.g., bias, assumptions, stereotyping).

Next Steps: The authors are completing additional qualitative analysis on the wrap-up session transcriptions to clarify factors that make the program successful, details of learners' experience, and any interprofessional differences in interpreting content. The authors believe this innovative addition to health care education warrants further research.
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http://dx.doi.org/10.1097/ACM.0000000000001631DOI Listing
September 2017

A Case Suspended in Time: The Educational Value of Case Reports.

Acad Med 2017 02;92(2):152-156

C.D. Packer is associate professor of medicine, Case Western Reserve University School of Medicine, and attending physician, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio. R.B. Katz is a third-year psychiatry resident, Yale-New Haven Hospital, New Haven, Connecticut. C.L. Iacopetti is a first-year pediatric resident, University of California, San Francisco Medical Center, San Francisco, California. J.D. Krimmel is a fourth-year medical student, Case Western Reserve University School of Medicine, Cleveland, Ohio. M.K. Singh is associate professor of medicine and assistant dean of health systems science, Case Western Reserve University, and attending physician, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio.

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.
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http://dx.doi.org/10.1097/ACM.0000000000001199DOI Listing
February 2017

A comparative evaluation of patient satisfaction outcomes in an interprofessional student-run free clinic.

J Interprof Care 2015 20;29(5):445-50. Epub 2015 Feb 20.

c School of Medicine, Case Western Reserve University , Cleveland , OH , USA.

As the evidence supporting the value of well-coordinated healthcare teams continues to grow, so to do the calls from medical educators and policy makers for the development of meaningful interprofessional educational experiences for health professions students. The student-run clinic has emerged as a unique venue for such experiential interprofessional learning experiences, with over 100 such clinics now in operation across North America. As the number and variety of these clinics rises, it has become increasingly important to understand the quality of care which they deliver. Here, patient satisfaction data from an interprofessional student-run free clinic are described, and these results are quantitatively compared to similar data obtained from a non-interprofessional, non-student-run clinic in a post-experience only, non-equivalent groups design. Student-run free clinic patients reported high levels of satisfaction with the patient care team and the facility quality, and lower levels of satisfaction with waiting times. When compared to the non-student-run clinic, there was no significant difference in the high levels of patient satisfaction with the patient care teams between the clinics. Student-run free clinic patients did, however, report significantly lower levels of satisfaction with the accessibility of care and with the perceived privacy of protected health information. Overall, this report provides evidence that an interprofessional student-run free clinic is capable of performing at the level of an experienced free clinic across many domains of patient satisfaction, while also identifying notable areas for improvement within the domains of clinic accessibility and the perception of the privacy of protected health information.
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http://dx.doi.org/10.3109/13561820.2015.1010718DOI Listing
January 2017

The Quality Improvement Knowledge Application Tool Revised (QIKAT-R).

Acad Med 2014 Oct;89(10):1386-91

Dr. Singh is associate professor of medicine, Division of General Medicine, Louis Stokes Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio. Dr. Ogrinc is associate professor of community and family medicine and of medicine, VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine, Hanover, New Hampshire. Dr. Cox is manager, Quality Improvement, Office of Clinical Effectiveness, University of Missouri Health Care, Columbia, Missouri. Dr. Dolansky is associate professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Dr. Brandt is associate director of quality improvement, School of Medicine, University of Missouri, Columbia, Missouri. Dr. Morrison is currently director of palliative medicine education, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, but was at Baylor College of Medicine in the Division of Geriatrics at the time of this study. Ms. Harwood is research associate, Geisel School of Medicine, Hanover, New Hampshire. Dr. Petroski is assistant professor of biostatistics, School of Medicine, University of Missouri, Columbia, Missouri. Dr. West is biostatistician, Department of Veterans Affairs, VA Medical Center, White River Junction, Vermont. Dr. Headrick is senior associate dean for education and professor of medicine, School of Medicine, University of Missouri, Columbia, Missouri.

Purpose: Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the "QIKAT-R."

Method: Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: "excellent," "fair," and "poor." Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses.

Results: Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between "poor" and "excellent" responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale.

Conclusions: The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.
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http://dx.doi.org/10.1097/ACM.0000000000000456DOI Listing
October 2014

Implementation of quality improvement skills by primary care teams: case study of a large academic practice.

J Prim Care Community Health 2014 Apr 27;5(2):101-6. Epub 2014 Jan 27.

Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.

Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects.

Objective: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams.

Design: We obtained qualitative and quantitative information about existing primary care team QI initiatives.

Participants: Eleven interdisciplinary primary care teams and 4 facilitators/coaches.

Methods: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators.

Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress.

Conclusions: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.
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http://dx.doi.org/10.1177/2150131913520601DOI Listing
April 2014

The effects of an early observational experience on medical students' attitudes toward end-of-life care.

Am J Hosp Palliat Care 2015 Feb 6;32(1):52-60. Epub 2013 Nov 6.

Case Western Reserve University School of Medicine, Cleveland, OH, USA.

End-of-life care is paramount in maintaining the quality of life of the terminally ill, protecting them from unnecessary treatment, and controlling costs incurred in their care. Training doctors to be effective end-of-life caregivers begins in medical school. A survey design was used to collect data from 166 first-year medical students before and after exposure to hospice or palliative care through an early clinical exposure program. Data demonstrated that students had a significant change in attitude scores after the observational experience (P < .05). Providing students with the opportunity to observe and participate in end-of-life care has a positive effect on attitudes toward the care of dying persons. We recommend that direct exposure to end-of-life care practices be incorporated early in the medical school curriculum.
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http://dx.doi.org/10.1177/1049909113505760DOI Listing
February 2015

Expanding educators' medical curriculum tool chest: minute papers as an underutilized option for obtaining immediate feedback.

J Grad Med Educ 2011 Jun;3(2):239-42

Background: One barrier to systematically assessing feedback about the content or format of teaching conferences in graduate medical education is the time needed to collect and analyze feedback data. Minute papers, brief surveys designed to obtain feedback in a concise format, have the potential to fill this gap.

Objectives: To assess whether minute papers were a feasible tool for obtaining immediate feedback on resident conferences and to use minute papers, with one added question, to assess the usefulness of changing the format of resident morning report.

Methods: Minute papers were administered at the end of internal medicine morning report conferences before and after changing the traditional combined format (all residents) to a separate format (postgraduate year [PGY] 1 met separately from PGY-2 and PGY-3 trainees). We collected information during 3 months during 2 traditional sessions and 8 sessions in the format that separated PGY-1s (3 for PGY-1 and 5 for PGY-2 and PGY-3). Participants responded to an item rating the usefulness of the session and 3 open-ended questions.

Results: Trainees completed the forms in 2 to 3 minutes. Trainee assessment of the usefulness of internal medicine morning report appeared to increase after the change (4.09 versus 4.45 for PGY-1; 3.75 versus 4.38 for PGY-2 and PGY-3 residents).

Conclusions: Minute papers are practical instruments that provide manageable amounts of immediate feedback. In addition, minute papers can be adjusted slightly to help assess the impact of change. In that way, faculty can create an iterative process of feedback that models small cycles of change, a key quality improvement concept.
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http://dx.doi.org/10.4300/JGME-D-10-00097.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184900PMC
June 2011

Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills.

J Grad Med Educ 2011 Mar;3(1):49-58

Background: We developed a practice-based learning and improvement (PBLI) curriculum to address important gaps in components of content and experiential learning activities through didactics and participation in systems-level quality improvement projects that focus on making changes in health care processes.

Methods: We evaluated the impact of our curriculum on resident PBLI knowledge, self-efficacy, and application skills. A quasi-experimental design assessed the impact of a curriculum (PBLI quality improvement systems compared with non-PBLI) on internal medicine residents' learning during a 4-week ambulatory block. We measured application skills, self-efficacy, and knowledge by using the Systems Quality Improvement Training and Assessment Tool. Exit evaluations assessed time invested and experiences related to the team projects and suggestions for improving the curriculum.

Results: The 2 groups showed differences in change scores. Relative to the comparison group, residents in the PBLI curriculum demonstrated a significant increase in the belief about their ability to implement a continuous quality improvement project (P  =  .020), comfort level in developing data collection plans (P  =  .010), and total knowledge scores (P < .001), after adjusting for prior PBLI experience. Participants in the PBLI curriculum also demonstrated significant improvement in providing a more complete aim statement for a proposed project after adjusting for prior PBLI experience (P  =  .001). Exit evaluations were completed by 96% of PBLI curriculum participants who reported high satisfaction with team performance.

Conclusion: Residents in our curriculum showed gains in areas fundamental for PBLI competency. The observed improvements were related to fundamental quality improvement knowledge, with limited gain in application skills. This suggests that while heading in the right direction, we need to conceptualize and structure PBLI training in a way that integrates it throughout the residency program and fosters the application of this knowledge and these skills.
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http://dx.doi.org/10.4300/JGME-D-10-00104.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3186260PMC
March 2011

Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program.

J Eval Clin Pract 2012 Apr 5;18(2):508-14. Epub 2012 Feb 5.

Birmingham Veterans Affairs Medical Center, Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.

Rationale, Aims And Objectives: Healthcare professionals need a new skill set to ensure the success of quality improvement in healthcare. The Department of Veterans Affairs (VA) initiated the VA National Quality Scholars fellowship in 1998; its mission is to improve the quality of care, ensure safety, accelerate healthcare re-design, and advance the improvement science by educating the next generation of leaders in quality and safety. We describe the critical need for leadership in quality and safety and interprofessional education, illustrate the curriculum, provide lessons learned by fellows, summarize key lessons learned from the implementation of an interprofessional education approach, and present most recent accomplishments.

Methods: Narrative review.

Results: As of 2011, 106 program alumni are embedded in the health care delivery system across the United States. Since 2009, when nurse fellows joined the program, of the first nine graduating interdisciplinary fellows, the tailored curriculum has resulted in five advanced academic degrees, 42 projects, 29 teaching activities, 44 presentations, 36 publications, six grants funded or submitted, and two awards.

Conclusions: The VA National Quality Scholars program continues to nurture and develop leaders for the new millennium focusing on interprofessional education. The nations' health care systems need strong interdisciplinary leaders in advanced quality improvement science who are dedicated to improving the overall quality of health and health care.
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http://dx.doi.org/10.1111/j.1365-2753.2011.01816.xDOI Listing
April 2012

A structured women's preventive health clinic for residents: a quality improvement project designed to meet training needs and improve cervical cancer screening rates.

Qual Saf Health Care 2010 Oct 10;19(5):e45. Epub 2010 Aug 10.

Louis Stokes Cleveland Department of Veterans Affairs Medical Center, VA HSR&D Center for Quality Improvement Research, Cleveland, Ohio 44106, USA.

Introduction: Multiple resident-related factors contribute to 'missed opportunities' in providing comprehensive preventive care for female patients, including comfort level, knowledge and experience--all of which are compounded by resident turnover rates. Of particular concern among Internal Medicine (IM) residents is their knowledge and comfort level in performing pelvic exams.

Aim: To evaluate the impact of a quality improvement project of implementing a Women's Preventive Health Clinic (WPHC) on addressing gaps identified by needs assessments: residents' comfort and knowledge with female preventive care and cervical cancer screening.

Programme Description: The WPHC, a multidisciplinary weekly clinic, focused on preventive services for women with chronic conditions. The alternating didactic and clinic sessions emphasised women's preventive health topics for IM residents.

Programme Evaluation: Sixty-three IM residents participated in WPHC between 2002 and 2005. Pre- and post-test design was used to assess resident knowledge and comfort levels. Cervical cancer screening rates of residents' patients were assessed pre- and post-WPHC initiation. There was a significant improvement in general knowledge (64% correct at pretest vs 73% at post-test, p=0.0002), resident comfort level in discussing women's health topics and performing gynaecological exams (p<0.0002). Cervical cancer screening rates among IM residents' patients improved from 54% (pre-WPHC initiation) to 65% (post-WPHC initiation period).

Discussion: The results indicate that a focused resident preventive programme can meet gaps identified by education and needs assessments, and simultaneously have a positive impact on cervical cancer screening rates and thus may serve as a model for other residency programmes.
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http://dx.doi.org/10.1136/qshc.2009.033274DOI Listing
October 2010

Quality and safety education: foreground and background.

Qual Manag Health Care 2009 Jul-Sep;18(3):151-7

Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio 44106, USA.

Since 1988, Case Western Reserve University (CWRU), through its School of Medicine, Frances Payne Bolton School of Nursing, and Division of Public Health, has committed to the development and implementation of quality improvement and safety education as a formal part of its health professions curriculum. Faculty moved quality and safety education from the "background" of implicit learning to the "foreground" of established curriculum. The transformation has affected not only course content but also many academic careers in the process. This article highlights 3 of the many quality and safety education activities that have evolved at the CWRU: the graduate-level course on quality improvement, medical student education, and doctoral education. Based on these activities, 4 key elements are presented as essential for a successful and sustainable quality and safety education program: quality improvement role models and champions, strong academic-practice partnerships, a variety of educational modalities, and a supportive learning environment.
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http://dx.doi.org/10.1097/QMH.0b013e3181aea292DOI Listing
September 2009

Quality management in health care. From the issue editors.

Qual Manag Health Care 2009 Jul-Sep;18(3):149-50

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http://dx.doi.org/10.1097/QMH.0b013e3181aea1ceDOI Listing
September 2009