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Simulation is often underutilized in quality improvement (QI) studies, especially at the systems level. Simulation can be used as an assessment methodology or educational intervention and can thus be a critical component or adjunct to established QI methodologies. This chapter describes how to integrate simulation into existing QI frameworks, using a plan-do-study-act (PDSA) model of improvement, and highlights how simulation can facilitate effective quality improvement work at both the “micro” and macro-systems level. The chapter also explores the use of simulation as both an intervention and assessment tool and provides examples of PDSA-focused study designs which use simulation to improve various domains of care.

Background Residents and fellows play a key role in patient care at academic medical centers and have unique insights into quality and safety improvement opportunities. To increase integration of trainees into the quality and safety mission of our hospital, the Housestaff Quality and Safety Council (HQSC) was created in 2018. The HQSC represents a collaboration between the housestaff, Graduate Medical Education, office of Quality and Safety, interprofessional hospital staff, and senior leadership. At our institution, Aim Statement Our objective was to increase the monthly incidence of event reporting by graduate medical trainees by 20% from baseline within 12 months. Interventions We used improvement methodology to identify critical drivers of barriers to submitting event reports, which included 1) education and awareness of the hospital's reporting system, 2) time and effort associated with submitting reports, 3) culture of safety, and 4) lack of feedback and transparency surrounding reports (Figure 1). We used an iterative approach with multiple PDSA cycles to increase knowledge and engagement of event reporting. Tests of change included tip sheets, development of a trainee-run Morbidity, Mortality, and Improvement (MM&I) conference, acknowledgement by senior leadership for submitting reports, and educational interventions. Measures The baseline mean number of safety reports by trainees in the 12 months prior to our project was 24.6 per month. Results The number of safety event reports placed by trainees increased in the initial 5 months of the project, reaching special cause variation in month 2 and 4. Educational interventions and tip sheets were implemented in PDSA #1, the MM&I conference was implemented in PDSA #2, and acknowledgement by senior leadership was implemented in PDSA #3. Conclusions and Next Steps Engaging trainees in patient safety concepts through education, interactive conferences, and appreciation can increase safety event reporting by trainees. Future planned PDSA cycles include implementing changes to increase timely feedback, developing patient safety faculty and resident experts, and increasing audit and feedback of reporting data to trainees.

Supplemental Digital Content is available in the text., Introduction: Inpatient rounding serves numerous roles. The American Academy of Pediatrics recommends a family-centered bedside model. Residents identified physical examination teaching during and satisfaction with rounds as areas for improvement. A resident group developed a project utilizing quality improvement (QI) methodology to address these concerns. We aimed to increase the frequency of bedside physical examination teaching most or every day on a single inpatient unit by 20% over 1 year, with secondary goals to increase the percentage of interns spending one hour or more at bedside per day by 10% and intern satisfaction by 15%, without impacting rounding duration. Methods: We developed an organizational structure to complete a long-term resident-led project. Interventions included daily bedside examination teaching on rounds, afternoon examinations, goal communication, topic recording, and a teaching “tip sheet.” Using an institutional QI framework, we utilized iterative plan-do-study-act cycles to implement interventions and surveys to assess outcomes, with rounding efficiency as a balancing measure. Results: The survey response rate was 57%. Bedside teaching frequency increased from a mean of 10% to 61%, perceived time at the bedside increased from 37% to 59%, and rounding satisfaction improved from a rating of 6.7/10 to 7.4/10. Efficiency was not impacted. Conclusions: We improved inpatient rounds bedside physical examination teaching and satisfaction without sacrificing efficiency. This project demonstrates the feasibility and success of a resident-driven education initiative to successfully motivate fellow residents and colleagues across disciplines to enact change. The organizational structure may serve as a model for resident-led QI projects across institutions.

BACKGROUND Previous studies attempting to distinguish preventable from nonpreventable readmissions reported challenges in completing reviews efficiently and consistently. OBJECTIVES (1) Examine the efficiency and reliability of a Web-based fault tree tool designed to guide physicians through chart reviews to a determination about preventability. (2) Investigate root causes of general pediatrics readmissions and identify the percent that are preventable. DESIGN/SETTING/PATIENTS General pediatricians from The Children's Hospital of Philadelphia used a Web-based fault tree tool to classify root causes of all general pediatrics 15-day readmissions in 2014. INTERVENTION/MEASUREMENTS The tool guided reviewers through a logical progression of questions, which resulted in 1 of 18 root causes of readmission, 8 of which were considered potentially preventable. Twenty percent of cases were cross-checked to measure inter-rater reliability. RESULTS Of the 7252 discharges, 248 were readmitted, for an all-cause general pediatrics 15-day readmission rate of 3.4%. Of those readmissions, 15 (6.0%) were deemed potentially preventable, corresponding to 0.2% of total discharges. The most common cause of potentially preventable readmissions was premature discharge. For the 50 cross-checked cases, both reviews resulted in the same root cause for 44 (86%) of files (κ = 0.79; 95% confidence interval: 0.60-0.98). Completing 1 review using the tool took approximately 20 minutes. CONCLUSION The Web-based fault tree tool helped physicians to identify root causes of hospital readmissions and classify them as either preventable or not preventable in an efficient and consistent way. It also confirmed that only a small percentage of general pediatrics 15-day readmissions are potentially preventable. Journal of Hospital Medicine 2016;11:329–335. © 2016 Society of Hospital Medicine

BACKGROUND: Readmission rates are frequently used as a hospital quality metric; yet multiple measures exist to evaluate pediatric readmission rates. We sought to assess how four different measures of pediatric readmission compare with assessment of both preventable and unplanned readmission. METHODS: Clinicians on hospital medicine, cardiology, neonatology, and neurology teams reviewed medical records for 30-day readmissions using an abstraction tool with high interrater reliability for preventability assessment. Readmissions between July 2014 and June 2016 were classified separately as preventable or not preventable and planned or unplanned. We compared the classifications to four existing readmission metrics: all-cause readmission, unplanned readmission/time flag classification, the pediatric all-condition readmission, and potentially preventable readmission. We calculated sensitivity and specificity for all readmission metrics. RESULTS: Among 30-day readmissions considered, 1,643 were eligible for medical record review; 1,125 reviews were completed by the clinical teams (68%). On medical record review, the majority of readmissions were determined not preventable (85%). Only 15% were classified as unplanned and preventable. None of the four readmission measures had appropriate sensitivity or specificity for identifying preventable readmission. The unplanned readmission/time flag classification had the highest sensitivity (95%) and specificity (90%) in identifying unplanned readmissions. CONCLUSION: None of the existing pediatric readmission measures can reliably determine preventability. The unplanned readmission/time flag measure performed best in identifying unplanned readmissions.

Previous studies attempting to distinguish preventable from nonpreventable readmissions reported challenges in completing reviews efficiently and consistently.(1) Examine the efficiency and reliability of a Web-based fault tree tool designed to guide physicians through chart reviews to a determination about preventability. (2) Investigate root causes of general pediatrics readmissions and identify the percent that are preventable.General pediatricians from The Children's Hospital of Philadelphia used a Web-based fault tree tool to classify root causes of all general pediatrics 15-day readmissions in 2014.The tool guided reviewers through a logical progression of questions, which resulted in 1 of 18 root causes of readmission, 8 of which were considered potentially preventable. Twenty percent of cases were cross-checked to measure inter-rater reliability.Of the 7252 discharges, 248 were readmitted, for an all-cause general pediatrics 15-day readmission rate of 3.4%. Of those readmissions, 15 (6.0%) were deemed potentially preventable, corresponding to 0.2% of total discharges. The most common cause of potentially preventable readmissions was premature discharge. For the 50 cross-checked cases, both reviews resulted in the same root cause for 44 (86%) of files (κ = 0.79; 95% confidence interval: 0.60-0.98). Completing 1 review using the tool took approximately 20 minutes.The Web-based fault tree tool helped physicians to identify root causes of hospital readmissions and classify them as either preventable or not preventable in an efficient and consistent way. It also confirmed that only a small percentage of general pediatrics 15-day readmissions are potentially preventable. Journal of Hospital Medicine 2016;11:329-335. © 2016 Society of Hospital Medicine.