Nancy D. Spector

Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs

Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education–Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.

Establishing a Multisite Education and Research Project Requires Leadership, Expertise, Collaboration, and an Important Aim

> This is the first in a series of articles to highlight the projects that were chosen for implementation by the IIPE Review Committee; each represents a work in progress. We wanted the readership to be aware of innovations that are underway and what the investigators have learned even though they are early in the process. The first article in this series focuses on building a multi-institutional collaborative project that links educational and patient care outcomes. > > Carol Carraccio, MD, MA Communication and handoff (sign-out) failures are a root cause of two-thirds of sentinel events in hospitals. Therefore, the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission have declared improving handoffs a national priority.1,–,7 As a response to that declaration, we have designed and implemented a multisite education and research project aimed at determining the effectiveness of a resident handoff bundle (team training, use of a verbal mnemonic, and written/computerized tools to supplement verbal handoffs) in standardizing the handoff process in 9 pediatric residency programs. This project, supported by the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) Network, is a unique example of a multisite collaborative that links improved educational outcomes with patient outcomes. Our report, at this early stage, shares lessons learned and illustrates key considerations for the effective development of a similar collaborative multisite education and research project that exists at the interface between education and patient care. Our project started when 1 of the authors (Dr Sectish) attended an institutional quality conference at which a pilot research study that examined resident handoffs was presented by a faculty member (Dr Landrigan) and a health services research fellow (Dr Starmer). The study measured the impact of a resident handoff bundle on patient safety. The 3 colleagues met after the … Address correspondence to Theodore C. Sectish, MD, Department of Medicine, Hunnewell 2, Childrens Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mail: theodore.sectish{at}childrens.harvard.edu

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

Gender and Generational Influences on the Pediatric Workforce and Practice

In response to demographic and other trends that may affect the future of the field of pediatrics, the Federation of Pediatric Organizations formed 4 working groups to participate in a year’s worth of research and discussion preliminary to a Visioning Summit focusing on pediatric practice, research, and training over the next 2 decades. This article, prepared by members of the Gender and Generations Working Group, summarizes findings relevant to the 2 broad categories of demographic trends represented in the name of the group and explores the interface of these trends with advances in technology and social media and the impact this is likely to have on the field of pediatrics. Available data suggest that the trends in the proportions of men and women entering pediatrics are similar to those over the past few decades and that changes in the overall ratio of men and women will not substantially affect pediatric practice. However, although women may be as likely to succeed in academic medicine and research, fewer women than men enter research, thereby potentially decreasing the number of pediatric researchers as the proportion of women increases. Complex generational differences affect both the workforce and interactions in the workplace. Differences between the 4 generational groups comprising the pediatric workforce are likely to result in an evolution of the role of the pediatrician, particularly as it relates to aspects of work–life balance and the use of technology and social media.

e-Professionalism: Challenges in the Age of Information

averse industry in the United States,’’ according to Christensen. The age of information clearly has affected the culture of medicine in ways that we are just beginning to understand. Never before have there been so many ways to communicate. In the past, we were limited to face-to-face conversations, postal mail, telegrams, and telephone calls. Physicians communicated about their credentials through listings in the telephone book and in local medical society publications, or by hanging a shingle outside the office. With the development and diffusion of new technologies, our means of communicating about ourselves, as well as with colleagues, patients, families, and learners grew enormously. At the same time, the types of new technologies expanded; e-mail, video conferences, webinars, text messaging, text pagers, websites, blogs, and social networking sites all entered our culture within the past 20 years. The use of these technologies is pervasive and increasing. Professionalism, as one of the core competencies established by the Accreditation Council of Graduate Medical Education (ACGME), has been the subject of much discussion in the last several years. The American Board of Internal Medicine developed a charter for medical professionalism in the new millennium that articulated fundamental principles and a set of professional responsibilities. 2 The American Board of Pediatrics, in conjunction with the Association of Pediatric Program Directors, developed a guidebook for teaching and assessing professionalism in pediatric residency that set forth specific examples of exemplary behavior, lapses in professionalism, and behaviors that warrant immediate attention. 3 Although much has been written and discussed about this subject recently, it is notable that the subject of professionalism in electronic communication, e-Professionalism, has not been addressed. Examples of lapses in professionalism in the electronic realm are just beginning to be appreciated. Personal cellular phones may be used for professional communication, which challenges the boundaries of patient confidentiality and may lead to blurred hierarchical roles between faculty and learners in education and clinical care. Physicians posting on online social networking sites must be reminded that their professionalism may be judged by such content. For example, photographs, social group affiliations, and personal information that are not generally shared in the doctor-patient relationship may be inadvertently revealed to patients via postings on social networking sites. In 2008, Thompson et al 4 at the University of Florida studied Facebook pages of medical students and residents and found that 46.3% of medical students and 12.8% of residents had accounts. A majority of the accounts were not private and, in some cases, there was inappropriate or unprofessional content posted. At a recent meeting of pediatric program directors, Matz et al 5 facilitated a workshop on e-Professionalism and began to illuminate this developing issue. At this workshop, the 3 that characterize electronic professionalism were coined: electronic communication is Public, Permanent, and Powerful.

Pediatrician's role in screening and treatment: bullying, prediabetes, oral health

Purpose of review To review recent literature on important topics in pediatric office practice: bullying, screening for the prediabetic state, and pediatric oral health. Recent findings Recent literature shows that bullying behaviors are common in children as young as kindergarten age, that there is a strong association between being a bully or victim and a range of psychosomatic and depressive symptoms in children, and that interventions including family therapy and school-based programs are effective for bullies and victims. Recent studies have further delineated glucose and insulin metabolism. Recent work has provided new models to help practitioners screen for the prediabetic state in hope of providing earlier opportunities to intervene and avoid the morbidities associated with type 2 diabetes mellitus. Recent literature emphasizes continued gaps in dental healthcare for patients who are most at risk. Recent studies emphasize the important role that diet and sealants have in preventing dental caries. Summary Recent literature emphasizes the important role that office-based pediatricians have in identifying patients who are involved in bullying, at risk of developing type 2 diabetes mellitus, or have poor dental health. Future research will help delineate these problems and provide us with refined primary prevention and treatment guidelines.

How can we assure procedural competence in pediatric residents in an era of diminishing opportunities? The answer is simulation-based training.

All rights reserved. 10.1016/j.jpeds.2010.02.058 xternal forces have greatly modified the learning environment of pediatric trainees. Restrictions of duty hours decrease the amount of time trainees spend in the clinical environment, reducing exposure to procedures and emergency situations. Consequentially, work compression and increasing complexity of patients’ problems have relegated procedures to a low priority. Patient safety initiatives have led to the creation of rapid response teams designed to take over care in an emergency, further decreasing trainee learning and leadership opportunities. As opportunities become limited, residents are competing with each other for experience. The increasing presence of attending physicians and the use of allied health providers contribute further to decrements in resident autonomy and sense of patient ownership. Fewer available ‘‘practice’’ hours are juxtaposed with increasing demands for documentation of procedural competency (as mandated by both the Pediatric Review Committee and Joint Commission on Accreditation of Healthcare Organizations). The net negative effect cannot be underestimated in pediatrics. Pediatric procedural skills and decision making have unique learning challenges as a child’s anatomy, physiology, and behavior all vary by age. Endotracheal intubation of an infant is different from intubation of a child. Cardiac arrests are rare in pediatrics—life-threatening events more likely begin as unrecognized respiratory emergencies that progress to cardiac arrest. The skill of recognizing an impending event is as important as the skills to manage the emergency. When that emergency occurs, competence in both procedural and critical thinking skills of responders is crucial for optimal outcomes. Nadel in 2000 surveyed pediatric residents and found that 44% of pediatric level-3 residents had never led a resuscitation event. The environment in the 2010s will have further decrements in trainee opportunities, practice, and skill. Together, these influences create what Weinstock, et al have referred to as the ‘‘pediatric training paradox.’’ There is inadequate clinical volume exposure for trainees to ensure optimal patient outcomes. Mastery of the management of medical crises requires teamwork, knowledge and technical skills, and opportunities for deliberate, rather than ‘‘accidental,’’ practice. Deliberate practice affords the learner a task with well-defined goals, a process for feedback, and opportunities for repetition to achieve expertise. Simulation can be the educational vehicle for this process. Simulation recreates events and conditions that may occur in actual patient encounters. Used equipment varies in fidelity. It can be as simple as an ‘‘intubation head’’ or as complex as a human patient simulator (eg, computer-driven mannequin with vital sign changes and physical examination findings) directed by the exercise objectives. The use of simulation is well established in many nonmedical industries, such as the military, the airline industry, and the nuclear power industry. As in medicine, the tasks require high reliability of skills when personnel react to life-threatening emergencies. The cognitive processes and experience of repetition and variation must be developed in a safe arena in which lives are not at stake. Nelson, et al described successful use of simulation to train counselors to deal with emergencies in a camp setting. The camp staff practiced simulations with the automated external defibrillator. Subsequently, a camper was struck by lightening and was successfully resuscitated by staff using the automated external defibrillator. One staff member noted that despite never having managed an actual cardiac arrest, ‘‘I knew what to do, because I’ve already done it a hundred times.’’ The extension of this technique to medicine makes intuitive sense. Simulation is not limited to procedural skills but can also powerfully engage the learner in the cognitive processes necessary to recognize a situation, sort options for intervention, act, and observe the consequences in real time. This far outstrips merely making differential diagnoses. Simulation is a safe, learner-driven environment that allows for the practice of critical thinking, team interaction, leadership, and communication skills. Simulation allows a trainee to enter a real-life situation (eg, in an intensive care unit or the general practice of pediatrics) with practiced skills, instead of the patient encounter or systems crisis being the first opportunity to acquire those skills. Simulation can bridge the experience gap and change chance encounters into deliberate practice. Satisfactory completion of a certain number of curricular block rotations pales as evidence of competence in comparison with cumulative achievement through simulation. The broadest application of simulation in medicine thus far has been in anesthesiology, as pioneered by Gaba. Simulation is nascent in pediatrics. Halamek et al developed a neonatal resuscitation course using both traditional and simulated

The Value of Speed Mentoring in a Pediatric Academic Organization

OBJECTIVE A reliable and supportive mentor is indispensable to the career development of successful academic professionals. The Academic Pediatric Association (APA) utilized a speed mentoring format at the 2012 Pediatric Academic Societies meeting to enhance mentoring potential. We sought to evaluate the structure of the speed mentoring event and to determine the benefits and impact from the perspectives of the mentors and mentees. METHODS Sixty mentees were matched with 60 mentors within various tracks. Each mentee met with 6 mentors for 10 minutes for each dyad. Participants were then asked to complete a survey 1 to 4 weeks after the event. Survey items included expectation, impact, and value of the experience along with potential for ongoing mentoring relationships. RESULTS Fifty-four (90%) of the 60 mentees and 52 (87%) of 60 of the mentors completed the evaluation. Mentees stated that the event allowed them to receive advice from multiple mentors in a short time period. Mentors appreciated that they gained new insights, reflected on their own careers, and were able to give back to their field. Both mentees and mentors agreed that the time was well spent, would participate again, and identified chemistry as a major factor in pursuing an ongoing relationship. CONCLUSIONS This national speed mentoring event provided an innovative, fun, and time-efficient mechanism to establish connections, network, and determine whether chemistry existed for potential mentor-mentee relationships. Further study should evaluate whether it can be used in other venues and lead to the development of lasting mentor-mentee relationships.

Important determinants of newborn health: postpartum depression, teen parenting, and breast-feeding.

Purpose of review The present article addresses recent research related to three important determinants of newborn health: postpartum depression, teenage parents and their offspring, and breast-feeding. Recent findings Postpartum depression can impact the entire family unit, and fathers may be affected more than previously recognized. Teenage mothers and their infants are at risk of a number of poor physical and mental health outcomes. New research continues to support the benefits of breast-feeding infants, and hospitals have adopted policies to improve breast-feeding rates. Summary Recognizing both maternal and paternal depression during outpatient visits is key to family well-being, as well as to infant development and attachment. Pediatric providers should address the unique emotional, socioeconomic, educational, and health needs of teen mothers. Hospital implementation of evidence-based policies may increase the number of mothers who are successful in establishing breast-feeding, and pediatric healthcare providers should be prepared to support mothers of breast-feeding infants.

Placing Faculty Development Front and Center in a Multisite Educational Initiative: Lessons From the I-PASS Handoff Study

From the University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr O’Toole); University of California San Francisco School of Medicine, Benioff Children’s Hospital, San Francisco, Calif (DrsWest andRosenbluth); HarvardMedical School, Boston Children’s Hospital (Drs Starmer, Landrigan, and Sectish); Uniformed Health Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Md (Drs Yu, Hepps, and Lopreiato); Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadephia, PA (Drs Calaman and Spector); and Brigham and Women’s Hospital, Boston, Mass (Dr Landrigan) Dr Landrigan is supported by the Children’s Hospital Association for his work as an Executive Council member of the PRIS Network. He has also received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for delivering lectures on sleep deprivation, physician performance, handoffs, and safety. The other authors declare no conflicts of interest. Address correspondence to Jennifer K. O’Toole, MD, MEd, Cincinnati Children’s Hospital Medical Center/Division of Hospital Medicine, 3333 Burnet Ave, MLC 5018, Cincinnati, OH 45229-3039 (e-mail: Jennifer.otoole@cchmc.org).