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OBJECTIVE We describe our five-year experience with a novel co-learning curriculum in quality improvement (CCQI) 1 for the largest reported cohort of surgical residents. The program introduces trainees to principles of quality improvement (QI) 2 and empowers them to complete collaborative projects with mentorship from faculty experts. DESIGN Each iteration consists of three interactive seminars. Residents are required to complete and present a QI project in the third seminar. To assess the impact of the program, graduates of the 2020-2021 iteration were surveyed using validated tools to examine changes in confidence and knowledge of QI principles. SETTING Department of Surgery, University of Toronto, Toronto, ON, Canada. PARTICIPANTS Participation ranged from 57 to 63 residents yearly, from diverse surgical disciplines including General Surgery, Plastic Surgery, Obstetrics and Gynecology, amongst others. Multiple small groups consisted of 4-6 residents from each speciality, mentored by a faculty lead from the same specialty. RESULTS Approximately 300 first-year surgical residents have participated in the CCQI since 2015, with over 60 completed QI projects. A total of 41(66%) and 51(82%) residents completed the survey in its pre- and post-course administration in 2020-2021, respectively. There was a significant increase in confidence scores with respect to describing a QI issue, building a team, and testing the change, amongst other aspects. There was also a statistically significant increase in mean knowledge scores for both scenarios of the Quality Improvement Knowledge Application Tool. 69% and 73% of residents reported “some improvement” in their knowledge, and confidence in applying QI principles to patient care, respectively. A majority of residents (73%) found the QI curriculum somewhat valuable, with 23% reporting it to be very valuable to their residency and future surgical career. CONCLUSIONS We describe successful long-term implementation of a novel co-learning curriculum in quality improvement. Residents derive value from this curriculum with a meaningful increase in confidence and knowledge of QI as an integral part of surgical practice.

Introduction Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education. Methods Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered. Results Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory. Discussion Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate. Supplementary Information The online version of this article (10.1007/s40037-021-00686-5) contains supplementary material, which is available to authorized users.

POINTS CLES Les activites classiques de developpement professionnel continu (DPC) permettent aux medecins d’ameliorer leurs connaissances, mais ratent en general la cible pour ce qui est de changer les pratiques cliniques ou d’ameliorer les resultats pour les patients[1][1]. Recemment

This article presents a performance update for the equity long–short mutual funds that were first described and analyzed in McCarthy (2014), extending that analysis to the period from July 2013–December 2019. The analyses confirm that the equity long–short mutual funds provide investment exposure similar to leading equity long–short hedge fund indexes. However, in this later time period, they underperformed the S&P 500 Index and traditional hedge fund indexes. In addition, none of the indexes (i.e., the Index of Equity Long–short Mutual Funds, the HFRI Equity Hedge Fund Index, the DJ-CS L/S Equity Hedge Fund Index, or the CISDM Equity Long–Short Index [as modified]) had positive risk-adjusted returns, as measured by alpha over this later period, and none of the 24 equity long–short mutual funds with full data for the period from July 2013–December 2019 had positive alpha. This article also presents data on the lack of performance persistence across the equity long–short mutual funds, analyzes the considerable change in asset sizes of some of these funds, reports on the closure rate of equity long–short mutual funds over this time period, and notes the positive relationship between excess performance over the S&P 500 Index and equity long–short mutual fund net asset flows. Finally, the appendix broadens the analysis to include equity long–short mutual funds started after July 2013. The performance results from this expanded universe of funds is materially the same as the original sample of mutual funds from 2013. TOPIC:Mutual fund performance Key Findings This article examines equity long-short mutual funds over the period from July 2013–December 2019. It extends an earlier analysis of these same mutual funds through June 2013 (McCarthy 2014) and finds the following: a) Equity long–short mutual funds continue to provide investment exposure similar to equity long–short hedge funds. b) Equity long–short mutual funds have substantially underperformed the S&P 500 Index in absolute return terms over the analysis period (3.4% p.a. vs. 13.7% for the S&P 500). Moreover, as a group, they generated negative alpha over this period (−4.0% p.a.). Further, no individual equity long–short mutual fund included in the analysis earned a positive alpha over this six-and-a-half-year period. c) Equity long–short mutual funds performed similarly to, although slightly behind, leading equity long-short indexes over the analysis period. d) Over the analysis period, no persistence in individual equity long–short mutual fund manager performance was identified. Additionally, as a group and individually, equity long–short mutual funds had difficulties maintaining their asset levels. Only one of the largest five funds in 2013 was still among the five largest at the end of 2019. The article also includes performance data for equity long–short mutual funds begun after June 2013. The results are largely indistinguishable from the funds begun before that date. That is, this expanded universe of funds also substantially underperformed the S&P 500 Index, as a group did not earn positive alpha, and underperformed leading hedge fund indexes.

Quality improvement and patient safety (QIPS) education programmes have proliferated in the past decade given the rising demand for healthcare professionals to develop the knowledge, skills and attitudes required to make improvements in healthcare.1–4 On the one hand, this proliferation is a positive sign of the institutionalisation of QIPS within our educational, practice, professional and regulatory spheres. On the other hand, while numerous QIPS education programmes are up and running, our understanding of key educational processes and how to optimise outcomes is still evolving. For instance, it remains unclear how to simultaneously optimise learning and project outcomes in quality improvement (QI) project-based learning or how to facilitate interprofessional learning in QIPS education. In this issue of BMJ Quality and Safety , Myers and colleagues5 studied the influence of two postgraduate QIPS fellowship training programme for physicians on graduates’ career outcomes and on the institutions in which they are located. The two programmes, The Center for Healthcare Improvement and Patient Safety Fellowship at the University of Pennsylvania and The Harvard Fellowship in Patient Safety and Quality, provide coursework, access to a Masters degree and opportunities to complete projects within the health system. The study involved interviews with 28 graduates and 16 of their mentors. The study findings are encouraging in that they demonstrate that these two education programmes had positive effects at different levels. Fellows reported improvements in QIPS knowledge, skills and attitudes and all pursued and completed a Masters degree. A very high percentage of graduates, on completion of their training, held academic and/or organisational leadership positions involved in QIPS administration, research or education. The programmes also attained positive health system outcomes through fellow-led QIPS capstone projects at the divisional, departmental and/or institutional levels. In some cases, the fellows’ impact went beyond their projects and contributed to changes …

Purpose To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. Method In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. Results For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. Conclusions In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.

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.

Resource stewardship and reducing low-value care have emerged as urgent priorities for health care delivery systems worldwide. However, few medical schools' curricula include adequate content to allow learners to master the knowledge, skills, and attitudes needed to contribute to this transformation toward value-based health care. This article describes a program to launch student-led curriculum enhancement initiatives in 7 countries. The program, called STARS (Students and Trainees Advocating for Resource Stewardship), was inspired by Choosing Wisely, a campaign by the American Board of Internal Medicine Foundation that seeks to promote conversations on avoiding unnecessary medical tests, treatments, and procedures.The initial STARS model, which originated in Canada in 2015, included a leadership summit, where students from multiple medical schools learned about Choosing Wisely principles, leadership, and advocacy. These students then led grassroots efforts at their local medical schools with faculty and other students to raise awareness and advocate for changes related to resource stewardship. Student-led efforts resulted in the integration of Choosing Wisely principles into case-based learning, the creation of student interest groups and electives, the launch of social media campaigns, and the organization of special presentations by local experts.The rapid spread of similar programs in 6 other countries (Italy, Japan, the Netherlands, New Zealand, Norway, and the United States) by 2018 suggests that STARS resonates across multiple settings and signals the potential for such a model to advance other important areas in medical education. This article documents results and lessons learned from the first 4 years of the program.

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in six hospitals serving as central hubs to 54 geographically associated NHs with 9,574 beds in Toronto, Canada. LTC+ provided to NHs with the following: 1) virtual general internal medicine (GIM) consultations; 2) nursing navigator support; 3) rapid access to laboratory and diagnostic imaging services; and 4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%) and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%) and system navigation (12%). One hundred and seventy-seven (46%; 95% CI 41-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step towards health system integration that values the expertise within the long-term care sector., Early impact of the implementation of a novel collaborative care program in nursing homes demonstrates feasibility in enhancing care, decreasing unnecessary acute care transfers, and building connections across sectors.

IntroductionUnwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards outcomes-based and competency-based medical education, current assessment strategies in residency do not routinely incorporate clinical outcomes. The widespread use of electronic health records (EHRs) may enable the implementation of in-training assessments that incorporate clinical care and patient outcomes.Methods and analysisThe General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED) is a retrospective cohort study of senior residents (postgraduate year 2/3) enrolled in the University of Toronto Internal Medicine (IM) programme between 1 April 2010 and 31 December 2020. This study focuses on senior IM residents and patients they admit overnight to four academic hospitals. Senior IM residents are responsible for overseeing all overnight admissions; thus, care processes and outcomes for these clinical encounters can be at least partially attributed to the care they provide. Call schedules from each hospital, which list the date, location and senior resident on-call, will be used to link senior residents to EHR data of patients admitted during their on-call shifts. Patient data will be derived from the GEMINI database, which contains administrative (eg, demographic and disposition) and clinical data (eg, laboratory and radiological investigation results) for patients admitted to IM at the four academic hospitals. Overall, this study will examine three domains of resident practice: (1) case-mix variation across residents, hospitals and academic year, (2) resident-sensitive quality measures (EHR-derived metrics that are partially attributable to resident care) and (3) variations in patient outcomes across residents and factors that contribute to such variation.Ethics and disseminationGEMINI MedED was approved by the University of Toronto Ethics Board (RIS#39339). Results from this study will be presented in academic conferences and peer-reviewed journals.

BACKGROUND: Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests. OBJECTIVE: This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients. DESIGN: This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants. PARTICIPANTS: Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5 years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions. MAIN MEASURES: Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2–4 h, 6–8 h, twice a day, daily, every 2–3 days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods. KEY RESULTS: Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories. CONCLUSIONS: A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.

Background: Resident doctors are integral to healthcare delivery in Canada. Engaging residents in resource stewardship is important for professional development, but also as they are drivers of healthcare resource use. To date, no national resident-specific resource stewardship guideline has been developed. Resident Doctors of Canada (RDoC) in collaboration with Choosing Wisely Canada (CWC) sought to develop an evidence-informed, consensus-based list of five recommendations to promote resource stewardship. Methods: RDoC convened a taskforce with diverse geographic and specialty representation to develop candidate recommendations targeting resident resource stewardship behaviours using a consensus-based process, supported by a literature review. Residents across the country provided feedback on the candidate recommendations via an online questionnaire. The taskforce used this feedback to finalize the list.Results: The taskforce prepared 28 candidate recommendations for consideration. A detailed literature review and consensus process narrowed this list to 12 candidate recommendations for consultation. A total of 754 residents (754/10,068 residents = 7.5%) representing all provinces and levels of residency training reviewed and ranked the candidate recommendations. The highest-ranked recommendations comprised the final list.Conclusion: Resident doctors are willing and able to demonstrate leadership in advancing resource stewardship by the development of a national resident-specific list of Choosing Wisely Canada recommendations.

It is widely accepted that quality improvement (QI) education should be experiential. Many training programs believe that making QI learning "hands-on" through project-based learning will translate into successful learning about QI. However, this pervasive and overly simplistic interpretation of experiential QI learning, and the general lack of empirical exploration of the factors that influence experiential learning processes, may limit the overall impact of project-based learning on educational outcomes.In this Perspective, the authors explore the opportunities afforded by a theoretically informed approach, to deepen understanding of the diverse factors that affect experiential QI learning processes in the clinical learning environment. The authors introduce the theoretical underpinnings of experiential learning more generally, and then draw on their experiences and data, obtained in organizing and studying QI education activities, to illuminate how sociocultural theories such as Billett's workplace learning theory, and sociomaterial perspectives such as actor-network theory, can provide valuable lenses for increasing our understanding of the varied individuals, objects, contexts, and their relationships that influence project-based experiential learning. The two theoretically informed approaches that the authors describe are amongst numerous others that can inform a QI education research agenda aimed at optimizing educational processes and outcomes. The authors conclude by highlighting how a theoretically informed QI education research agenda can advance the field of QI education; they then describe strategies for achieving this goal.

Background Conducting postcall morning handoffs using a resident handoff bundle such as I-PASS can prove challenging. This may delay recognizing and acting on clinically important patient issues that arose overnight. Objective We developed and implemented the I-CATCH morning handoff bundle and evaluated its impact on the proportion of overnight patient issues handed off from the on-call resident to the daytime team. Methods We evaluated the I-CATCH (Identify patient; Characterize situation; Action–what was done overnight?; To do for the team in the morning; Confirm the Handoff) handoff bundle from November 2015 to May 2016 on general internal medicine wards at 1 academic teaching hospital. The bundle entailed staff/resident training, structured communication, and dedicated handoff space and time. We compared handoffs of overnight on-call issues by evening resident to daytime medical team before and after implementation, and used statistical process control to analyze adherence to the mnemonic. Results We observed 435 handoffs (242 pre- and 193 postimplementation) over 63 days. There was no significant association between I-CATCH implementation and proportion of on-call overnight issues handed off (OR = 0.96; 95% confidence interval [CI] 0.52–1.47; P = .85). Running the list by going through patients one-by-one (OR = 1.74; 95% CI 1.1–2.77; P = .019), progress note documentation (OR = 3.80; 95% CI 2.19–6.60; P < .001), and direct handoff (OR = 4.84; 95% CI 1.43–16.42; P = .011) correlated with an increased likelihood of morning handoff. Conclusions Implementing the I-CATCH bundle did not improve handoff of overnight issues to the daytime team.

KEY POINTS Traditional continuing professional development (CPD) activities may increase physicians’ knowledge, but usually fall short of the goal of changing clinical practice, let alone improving patient outcomes.[1][1] The Future of Medical Education in Canada recently called for a new approach

Residency training represents a unique period when learners begin to personally experience the patient safety and quality-of-care issues that affect health care systems and increasingly take responsibility to address them. Their integration into the clinical workflow in clinics, wards, and operating rooms positions them perfectly to observe and characterize the underlying processes that contribute to patient safety and health care quality problems. Residents' practices and perspectives are less entrenched than those of their faculty counterparts, which enables them to offer fresh ideas on the quality improvement (QI) process. Their creativity and ingenuity serve as assets when coming up with new and innovative changes to test using rapid change cycles. As such, they are ideally suited to serve as health systems change agents. Training programs and clinical institutions typically see residents as frontline care providers whose primary role is to treat the patient in front of them. Yet, by enabling residents to "treat the system" through QI work, they can take on the role of residents as change agents, which has the potential to have long-lasting effects on patient care on a much wider scale. However, training programs must do more than simply harness residents' enthusiasm and root them on from the sidelines. Instead, they must create an environment that is conducive to successfully implementing changes at the curricular, institutional, and health systems levels.

Background The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. Methods We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. Results There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. Interpretation The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Context The explicit, intentional and systematic application of continuous quality improvement (QI) in medical education practice and research can improve medical education and help it achieve its goals. Quality improvement and medical education share a foundation centred on learning-experiencing, reflecting, thinking and acting in continuous cycles that spiral to sustained advancement. This suggests that a QI mindset can be brought to bear on various aspects of medical education research and practice. Discussion To explore this possibility, we turn to W. Edwards Deming's System of Profound Knowledge, widely regarded as one of the foundational frameworks in quality improvement, where he argues strongly that there are four highly interrelated elements that are required for improvement: Appreciation of a System, Theory of Knowledge, Knowledge about Variation and Knowledge of Psychology. In this article, we define and explore each of the four domains and their application in medical education, highlighting both opportunities and challenges. Conclusion Medical educators who utilise QI in their educational practices can help create learning environments that imprint positively on learners and contribute to better outcomes in their clinical learning environments. We provide recommendations for how educators' informed use of QI can improve medical education and help it achieve its ultimate goal of improved health and health care.

Background Otolaryngology–head and neck surgery is in the first wave of residency training programs in Canada to adopt Competence by Design (CBD), a model of competency-based medical education. CBD is built on frequent, low-stakes assessments and requires an increase in the number of feedback interactions. The University of Toronto otolaryngology–head and neck surgery residents piloted the CBD model but were completing only 1 assessment every 4 weeks, which was insufficient to support CBD. Objective This project aimed to increase assessment completion to once per resident per week using quality improvement methodology. Methods Stakeholder engagement activities had residents and faculty characterize barriers to assessment completion. Brief electronic assessment forms were completed by faculty on residents' personal mobile devices in face-to-face encounters, and the number completed per resident was tracked for 10 months during the 2016–2017 pilot year. Response to the intervention was analyzed using statistical process control charts. Results The first bundled intervention—a rule set dictating which clinical instance should be assessed, combined with a weekly reminder implemented for 10 weeks—was unsuccessful in increasing the frequency of assessments. The second intervention was a leaderboard, designed on an audit-and-feedback system, which sent weekly comparison e-mails of each resident's completion rate to all residents and the program director. The leaderboard demonstrated significant improvement from baseline over 10 weeks, increasing the assessment completion rate from 0.22 to 2.87 assessments per resident per week. Conclusions A resident-designed audit-and-feedback leaderboard system improved the frequency of CBD assessment completion.

Background There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF). Methods and Results We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate ( rA ), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI , 0.43–0.89), than the low ordering group. Conclusions Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02038101.

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals’ professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Background: The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. Methods and Results: A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65–0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66–0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55–0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22–0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04–2.28]), although all other outcomes were similar. Conclusions: Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02038101.

Background Resource stewardship is being increasingly recognized as an essential competency for physicians, but medical schools are just beginning to integrate this into education. We describe the evaluation of Choosing Wisely Canada's Students and Trainees Advocating for Resource Stewardship (STARS) campaign, a student-led campaign to advance resource stewardship education in medical schools across Canada. Methods We evaluated the campaign 6 months after its launch, in November 2015. STARS students were administered a telephone survey eliciting a description of the initiatives that they had implemented or planned to implement at their schools to promote resource stewardship, and exploring their perceptions of facilitators of and barriers to successful implementation of their initiatives. We used a mixed-methods approach to analyze and summarize the data. Results Twenty-seven (82%) of the 33 eligible students representing all 17 medical schools responded. In 14 schools (82%), students led various local activities (e.g., interest groups, campaign weeks) to raise awareness about resource stewardship among medical students and faculty. Students contributed to curriculum change (both planned and implemented) at 10 schools (59%). Thematic analysis revealed key program characteristics that facilitated success (e.g., pan-Canadian student network, local faculty champion) as well as barriers to implementing change (e.g., complex processes to change curriculum, hierarchical nature of medical school). Interpretation This student-led campaign, with support from local faculty and Choosing Wisely Canada staff, led to awareness-building activities and early curricula change at medical schools across Canada. Future plans will build on the initial momentum created by the STARS campaign to sustain and spread local initiatives.

Context Many of those involved in continuing professional development (CPD) over the past 10 years have engaged in discussions about its goals and activities. Whereas in the past CPD was viewed as an education intervention directed towards the medical expert role, recent research highlights the need to expand the scope of CPD and to promote its more explicit role in improving patient care and health outcomes. Recent developments in quality improvement (QI) and competency-based medical education (CBME), guided by appropriate theories of learning and change, can shed light on how the field might best advance. This paper describes principles of QI and CBME and how they might contribute to CPD, explores theoretical perspectives that inform such an integration and suggests a future model of CPD. Discussion Continuing professional development seeks to improve patient outcomes by increasing physician knowledge and skills and changing behaviours, whereas QI takes the approach of system and process change. Combining the strengths of a CPD approach with strategies known to be effective from the field of QI has the potential to harmonise the contributions of each, and thereby to lead to better patient outcomes. Similarly, competency-based CPD is envisioned to place health needs and patient outcomes at the centre of a CPD system that will be guided by a set of competencies to enhance the quality of practice and the safety of the health system. Conclusions We propose that the future CPD system should adhere to the following principles: it should be grounded in the everyday workplace, integrated into the health care system, oriented to patient outcomes, guided by multiple sources of performance and outcome data, and team-based; it should employ the principles and strategies of QI, and should be taken on as a collective responsibility by physicians, CPD provider organisations, regulators and the health system.

Background Appropriate use criteria (AUC) have defined transthoracic echocardiogram (TTE) indications for which there is a clear lack of benefit as rarely appropriate (rA). Objectives This study sought to investigate the impact of an AUC-based educational intervention on outpatient TTE ordering by cardiologists and primary care providers. Methods The authors conducted a prospective, investigator-blinded, multicenter, randomized controlled trial of an AUC-based educational intervention aimed at reducing rA outpatient TTEs. The study was conducted at 8 hospitals across 2 countries. The authors randomized cardiologists and primary care providers to receive either intervention or control (no intervention). The primary outcome measure was the proportion of rA TTEs. Results One hundred and ninety-six physicians were randomized, and 179 were included in the analysis. From December 2014 to April 2016, the authors assessed 14,697 TTEs for appropriateness, of which 99% were classifiable using the 2011 AUC. The mean proportion of rA TTEs was significantly lower in the intervention versus the control group (8.8% vs. 10.1%; odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.57 to 0.99; p = 0.039). In physicians who ordered, on average, at least 1 TTE per month, there was a significantly lower proportion of rA TTEs in the intervention versus the control group (8.6% vs. 11.1%; OR: 0.76; 95% CI: 0.57 to 0.99; p = 0.047). There was no difference in the TTE ordering volume between the intervention and control groups (mean 77.7 ± 89.3 vs. 85.4 ± 111.4; p = 0.83). Conclusions An educational intervention reduced the number of rA TTEs ordered by attending physicians in a variety of ambulatory care environments. This may prove to be an effective strategy to improve the use of imaging. (A Multi-Centered Feedback and Education Intervention Designed to Reduce Inappropriate Transthoracic Echocardiograms [Echo WISELY]; NCT02038101)

Patient safety is a core focus now in medical education, with an increasing number of training programmes educating learners about its key tenets.1–3 Residents now undergo formal training about the importance of contributing to a culture of safety by speaking up to avoid errors or harm, but still face difficulties enacting these behaviours in practice.4 In this issue of the journal, Martinez et al have attempted to tease out differences in speaking-out behaviours between traditional and professionalism-related patient safety threats.5 The authors have raised several interesting points worthy of further exploration. In this editorial we focus on unprofessional behaviour as a potential threat to patient safety and propose some new ways of thinking about how to integrate research and lessons from both the patient safety and professionalism literature. In the study by Martinez and colleagues, residents reported witnessing unprofessional behaviour more frequently than they observed patient safety breaches (75% vs 46%; p

Background Residents' attitudes toward error disclosure have improved over time. It is unclear whether this has been accompanied by improvements in disclosure skills. Objective To measure the disclosure skills of internal medicine (IM), paediatrics, and orthopaedic surgery residents, and to explore resident perceptions of formal versus informal training in preparing them for disclosure in real-world practice. Methods We assessed residents' error disclosure skills using a structured role play with a standardized patient in 2012–2013. We compared disclosure skills across programs using analysis of variance. We conducted a multiple linear regression, including data from a historical cohort of IM residents from 2005, to investigate the influence of predictor variables on performance: training program, cohort year, and prior disclosure training and experience. We conducted a qualitative descriptive analysis of data from semistructured interviews with residents to explore resident perceptions of formal versus informal disclosure training. Results In a comparison of disclosure skills for 49 residents, there was no difference in overall performance across specialties (4.1 to 4.4 of 5, P = .19). In regression analysis, only the current cohort was significantly associated with skill: current residents performed better than a historical cohort of 42 IM residents (P Conclusions Residents across specialties have similar skills in disclosure of errors. Residents identified role modeling and a strong local patient safety culture as key facilitators for disclosure.

Practical Applications In A Performance Update—Hedge Funds versus Hedged Mutual Funds:An Examination of Equity Long–Short Funds. from the Fall 2020 issue of The Journal of Alternative Investments, authors David F. McCarthy (of D. F. McCarthy LLC in Stockbridge, MA) and Brian M. Wong (an independent consultant in Mamaroneck, NY) extend the research McCarthy began in 2014. At that time, McCarthy studied equity long–short mutual funds and compared them to hedge funds that use long–short strategies. He found that long–short mutual funds offered performance and equity exposures similar to those of hedge funds—but since the available data came from a short time period (January 2008—June 2013), the findings were preliminary. In the current study, McCarthy and Wong update the 2014 study with data through December 2019. They find that long–short funds still offer lower volatility and equity exposures similar to those of hedge funds. However, long–short funds perform slightly worse than hedge funds and much worse than the S&P 500 Index. They also generate negative alpha—and no individual long–short fund generated positive alpha during the study period. This is important information for financial advisors to share with clients who are interested in equity long–short funds. TOPICS:Real assets/alternative investments/private equity, mutual funds/passive investing/indexing, performance measurement

T he Journal of Graduate Medical Education often receives submissions from trainees and educators highlighting work they do in quality improvement (QI). This is remarkably encouraging given the emphasis that the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System has placed on integrating QI into the clinical learning environment. A major challenge for editors reviewing these manuscripts is the inconsistency with which authors report QI initiatives. After reviewing a large number of these submissions, we have noted common problems that arise and have prepared the following guide to help prospective authors prepare QI reports for publication. Consistent with the Journal’s common format for Original Research or Educational Innovation articles (ie, Introduction, Methods, Results, Discussion, and Conclusion), our suggestions will highlight what authors should explicitly emphasize within each of these manuscript sections as it pertains to their QI initiative. We realize that a number of other frameworks and guidelines exist, the most common being the SQUIRE guidelines, which were updated in the fall of 2015. Our suggestions are synergistic with the updated SQUIRE 2.0 guidelines, yet they also provide a high-level view of the philosophies that underpin these guidelines to help authors not only at the time of writing, but also when planning and implementing their QI initiatives.

Over the past decade, quality improvement (QI) has gone from a secret skill expected only among trained staff in the quality office to a core competency for all health professionals.1–3 This expectation has generated new curricula which have introduced QI to a new generation of learners, but has also created some challenges for health professions educators.4–7 Identifying knowledgeable teachers, defining core content and securing time in the curriculum represent recurring issues, while emerging discussions now centre on how best to evaluate educational efforts in QI. It is here that we find ourselves at an impasse. In this issue of BMJ Quality and Safety, O’Leary and colleagues present their 5-year experience delivering an institutionally sponsored, team-based QI training programme which included attending physicians, residents and fellows and frontline interprofessional team members. They report on its impact on both learner outcomes and project outcomes.8 Their programme demonstrated improvements in participant knowledge, with 172 individuals comprising 32 teams reporting that they had applied their new knowledge and skills to improve clinical quality (87%) and implement QI interventions (62%) at 6 months. At 18 months, nearly half reported leading other QI projects (48%) and many had provided QI mentorship to others (41%). In addition to measuring these learner-focused outcomes, the authors summarise QI project outcomes at programme completion, 6 and 18 months. At one or more of these time points, 20 out of 32 projects (63%) had positive results, defined as showing improvement in one or more project measures without any measure declining in performance. This comprehensive programme evaluation, which includes both learner and project outcomes, provides a unique opportunity to reflect on the goals of QI education for the field of health professions education. Before reflecting on the goals of QI education specifically, it is important to review the yardstick by which best …

Background With rising healthcare costs and a focus on quality, there is a growing need to promote resource stewardship in medical education. Physicians need to be able to communicate effectively with patients/caregivers seeking tests and treatments that are unnecessary. This study aimed to evaluate the impact of an interactive workshop on residents’ knowledge of resource stewardship and communication skills when counseling patients/caregivers about requests for unnecessary testing. Methods Participants were 83 Internal Medicine and Pediatrics residents at the University of Toronto in 2014–15. The evaluation compared resource stewardship knowledge and communication skills of 57 (69%) residents that attended the resource stewardship workshop to 26 residents (31%) who did not. Knowledge and communication skills assessment consisted of a written test and a structured assessment using standardized patient raters, respectively. A linear regression was applied to determine predictors of overall communication skills performance. Results Workshop attendance resulted in better performance on the knowledge test (4.3 ± 1.9 vs. 3.1 ± 1.7 out of 8, p = 0.01), but not better performance on the communication skills assessment (4.1 ± 0.8 vs. 4.0 ± 0.9 out of 5, p = 0.56). Higher training level (p = 0.01) and knowledge test scores (p = 0.046) were independent predictors of better overall communication skills, after adjusting for gender, training level, workshop attendance, knowledge and self-reported prior feedback on communication skills. Conclusions An interactive workshop can improve knowledge of resource stewardship, but improving communication skills with patients/caregivers about unnecessary testing may require additional training or reinforcement in the clinical learning environment. These teaching and assessment approaches can support the integration of education on resource stewardship into medical education. Electronic supplementary material The online version of this article (10.1186/s12909-017-1086-x) contains supplementary material, which is available to authorized users.

BACKGROUND Accurate and complete documentation of hospitalized patients' code status is important to ensure that healthcare providers take appropriate action in the event of a cardiac arrest. OBJECTIVE Determine the frequency and clinical relevance of incomplete and inconsistent code status documentation. DESIGN Point-prevalence study. SETTING Academic medical centers. PATIENTS Patients admitted to general internal medicine wards. MEASUREMENTS Frequency and clinical relevance of inconsistent code status documentation across 5 documentation sources. RESULTS Thirty-eight (20%; 95% confidence interval [CI], 14%-26%) of 187 patients had complete and consistent code status documentation. Another 27 (14%; 95% CI, 9%-19%) patients had no code status documentation. The remaining 122 (65%; 95% CI, 58%-72%) patients had at least 1 code status documentation inconsistency. Of these, 38 (20%; 95% CI, 14%-26%) patients had a clinically relevant code status documentation inconsistency. Multivariate logistic regression analysis demonstrated that increased age (odds ratio [OR] = 1.07 [95% CI, 1.05-1.10] for every 1-year increase in age, P