University of Missouri

Dr. Linda Headrick and others published an article in the Academic Medicine journal. The article discusses a model for achieving continual improvement in care and learning in the clinical setting. It appears in the March 2016 issue.

Click here to read this publication.



The fourth annual MU Health Innovation and Improvement Sharing Days was held May 1, 2016 - May 4, 2016. A total of 328 posters were displayed throughout the health system.

Top posters from MU Health Care, School of Medicine, School of Nursing, and School of Health Professions were recognized at a ceremony.

Click here for photos from the event (internal only).

PI-LDP prepares a cadre of performance improvement leaders with the knowledge and skills to make significant improvements related to quality, safety and value of MUHC's patient care services.

Click here to learn more about our latest cohort.

The third annual MU Health Innovation and Improvement Sharing Days was held April 28, 2015 - April 30, 2015. A total of 88 posters were displayed throughout the health system.

Top posters from MU Health Care, School of Medicine, School of Nursing, and School of Health Professions were recognized at a ceremony on May 13.

Click here for photos from the event (internal only).

At the Institute for Healthcare Improvement's 26th Annual Forum, representatives from MU Health Care presented a storyboard outlining the journey to achieving a bold goal: requiring all health system employees to participate in two quality improvement initiatives.

Click here to see the storyboard.

Researchers at the MU School of Medicine have developed a test to measure medical students' ability to deliver patient-centered care. Students interact with a standardized patient actor and are assessed based on certain behaviors with the patient. Kimberly Hoffman, a CHCQ investigator, describes the test: "[It] forces the future physician to go beyond just determining a diagnosis and to focus on behaviors that play an essential role to the effectiveness of the care he or she provides." See the press release for more information, or read Dr. Hoffman's publication in Medical Teacher.

UHC Quality Leadership Award

On October 27, 2014, MU Health Care received the University Health Consortium's Quality Leadership Award. MU Health Care was one of 12 academic medical centers recognized for excellence in delivering high-quality, safe, efficient, patient-centered, and equitable care.

Click here for more information on this achievement.

Clinical Leaders' Quality Improvement Program (CL-QIP) provides quality improvement education and skills to leaders in order to support QI initiatives and projects across MU Health Care.

MU Health Innovation and Improvement Sharing Days 2014

The second annual MU Health Innovation and Improvement Sharing Days was held April 29, 2014 - May 1, 2014. 105 Posters were displayed throughout the health system.

Top posters from MU Health Care, School of Medicine, School of Nursing, and School of Health Professions were recognized at a ceremony on April 30.

Click here for photos from the event (internal only).

Teaching for Quality

The Association of American Medical Colleges (AAMC) released a report,Teaching for Quality: Integrating Quality Improvement and Patient Safety across the Continuum of Medical Education, produced by an expert panel led by Dr. Linda Headrick. Her team identifed a sizable gap in the training and education of health professional learners, across the continuum, in quality improvement and patient safety. In response, the AAMC has created a new faculty development program, Teaching for Quality (Te4Q).

Click here for more information about this program.

Educators' Stories of Creating Enduring Change

Dr. Linda Headrick's book, Educators' Stories of Creating Enduring Change, offers readers a deeper understanding of individual capacity for creating enduring change in health professional education. It examines how individuals in academic health science centers built and disseminated programs that mutually influenced their own personal growth and made a transformative impact on learners, teachers, and the cultures of their institutions at a national and international level.

Book Cover

MU Health Innovation and Improvement Sharing Days 2013

The first annual MU Health Innovation and Improvement Sharing Days was held in April 2013. 1

Top posters from MU Health Care, School of Medicine, School of Nursing, and School of Health Professions were recognized at a ceremony.

Click here for photos from the event (internal only).

Retooling for Quality and Safety Initiative

With support from the Institute for Healthcare Improvement and Josiah Macy Jr. Foundation, Dr. Linda Headrick, senior associate dean for education at the University of Missouri School of Medicine, and her co-authors reported in the December 2012 edition of Health Affairs on the Retooling Health Professions Education for Quality and Safety initiative. The initiative consisted of integrating quality improvement and patient safety curricula at 6 large universities with both a nursing and medical school from 2009-2010. Involving 1,374 student encounters, the curricular changes at the 6 universities involved interprofessional quality and safety learning opportunities in classroom, simulation, and clinical settings. The researchers uncovered several challenges to implementing an interprofessional curriculum in quality and safety, including coordinating medical and nursing student schedules, matching student proficiency to the learning experience, student engagement, faculty expertise with quality improvement and patient safety, and delivering a meaningful clinical experience to participating students.

"Our findings from this study and others indicate that every academic health system should have a critical mass of physicians who can perform and teach others about how to improve quality and safety," said Headrick. "Ultimately, our efforts should focus on ensuring that physicians become proficient in quality improvement to advance on their career paths."

The paper was also featured on AHRQ PSNet.

Dr. Linda Headrick teaching in the University of Missouri School of Medicine Russell D. and Mary B. Shelden Clinical Simulation Center
Dr. Linda Headrick teaching in the University of Missouri School of Medicine Russell D. and Mary B. Shelden Clinical Simulation Center.

2012 MU Institute for Healthcare Leadership (IHL)

The final session of the second cohort of the Institute for Healthcare Leadership (IHL) concluded on September 30, 2011. The IHL is designed to strengthen MU Health's leadership and management capabilities through an education and development program targeted on the clinical enterprise's emerging leaders, both clinical and executive. IHL participants are gaining a much deeper and clearer understanding in three major areas: 1) the MU Health clinical enterprise (e.g., strategic priorities, organization, leadership, financing, human capital…); 2) external forces driving major changes in patient care delivery (e.g., emerging payment models, quality and price transparency, meaningful use requirements…); and 3) leadership and management knowledge and skills.

A total of 24 individuals participated in this cohort (see below).

IHL First Cohort Group Photo: Front row: Eduardo Simoes, Peter Callan, Randall Floyd, Kevin Komes, Marjorie Matzes, Kathleen Quinn. Second row: Bryan Bliven, Bret Barrier, Neil Schmidt, Susan Recko, Deb Koivunen, Sue Scott. Back row: Dean Hainsworth, Stephen Barnes, Theadore Choma, Matt Levsen, John Dyer, Bertt Matthews, Laura Burnett.
Front row: Eduardo Simoes, Peter Callan, Randall Floyd, Kevin Komes, Marjorie Matzes, Kathleen Quinn.
Second row: Bryan Bliven, Bret Barrier, Neil Schmidt, Susan Recko, Deb Koivunen, Sue Scott.
Back row: Dean Hainsworth, Stephen Barnes, Theadore Choma, Matt Levsen, John Dyer, Bertt Matthews, Laura Burnett.
Not pictured: Marc Borenstein, Rez Farid, Tony Hall, Jerry Parker, Neil Trent.

Fundamentals of Health Care Improvement, Second Edition

The second edition of Fundamentals of Health Care Improvement is now available. The book, written by Gregory S. Ogrinc, M.D., M.S.; Linda A. Headrick, M.D., M.S.; Shirley M. Moore, R.N., Ph.D.; Amy J. Barton, R.N., Ph.D.; Mary A. Dolansky, R.N., Ph.D.; Wendy S. Madigosky, M.D., M.S.P.H. and copublished with the Institute for Healthcare Improvement, provides methods for implementing quality improvement (QI) initiatives with an interprofessional approach.

Book Cover

Highlighted Event: MOI Begins Patient-experience Improvement Pilot

On Monday Dec. 5, University of Missouri Health Care introduced a quality improvement pilot to improve the experience of Missouri Orthopaedic Institute patients. The project was created to provide patients with important information they will need before, during and after a hospital stay.

As an academic medical center, MU Health Care patients who come to us in a variety of ways from planned joint surgeries to unexpected visits to our emergency departments. To streamline the patient experience and prepare patients for their care, MU Health Care has created a guide called "My Health Care Journal" to provide patients with basic information they need and a way to organize their complex personal medical information.

Since July, a multidisciplinary team of staff from throughout MU Health Care has worked to create the patient information guide. The guide contains information for patients about what to expect before, during and after a hospital stay. It also provides space for health care professionals to include education materials, medication lists, care plans and other personalized information

"We modeled our notebook after best practices from other hospitals' information guides," said Julie Brandt, PhD, a project director in MU's Center for Health Care Quality and the My Health Care Journal project's team leader. "We tailored this guide to the specific needs of our patients, though. Our goal is for this guide to offer a framework for patients to have greater engagement in their care and find greater satisfaction with the care they receive here."

The pilot project will focus on joint surgery inpatients of Ajay Aggarwal, MD, Thomas Aleto, MD, and Sonny Bal, MD. After evaluating the effectiveness of the journal in pilot projects, the team plans to use the journal for planned and unplanned inpatients at all MU Health Care facilities.

Highlighted Program: 2011 MU Institute for Healthcare Leadership (IHL)

The final session of the Institute for Healthcare Leadership (IHL) concluded on September 30, 2011. The IHL is designed to strengthen MU Health's leadership and management capabilities through an education and development program targeted on the clinical enterprise's emerging leaders, both clinical and executive. IHL participants are gaining a much deeper and clearer understanding in three major areas: 1) the MU Health clinical enterprise (e.g., strategic priorities, organization, leadership, financing, human capital…); 2) external forces driving major changes in patient care delivery (e.g., emerging payment models, quality and price transparency, meaningful use requirements…); and 3) leadership and management knowledge and skills.

"I have learned about health systems and leadership which isn't taught in our usual medical curriculum. IHL gives you a broader understanding of health care and how we can manage and lead for the future."



"The IHL program has been an outstanding learning experience that has allowed me to understand our academic health system better."



"The IHL is an excellent way to learn more about our organization and who we are. It has helped me realize the type of leader I want to be and how I can help our team change the culture."

A total of 25 individuals participated in the first cohort (see below). The announcements for nominations for the second cohort will be released this fall, and the second cohort will begin on December 2, 2011.

IHL First Cohort Group Photo: Front row: Vince Cooper, Roger Higginbotham, Laura Gajda, Ray Foster, Ken Hammann, Arun Kumar, Carla Dyer, Tom Selva, Marty McCormick, Jennifer Doll, Anne Hackman, David Mountjoy, Angela Story. Back row: Matt Waterman, John Hornick, David Parker, John Lauriello, J.L. Reeves-Viets, Anne Fitzsimmons, Kristi Gafford, Jason Miller, Robert Schaal, Kristin Hahn-Cover. Not pictured: Deb Pasch, Keri Simon.
Front row: Vince Cooper, Roger Higginbotham, Laura Gajda, Ray Foster, Ken Hammann, Arun Kumar, Carla Dyer, Tom Selva, Marty McCormick, Jennifer Doll, Anne Hackman, David Mountjoy, Angela Story.
Back row: Matt Waterman, John Hornick, David Parker, John Lauriello, J.L. Reeves-Viets, Anne Fitzsimmons, Kristi Gafford, Jason Miller, Robert Schaal, Kristin Hahn-Cover.
Not pictured: Deb Pasch, Keri Simon.

Highlighted Event: MU Clarion Team Wins First Place

The Clarion National Case Competition is an outgrowth of the University of Minnesota's regional case competitions, which were designed and administered by medical students in their response to the perception of the need for interprofessional education and training in root cause analysis and practice-based problem solving. Along with faculty sponsors from the School of Health Professions, The School of Medicine, The Sinclair School of Nursing, and the Department of Health Management and Informatics, CHCQ has sent teams to this competition since 2005.

This year, the team made up of Jeffrey Trammell (Nursing), Ashley Millham (Medicine), Caitlin Alexander (Public Health), and David Clark (Healthcare Administration) placed first in the competition! The Medical University of South Carolina placed second, and Texas Tech University Health Sciences Center placed third. This is MU's third first place finish (along with 2005 and 2009). Join CHCQ in congratulating these students on an outstanding performance.

Left to Right: David Clark, Caitlin Alexander, Ashley Millham, Jeffrey Trammell

Highlighted Event: Faculty Mentoring Workshop

On March 21, 2011, the University of Missouri School of Medicine sponsored two half-day workshops focused on the improvement of faculty mentoring. Special speaker for the workshops was Dr. Tom Viggiano, the Associate Dean for Faculty Affairs at the Mayo Clinic. Dr. Viggiano is one of the authors of the book entitled Mentoring in Academic Medicine, published in 2010 by the American College of Physicians.

Approximately eighty School of Medicine faculty members and department administrators attended the mentoring workshops. Attendees represented a nice balance of physicians and scientists from almost every department in the School of Medicine, and also included those who were in the early, middle, and late phases of their careers. During the workshops, Dr. Viggiano led the group in discussions of how the mentoring needs of faculty change throughout their careers. He shared published information on the characteristics of highly functioning departments that create an atmosphere conducive to mentoring. In the final portion of each session, he led the group to contemplate additional steps that MU School of Medicine can take to improve our mentoring programs in the years ahead.

Highlighted Event: Quality Day at MU Health

The fifth cohort of the Performance Improvement Leadership Development Program (PI-LDP) concluded on Friday, February 18 with presentations from the six teams who participated in the program. PI-LPD prepares a cadre of performance improvement leaders with the knowledge and skills to make significant improvements related to quality, safety and value of MUHC's patient care services. All participants were members of an improvement team that worked on an improvement process relating specifically to patient and family centered care. Participants took part in one-full day and ten half-day sessions, learning how to: use process analysis, design, and monitoring tools and techniques; organize and lead improvement teams; and design and lead change management strategies. Below are the presentation titles with links to the presentations. Please contact the teams if you have questions or comments about the projects.

Row 1 (front to back): Cynthia Twenter, Rosie Powell, Jacqueline Ruplinger, Karla McNew, James Koller, Matt Wilp, Rhonda Spooner, and Susan Pereira. Row 2 (front to back): Tanya Aldridge, Susan Vollrath, Erica Schulte, Sherry Rickard, Tracy Riecke, Cindy Feutz, Lisa Brockman, and Debra Glodoski. Row 3 (front to back): Amanda Lewis, Kathy Brady, Annamalai Senthilkumar, Ward Childers, Krista Romanetto, Margaret Calaluce, and Barbara Boshard. Not pictured: Jordan Magdits.

In addition, short presentations were given in the afternoon, and posters were displayed in the SOM atrium by MU faculty and staff who presented their work to the 22nd Institute for Healthcare Improvement (IHI) Forum. The prestigious forum is the largest meeting dedicated to improving patient care quality, safety and value.

  • Improving Patient Satisfaction by Using Face-to-Face Bedside Nursing End-of-Shift Handoffs
  • Using Lean Tools to Improve On-Time First Start Cases in the Operating Room
  • Integration of Quality Improvement in Resident Curriculum Improves Patient Care Outcomes
  • A Stroke is a Stroke No Matter How Small - Bleeds and Clots Risk Factors for All - Enhancing Patient Awareness through Staff Education and Mentoring
  • Interprofessional Students Seek and Find Safety Hazards at the Bedside
  • Using Fall Prevention for Interprofessional Patient Safety Training at the Bedside

Highlighted Presentations: 22nd Annual National Forum on Quality Improvement in Health Care

The 22nd Annual National Forum on Quality Improvement in Health Care was held in Orlando, Florida, December 5-8. The Institute for Healthcare Improvement"s website notes: "This conference is the premier "meeting place" for people committed to the mission of providing safe, effective patient care at a reasonable cost. This annual event draws approximately 5,500 health care leaders from around the world in person and thousands more via satellite broadcast."

This year, several individuals from the University of Missouri Health System presented work they have been conducting within our system. This work represents a wide range of improvement efforts aimed at ensuring the safety of our patients.

Highlighted Presentation: It Takes a Village to Change a Process

On December 4, 2010, Dr. Karl Kochendorfer, Phil Vinyard, and Jan Gace, all from the Department of Family and Community Medicine, conducted a presentation entitled It Takes a Village to Change a Process: A Health Systems Approach to Practice Improvement at the annual Society of Teachers of Family Medicine conference on Practice Improvement. Focusing on improving perfect diabetes care, the presenters discussed the need for a multidisciplinary process to be successful with process improvement work. This presentation grew out of this team's work in the Fall 2009 Performance Improvement Leadership Development Program.

Highlighted Presentation: Lean Discharge

Beginning in July of 2010, a multi-disciplinary team (admissions, case management, nursing, pharmacy, medical staff, social work, and unit clerk) took on the task of improving the discharge process at University Hospital using Lean methods of process improvement. 5W at UH was chosen as the location for this work for several reasons. 5W has a diverse group of services (n=20), large volumes, and a variety of patient types who have differing discharge needs. The idea is that if the discharge process on 5W can be redesigned, rolling this out to other units will not be so daunting. The team began by mapping out the current process, which allowed them to identify areas of waste. One key issue they discovered was the amount of work occurring on the day of discharge. This backloading of tasks was creating frustration for staff, and the perception by patients that the discharge process was disorganized. The team then began collecting baseline data on patient and staff satisfaction with the current discharge process. They also collected data on the length of time from when discharge orders are written to when the patients are actually discharged. This work helped them develop their aim statement:

Currently, approximately 50% of our patients are discharged and exit the unit ? 2 hours from the time the discharge order is written. Our aim is to develop and improve a safe discharge process resulting in 80% of our patients being discharged within 2 hours and 95% of our patients being discharged within 4 hours of the written order.

The team is now conducting a pilot project. Using the whiteboard in 5W, which lists all patients by room number, residents from general surgery, trauma, and vascular surgery inform the unit clerk that a patient should be discharged the following day. A yellow sticker is then placed by that patient's room number. This alerts the patient's nurse of a pending discharge. At this point, nurses should begin all necessary work to get the patient discharged. This yellow sticker is then changed to green the day of discharge. This visual becomes a transparent means of communication for all involved with discharging a patient, and frontloads the work of discharge. The team will continue to work on this pilot and then will begin rolling this out to other services on 5W.

Highlighted Event: The 22nd Annual National Forum on Quality Improvement in Health Care

The 22nd Annual National Forum on Quality Improvement in Health Care will be held in Orlando, Florida, December 5-8. From the Institute for Healthcare Improvement's website: "This conference is the premier "meeting place" for people committed to the mission of providing safe, effective patient care at a reasonable cost. This annual event draws approximately 5,500 health care leaders from around the world in person and thousands more via satellite broadcast." This year, several individuals from the University of Missouri Health System will be presenting work they have been conducting within our system. This work represents a wide range improvement work, aimed at ensuring the safety of our patients.

  • Using Fall Prevention for Interprofessional Patient Safety Training at the Bedside, Carla Dyer, oral presentation
  • Interprofessional Students Seek and Find Safety Hazards at the Bedside, Gretchen Gregory, poster presentation
  • Using Lean Tools to Improve On-Time First Start Cases in the Operating Room, Kristin Harlan, poster presentation
  • Integration of Quality Improvement in Resident Curriculum Improves Patient Care Outcomes, Poorna R. Karuparthi, poster presentation
  • A Stroke is a Stroke No Matter How Small - Bleeds and Clots Risk Factors for All - Enhancing Patient Awareness through Staff Education and Mentoring, Margaret Leigh Kite
  • Improving Patient Satisfaction by Using Fact-to-Face Bedside Nursing End-of-Shift Handoffs, Roland Ragan

Highlighted Program: Achieving Competence Today (ACT)

Since 2005, University of Missouri Health Care (MUHC) has participated in the Achieving Competence Today (ACT) initiative, utilizing interprofessional teams of learners and health care workers to improve our health care system. Incorporating elements of a curriculum originally developed by Partnerships for Quality Education, the ACT program utilizes several principles of learning about improvement which have proven successful over the past several years:

  • Interprofessional teams -In order to achieve superior health outcomes, a highly functioning interprofessional team is needed.
  • Experiential learning - Health care workers learn best about improvement in the context of completing an improvement project.
  • The collaborative learning model - Several half day intensive learning sessions are punctuated throughout the five month ACT curriculum, when all teams meet together for group learning. Between these sessions, individual teams meet weekly or biweekly to pursue their project work.
  • Lifelong learning - By incorporation of health care workers, students, and residents into teams, all members of team learn together.

University of Missouri is one of seven academic health centers that received an additional two years of funding from the Robert Wood Johnson Foundation to develop this work into a team-based interprofessional experience in improvement.

Highlighted Event: Performance Improvement Leadership Development Program

The fifth cohort of the Performance Improvement Leadership Development Program, or PI-LDP began August 27, 2010 with guest lecturer Dr. Eugene Nelson (pictured below). Dr. Nelson is the Director of Quality Administration for the Dartmouth-Hitchcock Medical Center and Professor, Healthcare Improvement Leadership Development within The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School. He is a national leader in health care improvement and in the development and application of measures of system performance, health outcomes, and customer satisfaction. Dr. Nelson has been a pioneer in bringing modern quality improvement thinking into the mainstream of health care. He helped launch the Institute for Healthcare Improvement and served as a founding board member.

Dr. Eugene Nelson, from Dartmouth-Hitchcock Medical Center, lectures at the opening day of the Performance Improvement  Leadership Development Program (PI-LDP) on Clinical Microsystems.
Dr. Eugene Nelson, from Dartmouth-Hitchcock Medical Center, lectures at the opening day of the Performance Improvement Leadership Development Program (PI-LDP) on Clinical Microsystems.

From the left, Margaret Calaluce, Susan Vollrath, Annamalai Senthilkumar, Debra Glodoski, and Kathy Brady work on developing their aim statement. This team plans to focus on identifying and accommodating urgent and pending discharge non-invasive cardiology testing needs.
From the left, Margaret Calaluce, Susan Vollrath, Annamalai Senthilkumar, Debra Glodoski, and Kathy Brady work on developing their aim statement. This team plans to focus on identifying and accommodating urgent and pending discharge non-invasive cardiology testing needs.

Highlighted Event: CHCQ Launches Two New Lean Training Initiative Projects

Lean production systems were originally developed by Toyota as its core comprehensive management system. The term "lean" is used because of its focus on using only those resources (e.g., people, supplies, equipment) that are needed to do an organization's work. Lean thinking specifies three types of work: Value Added, Required Non-Value Added (e.g. requirements of regulators and payers), and Non-Required Non-Value Added (waste). The core focus of Lean is to develop work processes that minimize waste as a core strategy in order to maximize profit. Specific examples of waste identified by Lean that are of particular relevance to healthcare include reducing / eliminating:

  • delays
  • rework and work-arounds
  • defects and errors
  • excess searching for information, supplies, et cetera;
  • producing services and products that are not needed.

Beginning in June of 2009, CHCQ launched a Lean Training Initiative. The first project, Best Beginnings, focused on getting well newborns "reunited" with mothers in a timely fashion. The second project, OR First Start Delays, aimed to increase the number of first start cases wheeled out of the main OR holding by the scheduled start time to a room ready operative suite to 100%. Two projects will be launching in July of 2010. One will focus on turnover time in operating rooms, the second, on the discharge process at UH.

Highlighted Event: The Center for Health Policy's "Health Care Reform Explained"

Millions of Americans have questions about the sweeping national health care reform legislation that became law last month. The MU Center for Health Policy provided answers at "Health Reform Explained," a presentation and discussion held Wednesday, April 28, in Acuff Auditorium at the MU School of Medicine. Center director Karen Edison, MD, discussed various aspects of the Patient Protection and Affordable Care Act, including:

  • What was included and what was left out?
  • Timelines for when key reforms take effect
  • What has to happen for the bill to be implemented?

Highlighted Program: Performance Improvement Leadership Development Program (PI-LDP)

The fourth cohort of the Performance Improvement Leadership Development Program (PI-LDP) concluded on Friday, February 19 with presentations from the nine teams who participated in the program. PI-LPD prepares a cadre of performance improvement leaders with the knowledge and skills to make significant improvements related to quality, safety and value of MUHC's patient care services. Course participants are made up of physicians, nurses and administrators working within MUHC. All participants are members of an improvement team that is working on an improvement process that relates to one or more of MUHC's strategic goals. Participants take part in one-full day and eight half-day sessions and learn how to use process analysis, design, and monitoring tools and techniques, organize and lead improvement teams, and design and lead change management strategies. Below are the presentation titles with links to the presentations. Please contact the teams if you have questions or comments about the project.

Fall 2009 PILDP Group Photo: Front row: Karl Kochendorfer, Phil Vinyard, Rhonda Polly, Donna Neal, Jan Gace. Second row: Kay Steward, Nancy Jones, Kristin Sohl, Krista Hughes, Katie Dunne. Third row: Myra McCoig, Laura Hirschinger, Michelle Beaven, Koby Clements, Marjorie Thies, Lynn McKinney. Fourth row: Deepti Vyas, Cindy Roller, Shelly Jackman, Keith Hampton, Lynn Keplinger, Debbie Kaplan. Fifth row: Amanda Doty, Ryan Woodall, Jennifer Meyer, Stephanie Lumley-Hemme, Joe Cameron, Ed Ege. Last row: Gretchen Gregory, Carla Dyer, Dena Higbee, Gail Getzendaner, Francine Gory. Not pictured: Melissa Lingle and Marvin Eichelberger.
Front row: Karl Kochendorfer, Phil Vinyard, Rhonda Polly, Donna Neal, Jan Gace. Second row: Kay Steward, Nancy Jones, Kristin Sohl, Krista Hughes, Katie Dunne. Third row: Myra McCoig, Laura Hirschinger, Michelle Beaven, Koby Clements, Marjorie Thies, Lynn McKinney. Fourth row: Deepti Vyas, Cindy Roller, Shelly Jackman, Keith Hampton, Lynn Keplinger, Debbie Kaplan. Fifth row: Amanda Doty, Ryan Woodall, Jennifer Meyer, Stephanie Lumley-Hemme, Joe Cameron, Ed Ege. Last row: Gretchen Gregory, Carla Dyer, Dena Higbee, Gail Getzendaner, Francine Gory. Not pictured: Melissa Lingle and Marvin Eichelberger.

Highlighted Event: MITSS Hope Award

Congratulations to Sue Scott, Laura Hirschinger, Myra McCoig and the entire forYOU team on receiving the national MITSS Hope Award. The MITSS Hope Award was established in 2008 to recognize individuals or groups who support healing and restore hope to patients, families and clinicians affected by an unexpected medical event. This award recognized MU Health Care's newly established forYOU team as an industry leader in developing a unique support program for healthcare workers. The forYOU team consists of 51 volunteer staff members specifically trained to provide 24-hour on-call care to their co-workers. When activated, members of the forYOU team establish a confidential dialogue with the affected clinician. Rather than focusing on details of the event, the supportive discussions center on the emotional and physical reactions to the unexpected event.

Highlighted Program: Performance Improvement Leadership Development Program (PI-LDP)

The fourth cohort of PI-LDP began August 28, 2009 with guest lecturer Dr. Eugene Nelson. Dr. Nelson is Director of Quality Administration for the Dartmouth-Hitchcock Medical Center and Professor, Healthcare Improvement Leadership Development within The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School. He is a national leader in health care improvement and the development and application of measures of system performance, health outcomes, and customer satisfaction. Dr. Nelson has been a pioneer in bringing modern quality improvement thinking into the mainstream of health care. He helped launch the Institute for Healthcare Improvement and served as a founding board member.

Katie Dunne, Krista Hughes, and Kristin Sohl, an improvement team from the MU Thompson Center for Autism, work on their project aim statement.

Marvin Eichelberger, Koby Clements, Melissa Lingle, Michelle Beaven, Jennifer Meyer, Ed Ege, and Stephanie Lumley-Hemme participate in an affinity diagramming exercise. This helps teams maximize group information generation and consensus building.

Highlighted Research: Telehealth Strategies for Heart Failure after Hospitalization

An article by CHCQ Associate Bonnie Wakefield PhD, RN, et al, originally published in the October 2008 edition of Telemedicine and e-Health was named "Best Paper, 2008" at the American Telemedicine Association's 2009 Annual Meeting in Las Vegas. Entitled "Evaluation of Home Telehealth Following Hospitalization for Heart Failure: A Randomized Trial", the objective of the study was to evaluate the efficacy of a telehealth-facilitated post-discharge support program in reducing resource use in patients with heart failure. The intervention resulted in a significantly longer time to readmission with no effect on readmission rates or mortality, and subjects reported higher disease-specific quality of life scores at one year. This is only the second study to compare telephone and videophone to traditional care to deliver a home-based heart failure intervention program.

Highlighted Event: Clarion Team Competition

The Clarion National Case Competition is an outgrowth of the University of Minnesota's regional case competitions, which were designed and administered by medical students in their response to the perception of the need for interprofessional education and training in root cause analysis and practice-based problem solving. Schools from all over the country participate in this national competition. Each team receives the same case where a sentinel event occurred. The teams are then challenged to prepare a presentation containing a root cause analysis, as well as recommendations to prevent such events from occurring in the future.

This year (2009), the team made up of Jennifer Dine (Nursing), Sahil Hebbar (HMI), Cindy Thomas (Public Health), and Wesley Trueblood (Medicine) placed first in the competition! The University of Minnesota placed second, and Dartmouth College placed third. This is MU's second first place finish (the 2005 team also placed first). MU is the only school who has had two first place finishes. Faculty sponsors were Amanda Allmon (FCM), Robert DeGraff (HMI), Kris Hagglund (Health Profession), and Roxanne McDaniel (Nursing). Join CHCQ is congratulating these students on an outstanding performance. Pictured below: Wesley Trueblood, Cindy Thomas, Jennifer Dine, and Sahil Hebbar.

Highlighted Event: forYOU Team Training

When patients suffer unanticipated adverse outcomes, this can have a devastating impact upon the patient and their loved ones. However, health professionals caring for these patients can also be deeply impacted and often become "second victims" of such events. Second victims are healthcare providers who are involved in an unanticipated adverse patient event, medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed the patient, second-guessing their clinical skills and knowledge base."

On March 19 and 20, a total of 47 MU Health health professionals (6 MDs, 31 RNs, and 10 allied professionals) took part in a two-day training session to learn about this phenomenon and become skilled at how to provide support to second victims within MU Health. The forYOU Team is sponsored by MU Health under the direction of the Office of Clinical Effectiveness (OCE) to support second victims within our health system network. This team provides a form of 'emotional first aid' specifically designed to provide crisis support and critical incident stress management interventions for health care events. The ultimate goal of the forYOU team is to assist healthcare providers in understanding what is known about the second victim phenomenon and help them return to a high level of performance following an adverse or unanticipated patient outcome. A member of the team is available 24/7. If you feel that you are in need of the help of the forYOU team, please page 573-397-0044.

Highlighted Research: Verbal Orders

Face-to-face verbal and telephone orders are a common practice in hospitals and are used when physicians, nurse practitioners, or physician assistants are unable or unwilling to write or directly enter orders electronically using a computerized provider order entry (CPOE) system. However, verbal orders hold a substantial potential for miscommunication due to a variety of factors, including fatigue, workload, sound-alike medications, background noise, accents, dialects, and different pronunciations. These inherent dangers have been recognized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the National Quality Forum (NQF), and others. These groups have offered specific recommendations to improve the safety of verbal orders and/or limit their use, and to ensure that the verbal communication was understood and accurately transcribed into the hospitals' ordering systems.

While verbal and telephone orders are commonly used, there has been little systematic study of the strategies and tactics used to ensure their appropriate use, or how to ensure that they are accurately communicated, correctly understood, initially documented and subsequently transcribed into the medical record, and ultimately carried out as intended. Doug Wakefield, Director for CHCQ, and colleagues have conducted four studies investigating these practices, one of which is highlighted in the article Complexity of Medication-Related Verbal Orders (please provide link, the article is attached). The researchers have found that: 1) verbal orders are common and there appears to be substantial variation in the probability of using verbal orders among different medical and surgical specialties; 2) the level of potential risk in verbal orders is potentially increased by the presence of commonly confused medication names and high alert medications; and 3) verbal order communication, clarification and documentation processes, as well as receivers' mishearing spoken communications are associated with adverse events.


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