There is a lack of resources on how to prepare, execute, and sustain quality improvement (QI) initiatives in laboratory medicine. The project goal was to bridge this gap with the creation of a novel primer series. In this third and final primer, we discuss fundamental concepts related to project evaluation, dissemination, and sustainability. We also introduce useful tools to successfully assess and monitor QI project success over time, including run charts and statistical process control charts as well as a well established sustainability model. These concepts are illustrated by following through on the final results from our real-world clinical vignette related to serum protein electrophoresis (SPEP) utilization. The impact of interventions discussed in earlier articles of the primer series was evaluated over a one-year period. Data analysis showed there was a >99% reduction in repeat SPEP testing in less than 75 days. The secondary aim to reduce testing in patients <50 years was not met. By piecing together the central aspects of QI methodology and challenges encountered from project initiation to dissemination through a laboratory lens, this series aims to support engagement of clinical laboratory leaders in QI initiatives. This is essential to build a strong culture of QI within the clinical laboratory and beyond.

The quality improvement (QI) paradigm is a continual approach to systematic improvement that focuses on patient outcomes and safety. This framework should be applied to laboratory driven quality efforts across the total testing process. However, there is minimal guidance and few resources on how to prepare, implement, and evaluate a QI initiative from a clinical laboratory perspective. Relative to other disciplines in healthcare, the quality gaps and types of errors and challenges in laboratory medicine are quite unique. This presents a major gap and barrier for clinical laboratorians to drive QI projects. This article is the second in a three-part primer series that aims to bridge this knowledge gap and act as a guide for clinical laboratories to execute and sustain QI initiatives. In the first article, an approach to preparing a QI project was outlined, including problem identification, root cause analysis, and SMART aim establishment. A clinical vignette of a real QI initiative related to serum protein electrophoresis (SPEP) utilization at our institution was introduced. The second part of this primer series focuses on the implementation of a QI initiative. Throughout, we introduce fundamental concepts related to change concepts and ideas, hierarchy of effectiveness, family of measures, and implementation cycles. Theoretical concepts are applied to the clinical vignette where we continue to follow the progress of a real SPEP utilization initiative.

[Voir la version anglaise de l'article ici : www.cmaj.ca/lookup/doi/10.1503/cmaj.241071][1] Points clés Une femme de 86 ans s'est présentée à notre service des urgences en raison de la présence, depuis 4 semaines, de problèmes d'équilibre entraînant des chutes, de difficultés d'é

KEY POINTS An 86-year-old woman presented to our emergency department with a 4-week history of new-onset balance difficulties resulting in falls, slurred speech, and worsening blurry vision, prior to which she was independent in activities of daily living and ambulation and had no problems with

Quality in laboratory medicine encompasses multiple components related to total quality management, including quality control (QC), quality assurance (QA), quality indicators, and quality improvement (QI). Together, they contribute to minimizing errors (pre-analytical, analytical, or post-analytical) in clinical service delivery and improving process appropriateness and efficiency. In contrast to static quality benchmarks (QC, QA, quality indicators), the QI paradigm is a continuous approach to systemic process improvement for optimizing patient safety, timeliness, effectiveness, and efficiency. Healthcare institutions have placed emphasis on applying the QI framework to identify and improve healthcare delivery. Despite QI’s increasing importance, there is a lack of guidance on preparing, executing, and sustaining QI initiatives in the field of laboratory medicine. This has presented a significant barrier for clinical laboratorians to participate in and lead QI initiatives. This three-part primer series will bridge this knowledge gap by providing a guide for clinical laboratories to implement a QI project that issuccessful and sustainable. In the first article, we introduce the steps needed to prepare a QI project with focus on relevant methodology and tools related to problem identification, stakeholder engagement, root cause analysis (e.g., fishbone diagrams, Pareto charts and process mapping), and SMART aim establishment. Throughout, we describe a clinical vignette of a real QI project completed at our institution focused on serum protein electrophoresis (SPEP) utilization. This primer series is the first of its kind in laboratory medicine and will serve as a useful resource for future engagement of clinical laboratory leaders in QI initiatives.

### What you need to know Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs globally, often taken for longer than needed and at high financial cost to society. Among adults living in the community, the point prevalence of PPI use is 7-8% in the UK and Denmark,12 while rates of use of 40-50% have been reported in older people in Canada and in those living in residential care in Australia.3456 In England, more than 50 million prescriptions for PPIs were issued in 2015.7 While PPIs are effective for upper gastrointestinal disorders and may be continued long term (beyond 8 weeks)8 for specific conditions (box 1),11121314 people often continue taking them for years when guidelines recommend 4-8 weeks of treatment or, in the case of gastrointestinal bleeding prophylaxis for critically ill patients, cessation when the patient is no longer critically ill or the risk factor triggering prophylaxis is no longer present (box 2).9131516 Box 1 ### Indications for long term use (>8 weeks) of proton pump inhibitors (PPIs)910RETURN TO TEXT

The role of enhanced skills (ES) training programs in Canada has been the subject of extensive debate. These programs were designed to provide both residents and physicians in practice with opportunities to extend their competence in a focused area to support the delivery of comprehensive care that

Le rôle des programmes de formation en compétences avancées (CA) au Canada a fait l’objet de vastes débats. Ces programmes étaient conçus pour offrir aux résidents et aux médecins en pratique active des possibilités de parfaire leurs compétences dans des domaines ciblés afin de soutenir

As curricular reforms are implemented, there is often urgency among scholars to swiftly evaluate curricular outcomes and establish whether desired impacts have been realized. Consequently, many evaluative studies focus on summative program outcomes without accompanying evaluations of implementation. This runs the risk of Type III errors, whereby outcome evaluations rest on unverified assumptions about the appropriate implementation of prescribed curricular activities. Such errors challenge the usefulness of the evaluative studies, casting doubt on accumulated knowledge about curricular innovations, and posing problems for educational systems working to mobilize scarce resources. Unfortunately, however, there is long-standing inattention to the evaluation of implementation in health professions education (HPE). To address this, we propose an accessible framework that provides substantive guidance for evaluative research on implementation of curricular innovations. The Prescribed-Intended-Enacted-Sustainable (PIES) framework that is articulated in this paper, introduces new concepts to HPE-with a view to facilitating more nuanced examination of the evolution of curricula as they are implemented. Critically, the framework is theoretically grounded, integrating evaluation and implementation science as well as education theory. It outlines when, how, and why evaluators need to direct attention to curricular implementation, providing guidance on how programs can map out meaningful evaluative research agendas. Ultimately, this work is intended to support evaluators and educators, seeking to design evaluation studies that provide more faithful, useful representations of the intricacies of curricular change implementation.

L’examen physique est un art qui se perd. L’une des techniques d’examen physique les plus intimes est l’examen rectal digital (ERD). Le plus souvent, l’ERD est utilise en urologie pour acceder de facon optimale a la prostate par palpation par le rectum. Cependant, il existe d’autres

The physical examination is a dying art. One of the most intimate physical examination maneuvers is the digital rectal examination (DRE). Most commonly, the DRE is used in the urologic setting to optimally access the prostate by palpation through the rectum. However, there are other indications for

Strategies such as Choosing Wisely have been established to identify the overuse of interventions considered as low-value. Reduction of low-value practices will require patients to understand why certain interventions are no longer recommended. The objective of this study was to determine whether older adults accept the rationale for and perceive themselves ready to de-adopt annual electrocardiogram testing, imaging for low back pain, the use of antibiotics for sinusitis, the use of sedative-hypnotics for insomnia, and the use of antipsychotics to treat behavioural symptoms of dementia.

Problem Physician behaviors that promote overuse of health care resources develop early in training, and the medical education environment helps foster such behaviors. The authors describe the development of a Choosing Wisely list for medical students aimed at helping to curb overuse. Approach The list was developed in 2015 by Choosing Wisely Canada (CWC) in partnership with the Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec, which together represent all medical students in Canada. CWC convened a student-led taskforce to develop recommendations targeting medical student behaviors with respect to resource stewardship practices. Students at all 17 Canadian medical schools were consulted via an online questionnaire to solicit feedback on a list of 10 candidate recommendations. The taskforce used this student feedback in finalizing the list. Outcomes The final list of “Six Things That Medical Students and Trainees Should Question” highlights both behaviors students should avoid (e.g., “Don’t suggest ordering the most invasive test before considering other less invasive options”) and behaviors related to aspects of medical training that may promote overuse, such as the hierarchical nature of clinical supervision (e.g., “Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe may be ordered inappropriately”). Based on student requests for illustrative examples, clinical vignettes were developed. Next Steps This list highlights medical student behaviors and aspects of the academic environment that drive overuse. It is also relevant to faculty, whose behaviors and supervision practices influence trainees.

Outcome varies among patients with subarachnoid hemorrhage but known prognostic factors explain only a small portion of the variation in outcome. We hypothesized that individual genetic variations influence brain and vascular responses to subarachnoid hemorrhage and investigated this using inbred strains of mice. Subarachnoid hemorrhage was induced in seven inbred and a chromosome 7 substitution strain of mouse. Cerebral blood flow, vasospasm of the middle cerebral artery, and brain injury were assessed. After 48h of subarachnoid hemorrhage, mice showed significant middle cerebral artery vasospasm that correlated positively with reduction in cerebral blood flow at 45min. Mice also had increased neuronal injury compared to sham controls; A/J and C57BL/6J strains represented the most and least severe, respectively. However, brain injury did not correlate with cerebral blood flow reduction at 45min or with vasospasm at 48h. Chromosome 7 substitution did not influence the degree of vasospasm or brain injury. Our data suggested that mouse genetic background influences outcome of subarachnoid hemorrhage. Investigations into the genetic factors causing these inter-strain differences may provide insight into the etiology of the brain damage following subarachnoid hemorrhage. These findings also have implications for animal modeling of disease and suggest that genetic differences may also modulate outcome in other cardiovascular diseases.

Spontaneous subarachnoid hemorrhage (SAH) is a form of hemorrhagic stroke that accounts for approximately 7 % of all strokes worldwide and is associated with mortality in approximately 35 % of cases and morbidity in many of the survivors. Studies have suggested that genetic variations may affect the pathophysiology of SAH. The goal of this study was to investigate the effect of mouse genetic background on brain injury and large artery vasospasm after SAH. SAH was induced in seven inbred strains of mice, and the degree of large artery vasospasm and brain injury was assessed. After 48 h, SAH mice showed a significant reduction in middle cerebral artery diameter and increased neuronal injury in the cerebral cortex compared with sham-operated controls. Mouse strains also demonstrated variable degrees of vasospasm and brain injury. This data suggests that different genetic factors influence how much brain injury and vasospasm occur after SAH. Future investigations may provide insight into the causes of these differences between strains and into which genetic contributors may be responsible for vasospasm and brain injury after SAH.

OBJECT:Glutamate is important in the pathogenesis of brain damage after cerebral ischemia and traumatic brain injury. Notably, brain extracellular and cerebrospinal fluid as well as blood glutamate concentrations increase after experimental and clinical trauma. While neurons are one potential source of glutamate, platelets also release glutamate as part of their recruitment and might mediate neuronal damage. This study investigates the hypothesis that platelet microthrombi release glutamate that mediates excitotoxic brain injury and neuron dysfunction after subarachnoid hemorrhage (SAH).METHODS:The authors used two models, primary neuronal cultures exposed to activated platelets, as well as a whole-animal SAH preparation. Propidium iodide was used to evaluate neuronal viability, and surface glutamate receptor staining was used to evaluate the phenotype of platelet-exposed neurons.RESULTS:The authors demonstrate that thrombin-activated platelet-rich plasma releases glutamate, at concentrations that can exceed 300 μM. When applied to neuronal cultures, this activated plasma is neurotoxic, and the toxicity is attenuated in part by glutamate receptor antagonists. The authors also demonstrate that exposure to thrombin-activated platelets induces marked downregulation of the surface glutamate receptor glutamate receptor 2, a marker of excitotoxicity exposure and a possible mechanism of neuronal dysfunction. Linear regression demonstrated that 7 days after SAH in rats there was a strong correlation between proximity to microthrombi and reduction of surface glutamate receptors.CONCLUSIONS:The authors conclude that platelet-mediated microthrombosis contributes to neuronal glutamate receptor dysfunction and might mediate brain injury after SAH.