Niraj Sehgal

All Publications

• Understanding the Singapore COVID-19 Experience: Implications for Hospital Medicine. Journal of hospital medicine Vidyarthi, A. R., Bagdasarian, N., Esmaili, A. M., Archuleta, S., Monash, B., Sehgal, N. L., Green, A., Lim, A. 2020; 15 (5): 281–83

  View details for DOI 10.12788/jhm.3436

  View details for PubMedID 32379029

• Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach. Academic medicine : journal of the Association of American Medical Colleges van Schaik, S. M., Chang, A., Fogh, S., Haehn, M., Lyndon, A., O'Brien, B., O'Sullivan, P., Ranji, S., Rosenbluth, G., Sehgal, N., Tabas, J., Baron, R. B. 2019; 94 (11): 1728–32

  Abstract

  Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners.The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS.Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS.Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

  View details for DOI 10.1097/ACM.0000000000002784

  View details for PubMedID 31663959

• Aligning Delivery System and Training Missions in Academic Medical Centers to Promote High-Value Care. Academic medicine : journal of the Association of American Medical Colleges Gupta, R., Sehgal, N., Arora, V. M. 2019; 94 (9): 1289–92

  Abstract

  Academic medical centers (AMCs) are transforming to improve their care delivery and learning environments so that they build a culture that fosters high-value care. However, AMCs struggle to create learning environments where trainees are part of the reason for institutional success and their initiatives have high impact and are sustainable. The authors believe that AMCs can reach these goals if they codevelop strategic priorities and provide infrastructure to support alignment between the missions of health delivery systems and graduate medical education (GME).They outline four steps for AMCs and policy makers to create an infrastructure that supports this alignment to deliver value-based care. First, AMCs can align strategic priorities between delivery systems and educators by creating a common understanding of why initiatives require priorities within the health care system. Second, AMCs can support alignment with data from multiple sources that are reliable, valid, and actionable for trainees. Third, resident initiatives can create sustained impact by linking trainees to the institutional staff and infrastructure supporting value improvement efforts. Fourth, incentive payment programs through medical education could augment current system incentives to propel further alignment between education and delivery systems. The authors support their recommendations with concrete examples from emerging models created by GME and health delivery system leaders at AMCs across the country.

  View details for DOI 10.1097/ACM.0000000000002573

  View details for PubMedID 31460917

• A Learning Health System Approach to the Opioid Crisis: Never Let a Good Crisis Go to Waste. JAMA surgery Wick, E. C., Sehgal, N. L. 2018; 153 (10): 954

  View details for DOI 10.1001/jamasurg.2018.2731

  View details for PubMedID 30140850

• Early Experiences After Adopting a Quality Improvement Portfolio Into the Academic Advancement Process ACADEMIC MEDICINE Sehgal, N. L., Neeman, N., King, T. E. 2017; 92 (1): 78–82

  Abstract

  Academic medical centers (AMCs) and their academic departments are increasingly assuming leadership in the education, science, and implementation of quality improvement (QI) and patient safety efforts. Fostering, recognizing, and promoting faculty leading these efforts is challenging using traditional academic metrics for advancement.The authors adapted a nationally developed QI portfolio, adopted it into their own department's advancement process in 2012, and tracked its utilization and impact over the first two years of implementation.Sixty-seven QI portfolios were submitted with 100% of faculty receiving their requested academic advancement. Women represented 60% of the submitted portfolios, while the Divisions of General Internal Medicine and Hospital Medicine accounted for 60% of the submissions. The remaining 40% were from faculty in 10 different specialty divisions. Faculty attitudes about the QI portfolio were overwhelmingly positive, with 83% agreeing that it "was an effective tool for helping to better recognize faculty contributions in QI work" and 85% agreeing that it "was an effective tool for elevating the importance of QI work in our department."The QI portfolio was one part of a broader effort to create opportunities to recognize and support faculty involved in improvement work. Further adapting the tool to ensure that it complements-rather than duplicates-other elements of the advancement process is critical for continued utilization by faculty. This will also drive desired dissemination to other departments locally and other AMCs nationally who are similarly committed to cultivating faculty career paths in systems improvement.

  View details for DOI 10.1097/ACM.0000000000001213

  View details for Web of Science ID 000391961600025

  View details for PubMedID 27119329

• Improving the Ambulatory Patient Experience Within an Academic Department of Medicine AMERICAN JOURNAL OF MEDICAL QUALITY Neeman, N., Sehgal, N. L. 2016; 31 (3): 203–8

  Abstract

  Academic departments of medicine (ADOM) can provide an important vehicle to drive the sharing and dissemination of best practices in clinical care delivery. With the increased focus on improving the patient experience, particularly in the ambulatory setting, ADOM also should lead efforts to cultivate improvements in this arena. To address this need, the study ADOM established a Patient Experience Working Group (PEWG) that brought together physician and nonphysician leaders, set improvement goals, and created a structure for sharing and learning. Since initiation, the PEWG has implemented more than 20 performance improvement initiatives, which have resulted in measured positive changes at both the local practice settings and department-wide. Striking the right balance between top-down governance, bottom-up innovation and ownership, and shared goal setting was a key to success. This model is one that could easily be adopted by other ADOM in their own efforts to improve the patient experience.

  View details for DOI 10.1177/1062860614562274

  View details for Web of Science ID 000375592400002

  View details for PubMedID 25512951

• "Choosing Wisely" in an Academic Department of Medicine AMERICAN JOURNAL OF MEDICAL QUALITY Hines, J. Z., Sewell, J. L., Sehgal, N. L., Moriates, C., Horton, C. K., Chen, A. 2015; 30 (6): 566–70

  Abstract

  The "Choosing Wisely" campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents' values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.

  View details for DOI 10.1177/1062860614540982

  View details for Web of Science ID 000363470900009

  View details for PubMedID 24970279

• Meaningful Utilization of After-visit Summaries in the Ambulatory Setting AMERICAN JOURNAL OF MEDICINE Neeman, N., Sehgal, N. L. 2015; 128 (8): 828–30

  View details for DOI 10.1016/j.amjmed.2015.02.012

  View details for Web of Science ID 000358388500024

  View details for PubMedID 25818497

• Annual Perspective 2014: Handoffs and Transitions Sehgal, N. L. AHRQ Patient Safety Network. 2015
• Role-modeling and medical error disclosure: a national survey of trainees. Academic medicine Martinez, W., Hickson, G. B., Miller, B. M., Doukas, D. J., Buckley, J. D., Song, J., Sehgal, N. L., Deitz, J., Braddock, C. H., Lehmann, L. S. 2014; 89 (3): 482-489

  Abstract

  To measure trainees' exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees' attitudes and behaviors regarding error disclosure.Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error.The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, -0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees' nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15-1.64; P < .001).Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

  View details for DOI 10.1097/ACM.0000000000000156

  View details for PubMedID 24448052

• Demystify leadership in order to cultivate it. Academic medicine : journal of the Association of American Medical Colleges Dhaliwal, G., Sehgal, N. L. 2014; 89 (11): 1441

  View details for DOI 10.1097/ACM.0000000000000489

  View details for PubMedID 25350336

• Bringing continuing medical education to the bedside: the University of California, San Francisco Hospitalist Mini-College. Journal of hospital medicine Sehgal, N. L., Wachter, R. M., Vidyarthi, A. R. 2014; 9 (2): 129–34

  Abstract

  As a relatively new generalist specialty, hospitalists must acquire new competencies that may not have been taught during their training years. Continuing medical education (CME) has traditionally been a mechanism to meet training needs but often fails to apply adult learning principles and fulfill current demands.We developed an innovative 3-day course called the University of California, San Francisco Hospitalist Mini-College (UHMC) that brings adult learners to the bedside for small-group learning focused on content areas relevant to today's hospitalists. The program was built on a structure of 4 clinical domains and 2 clinical skills labs. Sessions about patient safety and immersion into traditional academic learning vehicles, such as morning report and a morbidity and mortality conference, were also included. Participants completed a precourse survey and a postcourse evaluation.Over 5 years, 152 participants enrolled and completed the program; 91% completed the pre-UHMC survey and 89% completed the postcourse evaluation. Overall, participants rated the quality of the UHMC course highly (4.65; 1-5 scale). Ninety-eight percent of UHMC participants (n = 57) in 2011 to 2012 reported a "high" or "definite" likelihood to change practice, higher than the 78% reported by the 11,447 participants in other UCSF CME courses during the same time period.The UHMC successfully brought participants to an academic health center for a participatory, hands-on, and small-group learning experience that was highly rated. A shift of CME from a hotel conference room to the bedside is feasible, valued by participants, and offers a new paradigm for how to maintain and improve hospitalist competencies.

  View details for DOI 10.1002/jhm.2111

  View details for PubMedID 24264936

• An advanced quality improvement and patient safety elective CLINICAL TEACHER Mookherjee, S., Ranji, S., Neeman, N., Sehgal, N. 2013; 10 (6): 368–73

  Abstract

  Practising doctors must be competent in quality improvement (QI) and patient safety (PS). Despite this need, QI and PS have yet to be fully integrated into the undergraduate medical curriculum. Furthermore, there are few resources available for motivated senior medical students to receive advanced training prior to starting residency. To address these needs, we piloted an elective in QI/PS for senior medical students.We measured changes in knowledge, attitude and QI/PS skills with before and after surveys and skill assessments. Post-elective measures included an assessment of reaction to the curriculum and an assessment of a QI project proposal.Six students participated in two 2-week electives. Mean knowledge test scores improved after the elective [mean score (SD)]: before, 7.3 (1.4), versus after, 8.2 (0.4); p = 0.19. There were improvements in confidence in all aspects queried, and this was significant in six of the seven confidence questions. Students had high motivation for future QI/PS involvement both before and after the elective. Validated measures assessing QI/PS skills showed high levels of performance both before and after the elective. Experiential components of the elective were most highly valued.Motivated students may not have the confidence needed to effectively actuate their desire to incorporate QI/PS in their continuing training and careers. This 2-week elective significantly improved students' confidence and maintained their motivation for QI/PS work. Experiential activities may be particularly beneficial for students to learn QI/PS throughout medical school.

  View details for DOI 10.1111/tct.12047

  View details for Web of Science ID 000213016300005

  View details for PubMedID 24219520

• Postdischarge Focus Groups to Improve the Hospital Experience AMERICAN JOURNAL OF MEDICAL QUALITY Neeman, N., Quinn, K., Shoeb, M., Mourad, M., Sehgal, N. L., Sliwka, D. 2013; 28 (6): 536–38

  View details for DOI 10.1177/1062860613488623

  View details for Web of Science ID 000329490100004

  View details for PubMedID 23687239

• ROLE MODELING AND MEDICAL ERROR DISCLOSURE: RESULTS OF A NATIONAL SURVEY OF FOURTH-YEAR MEDICAL STUDENTS Martinez, W., Hickson, G. B., Miller, B., Doukas, D. J., Buckley, J. D., Song, J., Sehgal, N., Deitz, J., Braddock, C. H., Lehamann, L. SPRINGER. 2013: S175

  View details for Web of Science ID 000331939301175

• Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture ACADEMIC MEDICINE Bowman, C., Neeman, N., Sehgal, N. L. 2013; 88 (6): 802–10

  Abstract

  Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students' perceptions of safety culture and identified curricular gaps in patient safety training.A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test.One hundred twenty-one students (71% response rate) rated "teamwork within units" and "organizational learning" highest among the survey domains; "communication openness" and "nonpunitive response to error" were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience.Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

  View details for DOI 10.1097/ACM.0b013e31828fd4f4

  View details for Web of Science ID 000319658500020

  View details for PubMedID 23619067

  View details for PubMedCentralID PMC4024094

• Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices. Journal of hospital medicine Ashbrook, L., Mourad, M., Sehgal, N. 2013; 8 (1): 36–41

  Abstract

  Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization.To understand nurse and physician communication practices around patient discharge education.University of California, San Francisco Medical Center (UCSFMC).Nurses, interns, and hospitalists caring for hospitalized medicine patients.Participants were surveyed regarding discharge education practices. The survey asked respondents about 13 elements of discharge education found in the literature. For each element, participants were queried regarding: 1) the provider responsible for this element of patient education; 2) the frequency with which they communicate this teaching to patients; 3) how often they directly communicate with the nurse or physician caring for the patient about each element; and 4) tools to improve nurse-physician communication.A total of 129/184 (70%) nurses, interns, and hospitalists responded to the survey. The majority of respondents in all 3 groups felt that 9 of 13 elements were a combined responsibility. Nurses reported educating patients on these 9 items significantly more often than physicians (P < 0.05). All groups also agreed that instruction on 2 of the elements, summary of hospital findings and pending results, should be primarily the physicians' responsibility; these were the elements least often discussed by any provider. Despite the majority of items being agreed upon as a shared responsibility, communication between nurses and physicians regarding discharge education was low. Standardized verbal communication on the day of discharge was supported most strongly by all providers.Ambiguous responsibility for providing discharge education and poor communication between nurses and physicians offers an opportunity for improvement. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.1986

  View details for PubMedID 23071078

• Engaging Trainees in Performance Improvement Projects: The Quality and Safety Innovation Challenge AMERICAN JOURNAL OF MEDICAL QUALITY Neeman, N., Ranji, S. R., Sehgal, N. L. 2012; 27 (4): 345–47

  View details for DOI 10.1177/1062860612438707

  View details for Web of Science ID 000305835600012

  View details for PubMedID 22550347

• Enhancing Quality of Trainee-written Consultation Notes AMERICAN JOURNAL OF MEDICINE Tuot, D. S., Sehgal, N. L., Neeman, N., Auerbach, A. 2012; 125 (7): 649–52

  View details for DOI 10.1016/j.amjmed.2012.01.021

  View details for Web of Science ID 000305752700016

  View details for PubMedID 22560812

  View details for PubMedCentralID PMC3832626

• Perspective: A Road Map for Academic Departments to Promote Scholarship in Quality Improvement and Patient Safety ACADEMIC MEDICINE Neeman, N., Sehgal, N. L. 2012; 87 (2): 168–71

  Abstract

  The fields of quality improvement and patient safety (QI/PS) continue to grow with greater attention and awareness, increased mandates and incentives, and more research. Academic medical centers and their academic departments have a long-standing tradition for innovation and scholarship within a multifaceted mission to provide patient care, educate the next generation, and conduct research. Academic departments are well positioned to lead the science, education, and application of QI/PS efforts nationally. However, meaningful engagement of faculty and trainees to lead this work is a major barrier. Understanding and developing programs that foster QI/PS work while also promoting a scholarly focus can generate the incentives and acknowledgment to help elevate QI/PS into the academic mission. Academic departments should define and articulate a QI/PS strategy, develop individual and departmental capacity to lead scholarly QI/PS programs, streamline and support access to data, share information and improve collaboration, and recognize and elevate academic success in QI/PS. A commitment to these goals can also serve to cultivate important collaborations between academic departments and their respective medical centers, divisions, and training programs. Ultimately, the elevation of QI/PS into the academic mission can improve the quality and safety of our health care delivery systems.

  View details for DOI 10.1097/ACM.0b013e31823f3c2c

  View details for Web of Science ID 000300402100012

  View details for PubMedID 22189889

• Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project BMJ QUALITY & SAFETY Auerbach, A. D., Sehgal, N. L., Blegen, M. A., Maselli, J., Alldredge, B. K., Vittinghoff, E., Wachter, R. M. 2012; 21 (2): 118–26

  Abstract

  Improving communication between caregivers is an important approach to improving safety.To implement teamwork and communication interventions and evaluate their impact on patient outcomes.A prospective, interrupted time series of a three-phasea run-in period (phase 1), during which a training programme was given to providers and staff on each unit; phase 2, which focused on unit-based safety teams to identify and address care problems using skills from phase 1; and phase 3, which focused on engaging patients in communication efforts.General medical inpatient units at three northern California hospitals.Administrative data were collected from all adults admitted to the target units, and a convenience sample of patients interviewed during and after hospitalisation.Readmission, length of stay and patient reports of teamwork, problems with care, and overall satisfaction.10 977 patients were admitted; 581 patients (5.3% of total sample) were interviewed in hospital, and 313 (2.9% overall, 53.8% of interviewed patients) completed 1-month surveys. No phase of the study was associated with adjusted differences in readmission or length of stay. The phase 2 intervention appeared to be associated with improvement in reports of whether physicians treated them with respect, whether nurses treated them with respect or understood their needs (p<0.05 for all). Interestingly, patients were more likely to perceive that an error took place with their care and agreed less that their caregivers worked well together as a team. No phase had a consistent impact on patient reports of care processes or overall satisfaction. Limitations The study lacks direct measures of patient safety.Efforts to simultaneously improve caregivers' ability to troubleshoot care and enhance communication may improve patients' perception of team functions, but may also increase patients' perception of safety gaps.

  View details for DOI 10.1136/bmjqs-2011-000311

  View details for Web of Science ID 000299324800005

  View details for PubMedID 22069113

• Complementary Telephone Strategies to Improve Postdischarge Communication AMERICAN JOURNAL OF MEDICINE Rennke, S., Kesh, S., Neeman, N., Sehgal, N. L. 2012; 125 (1): 28–30

  View details for DOI 10.1016/j.amjmed.2011.05.011

  View details for Web of Science ID 000298373300017

  View details for PubMedID 21871596

• Teamwork in Hospital Medicine Essentials of Hospital Medicine: A Practical Guide for Clinicians O'Leary, K., Sehgal, N. L. 2012
• Quality improvement and patient safety activities in academic departments of medicine. The American journal of medicine Neeman, N., Sehgal, N. L., Davis, R. B., Aronson, M. D. 2012; 125 (8): 831–35

  View details for DOI 10.1016/j.amjmed.2012.04.025

  View details for PubMedID 22840669

• Reducing radiology use on an inpatient medical service: choosing wisely. Archives of internal medicine Neeman, N., Quinn, K., Soni, K., Mourad, M., Sehgal, N. L. 2012; 172 (20): 1606–8

  View details for DOI 10.1001/archinternmed.2012.4293

  View details for PubMedID 22928182

• Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement. Journal of hospital medicine O'Leary, K. J., Sehgal, N. L., Terrell, G., Williams, M. V. 2012; 7 (1): 48–54

  Abstract

  Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

  View details for DOI 10.1002/jhm.970

  View details for PubMedID 22042511

• Communication Failures and a Call for New Systems to Promote Patient Safety ARCHIVES OF INTERNAL MEDICINE Sehgal, N. L., Auerbach, A. A. 2011; 171 (7): 684–85

  View details for Web of Science ID 000289867700016

  View details for PubMedID 21482845

• Critical Conversations: A Call for a Nonprocedural "Time Out" JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Fox, M., Sharpe, B. A., Vidyarthi, A. R., Blegen, M., Wachter, R. M. 2011; 6 (4): 225–30

  Abstract

  Communication failures are an ongoing threat to patient safety. Procedural "time outs" were developed as a method to enhance communication and mitigate patient harm. Nonprocedural settings generate equal risks for communication failure, yet lack a similar communication tool or practice that can be applied, particularly with a patient-driven focus.Rapidly changing clinical states and care plans are common in the hospital setting, placing patients at risk for adverse events. Certain junctures allow for the highest potential of patient harm-at the time of admission, at a change in clinical condition, and at the time of discharge. Direct communication among healthcare providers at these junctures, which we have dubbed Critical Conversations, can provide an opportunity to clarify plans of care, address or anticipate concerns, and foster greater teamwork. Information exchanged during Critical Conversations includes a combination of checklist-type items and more open-ended questions but they ultimately create a structure and expectation for communication.Integration of Critical Conversations into practice requires provider education and buy-in, as well as expectations for them to occur. Monitoring adherence, capturing stories of success, and demonstrating effectiveness may enhance implementation and continuous improvement in the process.Communication tools designed to reduce the likelihood of patient harm remain a focus of patient safety efforts. Critical Conversations are an innovative communication tool, intervention, and policy that potentially limits communication failures at critical junctures to ensure high quality and safe patient care.

  View details for DOI 10.1002/jhm.853

  View details for Web of Science ID 000289885000010

  View details for PubMedID 21480495

• Investing in the Future: Building an Academic Hospitalist Faculty Development Program JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Sharpe, B. A., Auerbach, A. A., Wachter, R. M. 2011; 6 (3): 161–66

  Abstract

  Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills.To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty.We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress.Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output.Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.

  View details for DOI 10.1002/jhm.845

  View details for Web of Science ID 000288462200010

  View details for PubMedID 21387552

• Using Patient-Centered Whiteboards as a Hospital Communication Tool Mistry, R., Lau, C., Sehgal, N. L. National Patient Safety Foundation's Focus on Patient Safety. 2011
• Republished paper: Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project POSTGRADUATE MEDICAL JOURNAL Blegen, M. A., Sehgal, N. L., Alldredge, B. K., Gearhart, S., Auerbach, A. A., Wachter, R. M. 2010; 86 (1022): 729–33

  Abstract

  The goal of this project was to improve unit-based safety culture through implementation of a multidisciplinary (pharmacy, nursing, medicine) teamwork and communication intervention.The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to determine the impact of the training with a before-after design.Surveys were returned from 454 healthcare staff before the training and 368 staff 1 year later. Five of eleven safety culture subscales showed significant improvement. Nurses perceived a stronger safety culture than physicians or pharmacists.While it is difficult to isolate the effects of the team training intervention from other events occurring during the year between training and postevaluation, overall the intervention seems to have improved the safety culture on these medical units.

  View details for DOI 10.1136/qshc.2008.031252rep

  View details for Web of Science ID 000284586000008

  View details for PubMedID 21106808

• Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project QUALITY & SAFETY IN HEALTH CARE Blegen, M. A., Sehgal, N. L., Alldredge, B. K., Gearhart, S., Auerbach, A. A., Wachter, R. M. 2010; 19 (4): 346–50

  Abstract

  The goal of this project was to improve unit-based safety culture through implementation of a multidisciplinary (pharmacy, nursing, medicine) teamwork and communication intervention.The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to determine the impact of the training with a before-after design.Surveys were returned from 454 healthcare staff before the training and 368 staff 1 year later. Five of eleven safety culture subscales showed significant improvement. Nurses perceived a stronger safety culture than physicians or pharmacists.While it is difficult to isolate the effects of the team training intervention from other events occurring during the year between training and postevaluation, overall the intervention seems to have improved the safety culture on these medical units.

  View details for DOI 10.1136/qshc.2008.031252

  View details for Web of Science ID 000284875300020

  View details for PubMedID 20693223

• Patient Whiteboards as a Communication Tool in the Hospital Setting: A Survey of Practices and Recommendations JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Green, A., Vidyarlhi, A. R., Blegen, M. A., Wachter, R. M. 2010; 5 (4): 234–39

  Abstract

  Patient whiteboards can serve as a communication tool between hospital providers and as a mechanism to engage patients in their care, but little is known about their current use or best practices.We surveyed bedside nurses, internal medicine housestaff, and hospitalists from the medical service at the University of California, San Francisco. A brief survey about self-reported whiteboard practices and their impact on patient care was administered via paper and a commercial online survey tool.Surveys were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to use and read whiteboards than physicians. While all respondents highly valued the utility of family contact information on whiteboards, nurses valued the importance of a "goal for the day" and an "anticipated discharge date" more than physicians. Most respondents believed that nurses should be responsible for accurate and updated information on whiteboards, that goals for the day should be created by a nurse and physician together, and that unavailability of pens was the greatest barrier to use.Despite differences in practice patterns of nurses and physicians in using whiteboards, our findings suggest that all providers value their potential as a tool to improve teamwork, communication, and patient care. Successful adoption of whiteboard use may be enhanced through strategies that emphasize a patient-centered focus while also addressing important barriers to use.

  View details for DOI 10.1002/jhm.638

  View details for Web of Science ID 000277053100008

  View details for PubMedID 20394030

• AHRQ's hospital survey on patient safety culture: psychometric analyses. Journal of patient safety Blegen, M. A., Gearhart, S., O'Brien, R., Sehgal, N. L., Alldredge, B. K. 2009; 5 (3): 139–44

  Abstract

  OBJECTIVE: This project analyzed the psychometric properties of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (HSOPSC) including factor structure, interitem reliability and intraclass correlations, usefulness for assessment, predictive validity, and sensitivity.METHODS: The survey was administered to 454 health care staff in 3 hospitals before and after a series of multidisciplinary interventions designed to improve safety culture. Respondents (before, 434; after, 368) included nurses, physicians, pharmacists, and other hospital staff members.RESULTS: Factor analysis partially confirmed the validity of the HSOPSC subscales. Interitem consistency reliability was above 0.7 for 5 subscales; the staffing subscale had the lowest reliability coefficients. The intraclass correlation coefficients, agreement among the members of each unit, were within recommended ranges. The pattern of high and low scores across the subscales of the HSOPSC in the study hospitals were similar to the sample of Pacific region hospitals reported by the Agency for Healthcare Research and Quality and corresponded to the proportion of items in each subscale that are worded negatively (reverse scored). Most of the unit and hospital dimensions were correlated with the Safety Grade outcome measure in the tool.CONCLUSION: Overall, the tool was shown to have moderate-to-strong validity and reliability, with the exception of the staffing subscale. The usefulness in assessing areas of strength and weakness for hospitals or units among the culture subscales is questionable. The culture subscales were shown to correlate with the perceived outcomes, but further study is needed to determine true predictive validity.

  View details for DOI 10.1097/PTS.0b013e3181b53f6e

  View details for PubMedID 19920453

• I-CaRe: a case review tool focused on improving inpatient care. Joint Commission journal on quality and patient safety Lee, J. H., Vidyarthi, A. R., Sehgal, N. L., Auerbach, A. D., Wachter, R. M. 2009; 35 (2): 115–19, 61

  Abstract

  I-CaRe, an inpatient case review tool that walks individual physician reviewers through the details of a patient case, facilitates the collection and assessment of quality and safety data both for internal quality improvement initiatives and external reporting.

  View details for DOI 10.1016/s1553-7250(09)35015-1

  View details for PubMedID 19241732

• A Multidisciplinary Teamwork Training Program: The Triad for Optimal Patient Safety (TOPS) Experience Sehgal, N. L., Fox, M., Vidyarthi, A. R., Sharpe, B. A., Gearhart, S., Bookwalter, T., Barker, J., Alldredge, B. K., Blegen, M. A., Wachter, R. M., Triad Optimal Patient Safety Proje SPRINGER. 2008: 2053–57

  Abstract

  Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills.To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills.Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center.We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team.We received 203 evaluations with a mean overall rating for the training of 4.49 +/- 0.79 on a 1-5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 +/- 0.68.We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.

  View details for DOI 10.1007/s11606-008-0793-8

  View details for Web of Science ID 000261424000018

  View details for PubMedID 18830769

  View details for PubMedCentralID PMC2596515

• Engaging Patients at Hospital Discharge JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L. 2008; 3 (6): 498–500

  View details for DOI 10.1002/jhm.265

  View details for Web of Science ID 000261965700010

  View details for PubMedID 19084888

• National Trends in Treatment of Type 2 Diabetes Mellitus, 1994-2007 ARCHIVES OF INTERNAL MEDICINE Alexander, G. C., Sehgal, N. L., Moloney, R. M., Stafford, R. S. 2008; 168 (19): 2088-2094

  Abstract

  Diabetes mellitus is common, costly, and increasingly prevalent. Despite innovations in therapy, little is known about patterns and costs of drug treatment.We used the National Disease and Therapeutic Index to analyze medications prescribed between 1994 and 2007 for all US office visits among patients 35 years and older with type 2 diabetes. We used the National Prescription Audit to assess medication costs between 2001 and 2007.The estimated number of patient visits for treated diabetes increased from 25 million (95% confidence interval [CI], 23 million to 27 million) in 1994 to 36 million (95% CI, 34 million to 38 million) by 2007. The mean number of diabetes medications per treated patient increased from 1.14 (95% CI, 1.06-1.22) in 1994 to 1.63 (1.54-1.72) in 2007. Monotherapy declined from 82% (95% CI, 75%-89%) of visits during which a treatment was used in 1994 to 47% (43%-51%) in 2007. Insulin use decreased from 38% of treatment visits in 1994 to a nadir of 25% in 2000 and then increased to 28% in 2007. Sulfonylurea use decreased from 67% of treatment visits in 1994 to 34% in 2007. By 2007, biguanides (54% of treatment visits) and glitazones (thiazolidinediones) (28%) were leading therapeutic classes. Increasing use of glitazones, newer insulins, sitagliptin phosphate, and exenatide largely accounted for recent increases in the mean cost per prescription ($56 in 2001 to $76 in 2007) and aggregate drug expenditures ($6.7 billion in 2001 to $12.5 billion in 2007).Increasingly complex and costly diabetes treatments are being applied to an increasing population. The magnitude of these rapid changes raises concerns about whether these more costly therapies will result in proportionately improved outcomes.

  View details for Web of Science ID 000260332400005

  View details for PubMedID 18955637

  View details for PubMedCentralID PMC2868588

• Non-housestaff medicine services in academic centers: Models and challenges JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Shah, H. M., Parekh, V. I., Roy, C. L., Williams, M. V. 2008; 3 (3): 247–55

  Abstract

  Non-housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non-housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission.

  View details for DOI 10.1002/jhm.311

  View details for Web of Science ID 000257229900011

  View details for PubMedID 18571780

• Tuberculosis: In and out of the airways JOURNAL OF HOSPITAL MEDICINE Bui, A. L., Sehgal, N. L. 2008; 3 (2): 167–68

  View details for DOI 10.1002/jhm.262

  View details for Web of Science ID 000255533000013

  View details for PubMedID 18438795

• National trends in treatment for type 2 diabetes mellitus, 1994-2007 Alexander, G. C., Sehgal, N. L., Moloney, R., Stafford, R. SPRINGER. 2008: 350

  View details for Web of Science ID 000254237100711

• Development of a Web-based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) Sehgal, N. L., Ranji, S. R., Shojania, K. G., Cucina, R. J., Hartman, E. E., Zipperer, L., Wachter, R. M. Agency for Healthcare Research and Quality. 2008 ; Advances in Patient Safety: New Directions and Alternative Approaches
• Identification of inpatient DNR status: A safety hazard begging for standardization JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Wachter, R. M. 2007; 2 (6): 366–71

  Abstract

  Ascertaining and documenting patients' preferences regarding end-of-life care is required by accrediting organizations at hospital admission. However, hospitals vary widely in their methods of making these preferences (including do-not-resuscitate [DNR] status) available to frontline providers, increasing the potential for errors.We surveyed 127 nursing executive members of the University HealthSystem Consortium (an alliance of academic medical centers), asking them to describe the current practices of their hospitals in identifying DNR orders. For those at institutions using color-coded wristbands, we also asked about other patient data depicted by wristbands and the choice of colors for DNR and these other indications. We used a commercial online survey tool with E-mail distribution.Sixty-nine nurse executives completed the survey (54%). Fifty-six percent of hospitals use paper documentation as their only mode to identify DNR orders, 16% use electronic health records, and 25% augment either paper or electronic documentation with a color-coded patient wristband. Of those using color-coded wristbands (n = 17), 8 color schemes were reported. More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care.Mechanisms to identify DNR orders vary significantly. For hospitals that use color-coded wristbands, the variety of color choices poses a risk for confusion and error. Building on existing and isolated state initiatives, a national mandate to standardize DNR identification and the color of patient wristbands would reduce the potential for errors and promote adherence to patients' wishes.

  View details for DOI 10.1002/jhm.283

  View details for Web of Science ID 000255258500003

  View details for PubMedID 18080337

• Color-coded wristbands: Promoting safety or confusion? JOURNAL OF HOSPITAL MEDICINE Sehgal, N. L., Wachter, R. M. 2007; 2 (6): 445

  View details for DOI 10.1002/jhm.254

  View details for Web of Science ID 000255258500015

  View details for PubMedID 18081179

• Hospitalists: A Field of Growing Opportunity. Resident and Staff Physician Sehgal, N. L., Wachter, R. M. 2007; 1 (53)
• The "Customer" Is Always Right Sehgal, N. L. AHRQ Web M&M: Case Study and Expert Commentary. 2007
• The expanding role of hospitalists in the United States SWISS MEDICAL WEEKLY Sehgal, N. L., Wachter, R. M. 2006; 136 (37-38): 591–96

  Abstract

  Hospitalists are the most rapidly growing group of providers in the United States; in a few years, there will be more hospitalists than cardiologists in the U.S. While early growth in the field was driven by financial demands on hospitals, more recent incentives include a growing focus on improving the quality and safety of care. With current evidence suggesting both financial and educational benefits from the increased presence of hospitalists in both teaching and non-teaching settings, the environment is ripe for further expansion. Hospitalists are likely to embrace a number of additional clinical and non-clinical roles in the coming years. They will serve as change agents, hospital leaders and experts in both quality improvement activities and research initiatives around improving inpatient care delivery. As their skills sets and unique competencies become more clearly outlined, the next step will likely be the development of an independent specialty with its own board certification.

  View details for Web of Science ID 000241197900002

  View details for PubMedID 17043952

• Photoclinic: Pyoderma Gangrenosum. Consultant Gratton, S. B., Sehgal, N. L. 2006; 7 (46): 821
• National trends in statin use by coronary heart disease risk category PLOS MEDICINE Ma, J., Sehgal, N. L., Ayanian, J. Z., Stafford, R. S. 2005; 2 (5): 434-440

  Abstract

  Only limited research tracks United States trends in the use of statins recorded during outpatient visits, particularly use by patients at moderate to high cardiovascular risk.Data collected between 1992 and 2002 in two federally administered surveys provided national estimates of statin use among ambulatory patients, stratified by coronary heart disease risk based on risk factor counting and clinical diagnoses. Statin use grew from 47% of all lipid-lowering medications in 1992 to 87% in 2002, with atorvastatin being the leading medication in 2002. Statin use by patients with hyperlipidemia, as recorded by the number of patient visits, increased significantly from 9% of patient visits in 1992 to 49% in 2000 but then declined to 36% in 2002. Absolute increases in the rate of statin use were greatest for high-risk patients, from 4% of patient visits in 1992 to 19% in 2002. Use among moderate-risk patients increased from 2% of patient visits in 1992 to 14% in 1999 but showed no continued growth subsequently. In 2002, 1 y after the release of the Adult Treatment Panel III recommendations, treatment gaps in statin use were detected for more than 50% of outpatient visits by moderate- and high-risk patients with reported hyperlipidemia. Lower statin use was independently associated with younger patient age, female gender, African American race (versus non-Hispanic white), and non-cardiologist care.Despite notable improvements in the past decade, clinical practice fails to institute recommended statin therapy during many ambulatory visits of patients at moderate-to-high cardiovascular risk. Innovative approaches are needed to promote appropriate, more aggressive statin use for eligible patients.

  View details for DOI 10.1371/journal.pmed.0020123

  View details for Web of Science ID 000229847900016

  View details for PubMedID 15916463

  View details for PubMedCentralID PMC1140942

• Assessment and improvement of quality and value Hospital Medicine Wachter, R. M., Sehgal, N. L. Lippincott. 2005; 2nd
• Clinical case conferences: Back to the future?. 26th Annual Meeting of the Society-of-General-Internal-Medicine Sehgal, N., Cucina, R., Marcus, G., Sharp, C., Yu, S., Hoffman, B. SPRINGER. 2003: 121–121

  View details for Web of Science ID 000182564300421

• The medical chief residency: A survey and recommendations. Sehgal, N., Skeff, K. SPRINGER. 2003: 255

  View details for Web of Science ID 000182564301041

• Halofuginone, a specific collagen type I inhibitor, reduces anastomotic intimal hyperplasia. Archives of surgery (Chicago, Ill. : 1960) Choi, E. T., Callow, A. D., Sehgal, N. L., Brown, D. M., Ryan, U. S. 1995; 130 (3): 257–61

  Abstract

  To determine if halofuginone hydrobromide, a specific type I collagen inhibitor, could prevent intimal hyperplasia at a vascular anastomosis.Intimal hyperplasia is characterized by smooth muscle cell proliferation and extracellular matrix accumulation. Halofuginone was used to block collagen production and smooth muscle cell proliferation in cell cultures and in a rabbit model of an end-to-end anastomosis of the right common carotid artery. Animals were fed a nontoxic dose of halofuginone. Eighteen rabbits were fed the inhibitor in a randomized blinded fashion and were examined after 4 weeks by harvesting the arteries after perfusion fixation at physiologic pressures.Halofuginone inhibited smooth muscle cell proliferation in vitro and had no effect on cell viability. Morphometric quantification verified that halofuginone treatment significantly attenuated anastomotic intimal thickness.Oral administration of halofuginone inhibits intimal hyperplasia at vascular anastomoses. Intimal hyperplasia inhibition by halofuginone may be a therapeutic option for preventing arterial stenosis in vascular surgery.

  View details for DOI 10.1001/archsurg.1995.01430030027004

  View details for PubMedID 7887792

• A specific inhibitor of alpha-1(I) procollagen mRNA inhibits anastomotic intimal hyperplasia. Archives of Surgery Choi, E. T., Callow, A. D., Sehgal, N. L., Brown, D., Ryan, U. S. 1995; 3 (130): 257-261
• A NOVEL-APPROACH TO PREVENTING INTIMAL HYPERPLASIA - INHIBITION OF SMOOTH-MUSCLE CELL-MIGRATION WITH ENALAPRIL CHOI, E. T., SEHGAL, N., SUN, S. P., TRACHTENBERG, J., RYAN, U. S., CALLOW, A. D., Chang, J. B. SPRINGER-VERLAG. 1994: 28–40

  View details for Web of Science ID A1994BB63Z00003