1.9 References

Institute for Healthcare Improvement (IHI). (2024). How to Improve: The Model for Improvement.

Overview of IHI's Model for Improvement as the series backbone

Module 1's learning objectives and the preview of Modules 2–6 are organized around the IHI Model for Improvement's three questions. This IHI resource is the authoritative online reference for that framework.

Batalden PB, Davidoff F. (2007). What is 'quality improvement' and how can it transform healthcare? Quality and Safety in Health Care, 16(1), 2–3.

Definition of QI as systematically improving local systems and processes

Module 1 opens by defining QI science and distinguishing it from blame-based thinking. Batalden & Davidoff (2007) provide the canonical peer-reviewed definition of QI in healthcare and ground the module's foundational framing.

Berwick DM. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320(1), 53–56

Continuous improvement as a core healthcare value

Berwick's landmark 1989 NEJM essay is the original call to apply continuous improvement to U.S. healthcare. Module 1's framing of QI as an ongoing, system-level discipline draws directly on this intellectual tradition.

Agency for Healthcare Research and Quality (AHRQ). (2024). Quality Improvement and Patient Safety Resources.

Patient safety infrastructure, anonymous reporting systems, and AHRQ tools

Section 2's discussion of system-level safety opportunities and the module's overall patient safety framing aligns with AHRQ's QI and patient safety resources, which serve as the federal policy backdrop for PMHCA improvement work.

Reason J. (2000). Human error: models and management. BMJ, 320(7237), 768–770.

The Swiss Cheese Model of error: systems thinking over individual blame

Module 1 explicitly references the Swiss Cheese Model to explain how errors reach patients when protective layers fail. Reason (2000) is the source of this model and underpins the module's central message that QI is about system design, not individual fault.

Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. (2016). SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986–992.

SQUIRE 2.0 guidelines for publishing QI work

Section 6 explicitly calls out SQUIRE 2.0 as the framework for writing up QI projects for publication. This is cited directly in the module text.

Institute for Healthcare Improvement (IHI). (2024). Failure Modes and Effects Analysis (FMEA) Tool.

SFMEA (Severity-Focused Failure Modes and Effects Analysis) for high-stakes processes

Section 3 introduces SFMEA for anticipating failures in high-stakes processes like suicide risk screening and medication handoffs. The IHI FMEA Tool resource provides the methodology foundation.

Health Resources and Services Administration (HRSA). (2024). Pediatric Mental Health Care Access Program.

HRSA PMHCA program as the programmatic context for the entire training series

The module is explicitly framed as training for PMHCA program participants. HRSA's PMHCA program page is the authoritative source for program goals, eligible settings, and funded activities that give this training series its purpose.

Institute for Healthcare Improvement (IHI). (2024). Cause and Effect (Fishbone) Diagram.

Fishbone (Cause-and-Effect) Diagram as a tool to understand root causes

Section 3 introduces the fishbone diagram as a primary QI tool, with a detailed scenario (ED discharge follow-up) showing how it maps root causes across People, Process, Equipment, Environment, and Policy. The IHI Fishbone Diagram resource provides the tool template referenced.

Institute for Healthcare Improvement (IHI). (2024). Process Mapping.

Process Mapping to visualize workflow and identify handoff failures

Section 3 explains process mapping in depth, including 'as-is' vs. 'desired state' mapping. The school clinician scenario specifically shows 3 undocumented handoffs revealed by mapping. The IHI Process Mapping resource is the companion tool.

Zima BT, Murphy JM, Scholle SH, et al. (2013). National quality measures for child mental health care: background, progress, and next steps. Pediatrics, 131(Suppl 1), S38–S49.

National quality measures for child mental health; measurement gaps in pediatric behavioral health

Module 1 highlights specific gaps in PMHCA (screening rates, wait times, follow-up) that mirror the national quality measure gaps documented by Zima et al. This peer-reviewed source justifies why these particular improvement targets are nationally significant.