8.8 References

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

FMEA as a proactive safety tool for anticipating failures before they occur; FMEA worksheet structure

Module 8, Section 2 explicitly includes FMEA as a named proactive safety tool, with an ED scenario showing mandatory safety plan documentation triggered by FMEA analysis. The IHI FMEA Tool provides the methodology and worksheet that learners are directed to use as companion resources.

Agency for Healthcare Research and Quality (AHRQ). (2023). Quality Improvement and Patient Safety Resources.

Anonymous safety reporting systems, trigger tools, and proactive safety infrastructure

Module 8 lists anonymous safety reporting systems and trigger tools as proactive safety tools. AHRQ's patient safety resources provide the evidence base and operational guidance for these tools, which are standard components of a robust patient safety system.

Nolan T, Resar R, Haraden C, Griffin FA. (2004). Improving the Reliability of Health Care. IHI Innovation Series white paper. Institute for Healthcare Improvement.

Reliability levels connection to sustainability: embedding changes so they don't erode over time

Module 8 references the reliability framework from Module 6 in its sustainability discussion, emphasizing that the goal is system-embedded (>99% reliable) practices. Nolan et al. (2004) is the source of this framework and remains relevant here.

Institute for Healthcare Improvement (IHI). (2024). IHI Open School: Quality Improvement Courses.

IHI Open School is a national QI education resource, connecting teams to training, templates, and community

Module 8, Section 5 explicitly recommends the IHI Open School as a national resource for connecting individuals and teams to QI training. This resource is named directly in the module.

American College of Emergency Physicians (ACEP). (2024). Quality and Patient Safety Resources.

ACEP QI resources for emergency medicine clinicians working on PMHCA improvement

Module 8, Section 5 explicitly names ACEP QI resources as a national resource for the emergency medicine audience. Given that ED providers are a primary audience for this series, this citation directly supports the module's resource guidance.

Weick KE, Sutcliffe KM. (2015). Managing the Unexpected: Sustained Performance in a Complex World (3rd ed.).

Mentor-mentee relationships as a mechanism for building organizational resilience and QI capacity

Module 8's Section 4 on mentorship discusses how distributed QI knowledge creates resilience when key champions leave. Weick & Sutcliffe's framework on resilient organizations in unexpected conditions provides the theoretical basis for why mentorship and knowledge distribution are sustainability strategies, not just nice-to-haves.

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

HRSA PMHCA program as the context for the resources, coaching networks, and state-based collaboratives referenced

Module 8 references 'state PMHCA networks' and program-level coaching directories. The HRSA PMHCA program page is the authoritative source for these collaborative networks and the programmatic context in which these resources exist.

Liker JK. (2004). The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer.

Gemba walkthrough visits as a focused study method involve direct observation of the actual care process alongside staff

Module 8.3 names ‘gemba’ walkthrough visits directly as one of four focus study methods. Liker's text is the foundational source for genchi genbutsu (“go and see”), the Lean principle underlying gemba walks, providing the conceptual basis for this named tool.