Rhonda A. Sparks, M.D.

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Multidisciplinary SimulationMoving Clinical
EducationfromGroup Training to Team Training

• Rhonda A. Sparks, M.D.
• Medical Director
• Clinical Skills Education and Testing Center
• University of Oklahoma College of Medicine

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Where are we going?

• Why is the time right for change in clinical
  education?
• What are the obstacles to instituting
  multidisciplinary simulation?
• How can we design the most effective
  multidisciplinary simulation activities?

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Time for ChangeThe Perfect Storm
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Time for Change

• Changes in Clinical Education
• Curriculum Reform
• Competency Evaluation
• Patient Safety
• Demand for Improved Safety and Quality
• Healthcare Reform
• Increased Access and Cost Containment

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Changes in Clinical Education -How We Teach

• Revolutions in Medical Education
• Flexner Report 1910
• Quackery to Credible Scientists
• Case Western Reserve University 1952
• Increased Integration of BS and CS
• Increased Clinical Relevance
• McMaster University 1969
• Social Unrest/Time of ExperimentationEducationall
  y!
• Canadian Universal Healthcare
• Clinician Shortage

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Changes in Clinical Education - What We Teach

• 95 of Medical Schools are Expanding Class Size
• The Nurse Education, Expansion, and Development
  Act of 2009
• Macy Foundation 2008 - Urgent Need to Bring
  Medical Education into Better Alignment with
  Societal Needs
• Foster greater inter-professional teamwork and
  collaboration
• Increase curricular focus on knowledge and skills
  for improving the quality and safety of patient
  care
• Foster inter-professional, team based education
  and patient care

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Changes in Clinical Education Evaluation/Compete
ncy

• Theory and Practice of Teams and Teamwork
• Knowledge
• Skills
• Attitudes
• Millers Pyramid of Competency
• Knows - information
• Knows How to use information
• Shows how to use information
• Does performs in clinical setting

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Changes in Physician Culture 1910 - 2010

• The 21st Century Physician
• Acquire and Use Knowledge
• Interdisciplinary Research
• Collaborative
• Share Accountability
• Interdisciplinary Teams
• Coordination of Care

• The 20th Century Physician
• Accumulate Knowledge
• Individual Scholarly Work
• Autonomous
• Cooperative
• Individual Achievements
• Solo Expert

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Patient Safety

• 1999 Institute of Medicine Report To Err is
  Human Building a Safer Health System
• Medical Error 8th Leading Cause of Death
• 99,000 Deaths Annually
• Non-technical Errors
• System Errors
• 7 Inpatients subjected to a medical error
• Cost 8 to 29 Billion Annually

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Patient Safety

• 1999 - AHRQ directed by the Healthcare Research
  and Quality Act to
• Identify the causes of preventable health care
  errors and patient injury in health care delivery
• Develop, demonstrate, and evaluate strategies for
  reducing errors and improving patient safety
• Disseminate effective strategies throughout the
  health care industry

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Patient Safety

• 2003 JCAHO National Patient Safety Goals
• 3 of 7 Goals Non-technical skills
• Instituted Safety Practices
• Clinical Effectiveness of Safe Practices
• 2004 The 100K Lives Campaign
• Rapid Response Teams
• AMI Guidelines
• Prevent Adverse Drug Events (ADE)
• Prevent Central Line Infections
• 2005 Resident Work Hour Limits

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Patient Safety

• 2005 Patient Safety and Quality Improvement Act
• Patient Safety Organizations (PSO)
• Limits Use of Reported Adverse Event Information
• Established a Network of Patient Safety Databases
  (NPSD)
• 2005 TeamSTEPPS
• 2006 Keystone Project
• Team Approach to Decreasing Line Infections

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Patient Safety

• 2006 AHRQ Improving Patient Safety through
  Simulation Research Grants
• 2008 CDC Data Suggests that HAIs effect 2
  million patients
• 2008 Project RED Re-Engineered Hospital
  Discharge Program
• 2009 PSOs Refined and Consumer Avenue for
  Reporting Developed

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Healthcare Reform

• H.R. 3590 - Patient Protection and Affordable
  Care Act 3/23/2010
• Expand health care coverage to 31 million
  currently uninsured Americans through a
  combination of cost controls, subsidies and
  mandates.
• It is estimated to cost 848 billion over a 10
  year period, but would be fully offset by new
  taxes and revenues and would actually reduce the
  deficit by 131 billion over the same period
• What will this look like?
• Increase Access - Yes

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Healthcare Reform

• Beginning in October 2012, non-rural acute care
  hospitals that meet or exceed performance
  standards established by the Secretary of Health
  and Human Services (HHS) for at least five
  measures will receive higher Medicare payments
  from a pool of money collected from all hospitals
• Starting in October 2012, hospitals with high
  readmission rates for patients with these
  conditions will have their Medicare payments
  reduced

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How Effective is Team Training?

• What we know
• Microsystems over a define period of time
• What we dont know
• Long-term outcomes

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(Sexton, 2006) Johns Hopkins
(Pronovost, 2003) Johns Hopkins Journal of
Critical Care Medicine
(Mann, 2006) Beth Israel Deaconess Medical
Center Contemporary OB/GYN
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What are the obstacles to wider utilization of
multidisciplinary simulation?

• Change is Hard
• Culture of Silos
• Culture of Innovation
• Lack of Transparency
• Error reporting systems

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Making It Work

• Utilize Group Training for Tasks
• Define Our Teams
• Micro-environments
• Use Patient Safety Data to Drive Team Training
  Initiatives
• Clearly Define Team Objectives
• Use Established Team Training Methodology
• TeamSTEPPS

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TeamSTEPPS

• Department of Defense DoD and AHRQ
• Research Based and Field Tested (MHS)
• Four Core Competency Areas
• Team Leadership
• Situation Monitoring
• Mutual Support
• Communication

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Eight Stepsof Change
John Kotter
Team Strategies Tools to Enhance Performance
Patient Safety
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We can assure our patients that their care is
always provided by a team of experts, but we
cannot assure our patients that their care is
always provided by expert teams

• Allan S. Frankel, M.D.

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Tulsa
Yall come back now, ya hear?
Oklahoma City
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Tulsa High Rise
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OKC High Rise
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Yacht on Grand Lake
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Yacht on Lake Hefner - OKC
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Tulsa Speed Boat
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OKC Speed Boat
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Typical Tulsa Swimming Pool
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Typical OKC Swimming Pool
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Bibliography

• Neville AJ, Norman GR. PBL in the Undergraduate
  MD Program at McMaster University Three
  Iterations in Three Decades. Acad Med.
  200782370-374
• Morrison G, et al. Team Training of Medical
  Studnets in the 21stCenturyWould Flexner
  Approve? Acad Med. 201085254-259
• Hamman WR. The Complexity of team training what
  we have learned from aviation and its
  applications to medicine. QualSaf Health Care.
  200413i72-i79
• Issenberg B, et al. Features and uses of
  high-fidelity medical simulation that lead to
  effective learning a BEME Systematic Review.
  Medical Teacher. 20052710-28
• Morey JC. Error Reduction and Performance
  Improvement in the Emergency Department through
  Formal Teamwork TrainingEvaluation Results of
  the MedTeams Project. Health Services Research.
  2002371553-1581
• Nishisaki A, et al. Does Simulation Improve
  Patient Safety? Self-efficacy, Competence,
  Operational Performance, and Patient Safety.
  Anesthesiology Clinics. 200725225-236

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Bibliography

• Miller G. The Assessment of Clinical
  Skills/Competence/Performance. Acad Med. 199 63
  563-567
• Beckett M, Fussum D, et al. A Review of Current
  State Level Adverse Event Reporting Practices
  Toward National Standards. AHRQ Report. 2007
• LeapeL,Berwick DM. Five Years After to Err is
  Human What have We Learned?. JAMA.
  20052932384-2390
• The Patient Safety and Quality Improvement Act of
  2005. Overview, June 2008. Agency for Healthcare
  Research and Quality, Rockville, MD.
• http//www.ahrq.gov/qual
• Institute of Medicine (IOM).(2000). To err is
  human Building a safer health system. L. T.
  Kohn, J. M. Corrigan, M. S. Donaldson (Eds.).
  Washington, DC National Academy Press
• Clancy CM, Tornberg D. TeamSTEPPSIntegratingTeamw
  ork Principles into Healthcare Practice. Patient
  Safety and Quality Healthcare. 2006
  http//www.psqh.com