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Quality and Patient Safety 2008-09

• A UF COM Educational Initiative
• Curriculum Committee
• June 10, 2008

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UF COM Patient Safety Task Force

• Lou Ann Cooper
• Rick Davidson
• Marvin Dewar
• Tim Flynn
• Laura Gruber
• Nancy Hardt

• Heather Harrell
• Omayra Marrero, MS-3
• Eric Rosenberg
• Amy Stevens
• Bob Wears

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Themes

• Why develop a UF Patient Safety/Quality
  Improvement Course
• Now?
• For medical students?
• How did we go about drafting a curriculum?
• What are we proposing to do in each year and
  especially the 3rd year?

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Why a Patient Safety/QI Course for Students now?

• Institutional momentum
• Ferrero Case
• Influence of faculty trained in QI/safety to
  organize existing bits and pieces
• Organizational momentum
• AAMC improving patient safety is our
  responsibility (2004)
• NSPF (VA), AMA, ACGME
• National momentum
• CMS (non-payment for non-performance/error)

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(some) Preliminary Efforts

• Sub-I Introductory Lecture and Observed Case
  reporting (Heather Harrell, Eric Rosenberg)
• EBM, Clerkship Introductory talks (Rosenberg)
• Simulation Exercises (Armstrong, others)

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Students get it

• my patient came into the ED for presyncope she
  was getting Clonidine instead of Klonipin for
  her anxiety
• my patient refused to go to radiology to get a
  dialysis catheter placed she was right to refuse
  -- they had come for the wrong patient
• my patient told the team he was on the same med
  list as before we didnt review his medications
  with him, we just recopied the old ones. He
  didnt tell us that his cholesterol medication
  had been changed because hed had rhabdomyolysis
  recently he again developed rhabdomyolysis while
  on our service.

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Rosenberg, Cooper, Harrell, Menzel, Davidson
(2008).
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How did we go about drafting a curriculum?

• 8 Task Force Meetings 12/07 5/08
• Surveyed published curricula
• Agreed on multi-year course integrated into
  existing courses, but with distinct identity,
  course directors
• Developed goals and objectives for each year
• Developed specific activities, options, and
  themes for each year

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Curriculum Goals MS-1, MS-2

• Understand patient safety fundamentals including
  the importance of an organizational culture that
  promotes teamwork and safety, the public focus on
  patient safety and adverse events, patient safety
  terminology, and the human impact of adverse
  events.
• Understand key aspects of methods to improve
  patient safety and clinical quality as well as
  the interaction between quality improvement
  efforts in the medical malpractice tort system.

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Curriculum Goals MS-3

• Recognize and describe adverse event and patient
  safety challenges unique to different specialties
  and be able to apply strategies and techniques
  designed to prevent or mitigate those events.

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Objectives MS-3

• Identify and analyze common clinical adverse
  events.
• Differentiate the impact of system failures and
  human factors in the development of adverse
  events and discuss approaches to preventing and
  mitigating those events.
• Identify and describe system level improvements
  which will improve patient safety and reduce
  adverse events.
• Identify and be able to apply individual
  strategies and approaches to improve patient
  safety and reduce adverse events.

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Curriculum Goals MS-4

• Demonstrate competence in key patient safety and
  quality improvement skills and conduct an
  individual project related to patient safety in
  the students specialty choice area.

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Patient safety curriculum to be incorporated
longitudinally into existing curriculum
Pre-orientation
Year 1
Year 2
Year 3
Year 4

Pre-orientation assigned readings on the
importance of developing a culture of safety in
health care

• Quality and Safety Grand Rounds on the impact of
  medical errors on patients and families
• Culture of safety workshop at the beginning of
  the EPC course to discuss the pre-orientation
  reading materials and follow up on the discussion
  questions handed out at the first Quality and
  Safety Grand Rounds
• Epidemiology of medical error online module
• Online module on national quality improvement and
  patient safety organizations
• Quality and Safety Grand Rounds on the impact of
  medical errors on providers

• QI/PI workshops (at least two) on the application
  of common performance improvement techniques
  to a standard problem, including problem
  statement, process mapping and solution
  generation.
• Multidisciplinary panel discussion on teamwork
  and communication issues.
• Communication workshop that includes a focus on
  difficult communications and role-playing around
  the use of structures communications (i.e.,
  SBAR).
• Panel discussion on safety lessons from other
  disciplines
• Lecture on the effectiveness (or lack of
  effectiveness) of the medical malpractice system
  as a patient safety tool.
• Portfolio reflections on quality and safety
  observations during the preceptorship experience.

• Pre-reading (examples of residents, medical
  students who have successfully completed patient
  safety interventions)
• Clerkship CPCs devoted to quality and safety
  topics
• Workshops on QI methods
• Over time develop a threaded hypothetical case to
  be used for quality CPC across clerkships
• Student reflection on errors seen on clerkship
  with course directors/quality directors
• Student maintains registry of opportunities for
  clinical improvement to be discussed with
  departmental quality directors

• Pre-reading (i.e. How Doctors Think by Jerome
  Groopman, M.D.)
• Simulator session teamwork and spot the error
• Multi-disciplinary workshops re communication
  SBAR
• Role playing exercise re delivering bad news
• Root cause analysis workshop
• Self-directed individual learning project on
  future specialty patient safety issues
• Seminar to reflect on curriculum and identify
  opportunities to take leadership roles in quality
  and safety
• Seminar to reflect on gaps between ideal and
  optimal care systems vs. actual performance

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Quality and Patient Safety I IV

• Four, year-long segments (analogous to the EPC
  semester series)
• Lecture, seminar, online/independent study,
  reflective writing, clinical simulation
  activities integrated into existing preclinical
  and clinical coursework.
• Collaboration on quality improvement projects
  aligned with their specialty areas.
• https//medinfo.ufl.edu/courses/php/content.php

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Course Directors

• Eric Rosenberg UF Gville Internal Medicine
• ACP Patient Safety (2002) yearly CME program
• DOM Physician Director for QI
• Medication Safety
• Bob Wears UF Jax Emergency Medicine
• 1st presentations in 1998
• Faculty in U Wisconsic Human Factors
  Engineering in Pt Safety short course X 4 years
• Faculty in NWU Master's program in pt safety x 2
  years
• Multiple funded safety research efforts.
• Multiple research publications and book chapters
  on subject
• Editor of Patient Safety in Emergency Medicine

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Quality and Patient Safety I

• Online Module I The scope and gravity of
  adverse events (A. Stevens)
• Online Module II The scope of quality problems
  in the U.S. medical system (E. Rosenberg)
• Quality and Safety Student Grand Rounds I The
  Impact of Medical Harm on Patients and Families
  (EPC-1)
• Workshop I Review of Readings and Grand Rounds
  I (EPC-1)
• Executive Summary To Err is Human (IOM 1999)
• When Doctors Make Mistakes (Atul Gawande)
• Excerpts from executive summaries of IOM/Quality
  Chasm Reports
• The Nature and Frequency of Medical Errors
  (Wachter, Ch 1)

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QPS I (contd)

• Quality and Safety Student Grand Rounds II The
  Impact of Medical Harm on Physicians and other
  Medical Professionals (EPC)
• Workshop II Reflective Writing on
  Quality/Safety (EPC-2)
• Clinical Skills Exam Module

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Quality and Patient Safety II

• Online Module III Introduction to Root Cause
  Analysis
• Online Module IV Introduction to Quality
  Improvement
• Workshop III Root Cause Analysis Exercise
  (EBM)
• Workshop IV Quality Improvement Concepts
• Workshop V The Hidden Patient Safety
  Curriculum Current Reality on the Wards and in
  Clinic / Ethical Issues Surrounding Safety
  (MS-4, residents, faculty) (Clerkship Orientation
  2009 Ethics)

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QPS II (contd)

• Workshop VI Improving Interdisciplinary
  Communication (Winter/Crawford)
• Workshop VII Improving Patient Communication
  Assessing Barriers to Care (EPC-3)
• Lecture I The Tort System and its Impact on
  Quality Improvement (Ethics J. Osgard SUF Self
  Insurance Trust Fund)
• Quality and Safety Student Grand Rounds III
  Interdisciplinary Communication and Teamwork
  Challenges (outside speaker)
• Quality and Safety Student Grand Rounds IV
  Lessons from Industry (outside speaker)
• Clinical Skills Exam

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Quality and Patient Safety III

• Students may consider a menu of options to choose
  from during the year to satisfy requirements
• We want to encourage a high degree of
  flexibility.
• 4 Multidisciplinary Themes
• Role of Hospital Quality Depts.
• Role of Nursing in QI
• Avoidance of Medication Errors
• Laboratory / Radiographic Errors

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QPS III

• Inter-Clerkship Seminar Series Case Studies in
  Patient Safety
• Presentation of Actual/Averted Errors with mock
  root cause analyses
• Presentation/Analyses of Quality Data with
  discussion of methods of performance improvement
• Patient Safety Rounds at GAVAMC
• Clinical Skills Exam

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Clerkship Directors Proposals June 6, 2008

• ER (Jacksonville)
• Daily shift-change w/ more student involvement --
  focus on safety problems/hand off issues
• Family Medicine/Neurology
• Root cause analysis case conference using errors
  reported by students on  
• Medicine
• Likely to incorporate root cause analysis into
  existing "doc in box" sessions
• Surgery
• Day 1 orientation lecture focusing on surgical
  complication prevention
• MM to focus on root cause analyses
• Increased involvement of subspecialty rotations 
•  OB/GYN
• Creating CPC series on quality/error prevention
• Incorporate TeamSTEPPS (http//dodpatientsafety.us
  uhs.mil/index.php?nameNewsfilearticlesid31)
• Pediatrics
• Students may identify errors and include as part
  of portfolio) or work through scenarios in
  conference geared towards specific pediatrics
  issues (wt. based dosing, etc.)
• Psychiatry
• Ethics Case Conference series to focus on error
  prevention

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Quality and Patient Safety IV

• Workshop VIII Clinical Decision Making How
  Doctors Think
• Online Module V Disclosing Errors to Patients
• Online Module VI Anticipating Error to Avert
  Harm
• Simulation Exercises
• Harrell Professional Development and Assessment
  Center
• Disclosing Errors to Patients and Families
• Discussion of Errors on Rounds
• Operating Room Simulation
• Spot the Error Exercise (John Armstrong, Jane
  Carthy)
• Anesthesiology simulators
• Bedside Procedure Simulation

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QPS IV (contd)

• Workshop IX The Hidden Patient Safety
  Curriculum (contd)
• Development of CQI Project (with input from
  Physician Quality Directors)
• Research/Write about quality of care issues
  surrounding a disease, procedure, patient
  population
• Adopt a CQI project participate in data
  collection, analysis of ongoing research at SUF

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Methods of Evaluation

• Non-credit, required course
• Attendance at all required course activities
• Final exam at close of 1st, 2nd, 3rd, (and 4th)
  year (incorporate into clinical skills exam
  series if possible)
• Completion of writing assignments
• Completion of Quality Improvement Project

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Who will teach it?

• We all will.
• We need more faculty development in this area,
  but a wide variety of open source, practical,
  case-based materials
• Many key concepts are intuitive for the
  experienced clinician
• For example, to do a root cause analysis
  describe the event, identify the immediate cause
  of the adverse event, identify the contributing
  causes (latent errors), create an action plan.

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How will we know if this is effective?

• Plan continuing evaluation, evolution of the
  curriculum
• Administration of surveys to gauge changes in
  attitudes, knowledge, skills
• Establishment of more formal curricula in UF
  residency training programs
• Impact on institutional culture, patient
  satisfaction, quality

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Is it safe to speak up?

• Speak up scripts I need clarification to avoid
  confrontational speech
• People may ignore you
• Cant change the world even though the world
  needs changing
• There are specific avenues to explore in the
  longer term even if people are ignoring you in
  the short term
• We can put you in touch with people interested in
  fixing this problem it wont be business as
  usual forever
• There are others to talk to in the hierarchy
  (dean, chairs, QI directors, clerkship directors)
• We can ask departments to make a general
  commitment to respond to those who report
  problems
• Weve made a general commitment to respond in a
  certain way
• We will engage and not attack people
• Wears perhaps the best test of whether safety
  culture exists is what happens when a lower
  status hierarchy person brings up a problem and
  theyre mistaken about whose patient it is if
  they dont get beat up, thats a healthy culture

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Quality is not just meeting Performance Measures

• a hospital can be seen as a high quality
  organization receiving awards for being a
  stellar performer and oodles of cash from P4P
  programs if all of its pneumonia patients
  receive the correct antibiotics, all its CHF
  patients are prescribed ACE inhibitors, and all
  its MI patients get aspirin and beta blockers.
  Even if every one of the diagnoses was wrong.
  Bob Wachter