Translational Safety Through Immersive Learning: Practice What you Preach Gregory Botz, MD, FCCM Professor, Department of Critical Care Division of Anesthesiology and Critical Care The University of Texas, MD Anderson Cancer Center, Houston, TX LEADING INNOVATION IN PATIENT SAFETY
Patient Safety Innovation: Translational Safety through Immersive Learning: Practice what you preach! Gregory H. Botz, MD, FCCM UT System Distinguished Teaching Professor Professor of Anesthesiology and Critical Care Associate Medical Director of Intensive Care Medical Director, Simulation Center UT M.D. Anderson Cancer Center UT System Chancellor s Health Fellow for Quality of Care and Patient Safety DISCLOSURE I have no financial relationships with commercial support to disclose.
Hospitals are Dangerous!
November 30, 1999: Medical Injuries in the U.S. account for: 44,000-98,000 deaths per year More people die from medical errors than from breast cancer or AIDS or motor vehicle accidents Direct health care costs: $9-15 billion per year Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.
Key Findings: Errors occur because of system failures Preventing errors means designing safer systems of care Organizations, not individual physicians and nurses control those systems of care Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.
Key Findings: Between the health care we have and the care we could have lies not just a gap, but a chasm. Trying harder will not work! Changing systems of care will Committee on Quality of Health Care in America. Crossing the Quality Chasm. Institute of Medicine, 2001.
[T]he true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm James JT: A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety 2013; 9:122-8
How Hazardous is Healthcare? 100000 DANGEROUS (>1/1000) Healthcare REGULATED ULTRA-SAFE (<1/100K) 10000 Driving 1000 100 Scheduled Airlines 10 1 Bungee Jumping Mountain Climbing Chemical Manufacturing Chartered Flights European Railroads Nuclear Power 1 10 100 1000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality Source: 2002 Institute of Healthcare Improvement
Modern Medicine!
So, What s the Problem? The science and technology of our current healthcare system is the best the world has ever seen; (and continues to improve rapidly) while the performance of American Healthcare delivery leaves much to be desired. It s a Failure of Execution! Adapted From Brent James: Managing Clinical Processes: Doing Well by Doing Good Advanced Training Program in Healthcare Delivery Improvement. IHC Chassin, MR, Galvin, RW, and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA 1998; 280(11):1000-1005. Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.
Performance Gaps There is often a GAP between how we think we BEHAVE and PERFORM and how we actually BEHAVE and PERFORM. Within that GAP, there is a potential for: Efficiency Waste, Patient Safety Lapses, and Harm
Recent Approaches
Best Practices!
Translational Patient Safety Translate What You Know into What You Do!
Translational Research
Immersive Learning
Modern Aviation Simulator
Medical Simulation
Medical Simulation Simulation is a technique, not a technology Gaba, 1992, 1993, 1994, 1995 Realistic Environment Realistic Circumstances Realistic Stressors Stress Inoculation Safe and Supportive Reproducible
Medical Simulation Education Training Assessment
Medical Simulation Education Training Assessment Teaching Knowledge-building Adult Learning Doing Deliberate Practice Mastery Learning Measuring Performance Evaluation
Medical School Education
Surgical Skills Training
Radiation Therapy
Education vs. Training Education does not mean teaching people to know what they do not know. It means teaching them to behave as they do not behave. (Glavin) Training is learning an expected behavior Evaluation is measuring the performance of that behavior Deliberate Practice is a strategy to periodically practice in order to gain mastery of, and maintenance of the behavior.
Deliberate Practice Expert Performance is not necessarily innate Expert-level performance is primarily the result of expert-level practice 10,000 Hours threshold to expert performance (Gladwell, Outliers. 2008)
Deliberate Practice in Industry Aviation Nuclear Power Maritime Services Rail Services Law Enforcement Emergency Medical Services Fire Services Manufacturing Litigation Computer Science Food Services Hospitality Performing Arts Sports
Examples from Other Domains
Examples of Deliberate Practice in Healthcare
Life Support Training
Procedural Training http://laparoscopytraining.net/main/ https://cuschieri.dundee.ac.uk/courses/general-surgery/core-skills-laparoscopic-surgery-course
Anesthesia Crisis Resource Management Development of the ACRM Concept Anticipation and Planning Communication Leadership and Assertiveness Use of all available resources Anesthesia resident utilizing a cognitive aid during ACRM training Distribution of Workload & mobilization of help Re-evaluation of situations Use of all available information and cross checking of redundant data
Breaking Bad News
Medical Error Disclosure
Deliberate Practice in Healthcare Emergency Medicine Trauma Team Skills Medical Emergencies Highly Infectious Diseases High Risk Transports Intensive Care Urgent Admissions Medical Emergencies Unplanned Extubation Equipment Failure Operating Room Emergent Surgery Medical Emergency Massive Bleeding Equipment Failure Procedure Areas Medical Emergencies Oversedation Procedural Complications Equipment Failure
Systems-Probing In-Situ Simulation Periodic Performance Measurement Assessment of: System Performance Provider Performance Training Effectiveness Deliberate Practice: Booster Shot Mock Codes for Medical Emergencies Fire Drills for Life Safety
Practice What You Preach!