Developing a Curriculum in Patient Safety and Quality Improvement for Your Clerkship Diane Levine, Wayne State University Allison Heacock, The Ohio State University Amy Shaheen, University of North Carolina Leigh Simmons, Harvard Medical School Licensing agreement purchased from https://www.cartoonstock.com/licenseagreement.asp
Objectives Be familiar with the core entrustable professional activities for entering residency (CEPAR) that relate to patient safety (PS) and quality improvement (QI). Identify 2 opportunities in the IM clerkship to integrate a PS or QI curriculum. Generate an idea and plan for a PS or QI initiative in your clerkship. Introductions Background EPAs, USMLE Barriers Best practices Preventing pitfalls Break out session Wrap up Agenda
Medical errors result in death 44,000 98,000 people die annually from medical errors Breast cancer 42,297 Motor vehicle accidents 43,458 Drug overdose deaths 43,982 AIDS 16,516 1999
US Health care system is flawed Does not provide consistent high quality healthcare to all people between the health care that we now have and the health care that we could have lies not just a gap, but a chasm. Called for reinvention of the healthcare system 2001 Scope of the problem Worse than we thought 400, 000 premature deaths associated with preventable harm/year 1 Serious harm 10 to 20 fold more common than lethal harm 1 Medical error the third leading cause of death 2 http://khongthe.com/wallpapers/nature/ tip of the iceberg 90839.jpg 1. James JT, J Patient Saf. 2013 Sep;9(3):122 8. doi: 10.1097/PTS.0b013e3182948a69 2. BMJ 2016;353:i2139 doi: 10.1136/bmj.i2139 (Published 3 May 2016)
Diagnostic errors persist in all settings and continue to harm New definition of error Failure to establish an accurate and timely explanation of the patient s health problems or communicate that explanation to the patient New model: Diagnosis as a process Calls for patients to be active participants in the dx process 2015 Training in PS/QI Integration of patient safety training across the continuum of medical education is essential to prevent medical errors. WHO and American Association of Medical Colleges (AAMC) endorse increased patient safety education during medical school.
Medical students have low knowledge of PS/QI 1 Only 25% of US and Canadian medical schools had explicit PS curricula. 2 With development of CEPAERs, incorporating PS education into medical school curricula will be mandatory to align with graduation requirements that include a focus on the culture of safety and improvement. 3 1. Blasiak RC, et. al.a cross sectional study of medical students knowledge of patient safety and quality improvement. N C Med J;75:15 20. 7 2. Alper E, et al. Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey. Acad Med 2009;84:1672 6. 3. Caverzagie KJ, et al. The Development of Entrustable Professional Activities for Internal Medicine Residency Training: A Report From the Education Redesign Committee of the Alliance for Academic Internal Medicine. Academic Medicine: April 2015 Volume 90 Issue 4 p 479 484 "Core Entrustable Professional Activities for Entering Residency (CEPAER) AAMC identified CEPAERs for all entering residents to perform without direct supervision on day one of residency. The ability to identify system failure and contribute to a culture of safety and improvement was identified as a critical CEPAER. 2014
2015 AAMC graduation questionnaire Understanding the Gap between Expectations and Residents Performance on Day 1: Baseline data from the Program Directors and Learners GQ 4 or 5 Program Directors 8. Give or receive a patient handover to transition care responsibility 13. Identify system failures and contribute to a culture of safety and improvement 77.3 54.7 67.1% 30.7%
Increasing focus on PS/QI PS principles Specific types of error Strategies to reduce errors E.g. Human factors engineering, error analysis tools, morbidity and mortality reviews, root cause analysis Improvement science principles Models of QI e.g. PDSA Quality measurement Strategies to improve QI Attributes of high quality health care
Percentage of programs that teach topic verses think it should be taught Teach Should teach Teach Infection control 55 70 Overview of PS 21 66 Handoffs and sign outs 48 81 Outpatient core measures 21 48 Medical safety 39 79 Serious event disclosure 20 58 Inpatient core measures 36 75 Understanding & managing clinical risk Effective Team Function 31 72 Health systems & impact of complexity on PS Understanding & Learning from Errors Safety issues in transitions of care Engaging with patients & care givers to maximize safety 32 68 Human factors engineering & its importance to PS 18 55 18 60 13 34 30 76 Never Events 10 43 24 70 P/Q implications of Using the EMR 10 60 Should teach J Patient Saf Volume 00, Number 00, Month 2015 Medical errors affect students 79% of 4th-year students 98% of senior residents had been personally involved in a medical error Virtual Mentor. September 2011, Volume 13, Number 9: 593-600
Challenges Scheduling Student on multiple sites Administrative Support Faculty development TIME Student time Faculty time Room availability and size Assessment Money Translation of others innovations due to variability in clerkship structure
Health Systems, Informatics & Quality Longitudinal Course HSIQ spans all 4 years of OSU COM LSI Curriculum LSI Curriculum has 3 Parts Part 1 18 months Clinical Foundations Part 2 12 months Clinical Applications Part 3 12 months Advanced Clinical Management Many different types of Teaching and Learning Methods which could be used during a clerkship. Focus on Quality and Patient Safety 21 Part 1: TLMs are spread throughout System Block Based Curriculum 1. IHI modules 2. Crew Resource Management Training 3. Disease focused Patient/Physician Panels Patient satisfaction Disease specific quality guidelines/metrics 4. Small group activities Case based Root Cause Analysis using Fishbone Case based High Value Care Discussions Inpatient verse outpatient treatment of DVT Likelihood Ratios 22
Part 2: Monthly small group sessions over year with Quality Coach 1. Introduction to QI / PS 2. High Value Care and Disease Specific Quality Lectures within clerkships 3. Application Work through mock QI project in flipped classroom Field Trip to experience QI on wards with Quality Coach Assignments Clinical problem identification and process/value stream mapping Event Report, Just Culture and Identification of appropriate follow up Problem statement generation, roles and intervention Quality Guideline and BPA Review 23 Part 3: Asynchronous Work 1. Finish IHI Modules for certificate Focus on High Value Care this year 2. Individual patient satisfaction assignment Data provided Literature review Problem Statement generation and Improvement Solution recommendation based on literature 3. Group High Value Care Project Work through DMAIC to complete QI project Group Project with mentor in specialty of choice Implement Intervention Data Analysis Present Poster at Patient Safety Fair 24
WSU Clerkship PS /QI Curriculum Online modules and cases IHI modules AHRQ M&M cases (3) of students choosing Inter professional Patient safety workshop Human factors engineering Error analysis using Gray s Anatomy episode High functioning systems, Just culture, and safety committee Medication safety and error reporting Process improvement science, process mapping, AIM statement, PDSA using an M&M case Patient related safety assignments Hand offs/sign outs Handoff observation Occurred face to face Included a written component Includes a verbal component Allowed the receiver to ask clarifying questions Occurred in a place with minimal distractions Occurred in a place with minimal interruptions Final brief reflection on safety of hand off I PASS handoff Reviewed with supervising intern Uploaded for faculty review
Post discharge phone call Do you understand why you were hospitalized, what your dx is, and what treatments you received? Are there any test results you are still waiting for? Who should you contact for those results? Has a provider reviewed your medications with you? Do you know which of your home medications to continue, what the current doses are, and which you should stop taking? Where and when are your follow up appointments? What are the warning signs of relapse or medication side affects you should look for? Who should you contact if you are having difficulties? Does your primary care physician know you were here and that you are leaving? What did you think of the care you received in the hospital? How did I do? What could I have done to improve the care that I provided? Near miss/adverse event report
Ambulatory care transition assignment Meet with preceptor to discuss transitions of care from the PCP s point of view. Does your preceptor see his or her patients when hospitalized? If no, whom are his or her patients admitted to? How does your provider find out if his or her patient has been admitted? Is your preceptor satisfied with the notification process? Ask your preceptor to rate the timeliness of receipt of the discharge summary. Ask your preceptor to rate the usefulness of discharge summaries. What would improve the usefulness of the discharge summaries received? Is your preceptor content with the overall safety of the transition of his or her patients from the inpatient to the outpatient setting? Has your preceptor tried to improve the process? Please rate the utility of this clinical learning exercise in increasing your understanding of safety issues related to transitions of care. Inpatient Clinical Year Critical incident, reporting, and reflection Lean Six Sigma introduction Outpatient 180 students/year over 3 Trimesters Care management assignment Preventative services Social determinants of Health Population health management
Population Health Management Looking at the health of a group (population) of individuals with a shared problem (or disease) Finding variance in measures of quality care due to social, environmental, cultural, educational, and financial reasons OR due to delivery of care issues Use QI techniques to improve outcomes for individuals within that population Culture of improvement and culture of blame Evolution of the Curriculum Iterative process Course structure change Curriculum change Experiential QI project Data and population health tools Practice engagement and faculty development
Curriculum 16 weeks IHI Open School: 8 basic certificate modules Four lectures Week 1: What is Population health Why Learn Quality Improvement Week 2: Driver Diagrams and AIM statements Week 4: Types of change with Effort/Yield Teams and stakeholders Process versus outcomes measures PDSAs with Peer and faculty feedback Week 10: Social determinants of health and variance Planning for sustainability QI teams and leadership Reached out to health system leadership Expressed desire for bidirectional value Partner with QI leaders, coaches, practice managers Have the QI experts work with the students Explain leadership expectations for students on projects
Choosing a project Alignment with Practice goals Importance Educational value Data Student interest Practice Alignment What is practice being judged on? o Institutional Goals o PCIC Goals o Clinic Goals o PCMH and MU o NCQA Recognition What processes aren t working in your practice? o Brainstorming o Multi voting o Near misses
Choosing a project Small enough to be doable in the time frame Examples of 4 week, 8 week, 16 week projects Choose project and mentor prior to student arrival Faculty Development Learn and then mentor Help your student dinners Work on Driver diagrams, Aim statements, PDSAs, together Discuss practice alignment & educational value Poster session at the end of 16 weeks to show off projects AND learn from each otherpreceptors are judges
Breakout Use EPAs or USMLE blueprint to identify which objectives you will introduce into your clerkship. What is your goal? Frame as an AIM statement (see worksheet) Develop your idea. What, When, Where, How Use worksheet to identify existing opportunities, resources, and collaborators What barriers might you face? How will you handle? How will you assess? Debrief and Wrap up Integrating PS/QI is challenging but has successfully been accomplished at different institutions with different clerkship structures and limited resources. YOU CAN introduce a PS/QI into your clerkship. Start small. Learn with your students. Celebrate your successes!