Patient safety

Residents

Safety Science as Second Nature: Training Residents to Use Best Practices Instinctively to Keep Patients Safe By Robert Dressier, MD, MBA, Loretta Consiglio-Ward, MSN. Carol Moore, MS, RN, FNP, BC. Margot Savoy, MD. MPH. FAAFP. Brian Aboff. MD. MMM. FACP. Tabassum Salam, MD. FACP. Janine Jordan. MD. FACP. and Virginia U. Collier. MD. MACP

in this article...

Explore Christiana Care Health System's multi- pronged approach to training residents about quality improvement and patient safety.

ACPE is pleased to announce the selection of Christiana

Care Health System in Newark, DE, as the winner of the

Leape Ahead Award that recognizes medical schools and

teaching hospitals making extraordinary strides in promot-

ing a culture of leadership, professionalism, communication

and teamwork among medical students and residents. The

winning program is Christiana Care's multipronged aca-

demic training program for quality improvement and patient

safety that seeks to incorporate the principles of patient

safety and the importance of teamwork into the "adaptive

unconscious" of resident and medical student learners.

In 2010, the Lucian Leape Institute of the National Patient Safety Foundation (NPSF) released a seminal report, "Unmet Needs: Teaching Physicians to Provide Safe Patient Care."

The report concluded that "Health care delivery con- tinues to be unsafe...[and] that substantive improvements In patient safety will be difficult to achieve without major medical education reform at the medical school and resi- dency training program levels.'"

Working collaboratively, the Christiana Care Health System departments of medicine, family and community medicine, emergency medicine, nursing, patient safety and quality, the Learning Institute, the Value Institute, aca- demic affairs, organizational excellence, and the Center for Transforming Leadership have used a multipronged approach to training residents, medical students and faculty that combines didactic and experiential learning in patient safety and interdisciplinary team-based care. In doing so, we have taken steps to address the fundamental deficit identified in the NPSF report.

Background Christiana Care is a top-rated, independent academic

medical center combining the best of community and aca- demic hospital settings. Our two-hospital system ranks 17th in the nation for hospital admissions and has earned nation- al recognition for providing safe and effective patient care.

The institution is a major teaching affiliate and the Delaware Branch Campus of Jefferson Medical College in Philadelphia, PA. More than 250 medical students at all levels rotate through our departments every year. We offer residency training in 18 specialties. The departments of medicine, family medicine and emergency medicine train 126 residents annually.

The Learning Institute, inaugurated in 2011, supports Christiana Care's robust culture of learning through cen- ters for educator development, evaluation and simulation education, and transforming leadership. A critical resource is our 9,280-square-foot, state-of-the-art Virtual Education and Simulation Training (VEST) Center.

All aspects of Christiana Care are guided by its overarching vision, the Christiana Care Way:

We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value.

What we hope to accomplish The goal of our approach to teaching patient safety and

quality for residents is that the principles of patient safety and team-based care will be inculcated so deeply that residents will instinctively follow best practices without even knowing they are doing so.

In essence, our approach reflects an institutional priority to build a culture of learning that emphasizes patient safety, professionalism, collaboration, transparency and the importance of the individual learner, all of which were iterated in NPSF recommendations.

Our efforts are part of a systemwide commitment to promote these values, to encourage teamwork and leadership, and to enhance faculty capabilities in teaching

66 PEJ MAY-JUNE/2014

residents and students how to iden- tify, report and resolve patient safety issues.

Our objectives are four-fold:

1. Teach principles of patient safety and quality to faculty, residents and students.

2. Use simulation in procedural and team-based interdisciplinary edu- cation for residents, students and post-graduate nurses.

3. Promote interdisciplinary, project- based experiential education for residents in patient safety and quality.

4. Develop and support current and future resident leadership capabili- ties and opportunities.

Our intent is that our residents will become "bright spots" who will fully incorporate this knowledge into their future careers and will serve to advance, one resident at a time, the critically important concepts imbed- ded in the science of patient safety.

Teaching for safety and quality

Our multipronged approach grew from a systcmwide initiative to embed the culture of safety into our daily work.

By marrying cross-disciplinary talents with varied educational tech- niques, we can more fully inculcate didactic and team-based experiential learning about patient safety and quality into faculty teaching and faculty, resident and student patient care activities.

We carefully track the outcomes of each component of our efforts. Pre- and post- surveys from each initiative have demonstrated their effectiveness.

Here are the major ongoing ini- tiatives involving medical students, residents, fellows and faculty.

Christiana Care is a top-rated, independent academic medical center combining the best of community and academic hospital settings. Our two-hospital system ranks 17th in the nation for hospital admissions and has earned national recognition for providing safe and effective patient care.

1. Train the trainer initiative. Since the majority of our faculty had no formal training in patient safety, we developed a nine-month didac- tic and project-based curriculum in advanced quality and safety improvement science for faculty. Now in its second year, 23 faculty members from nine different departments have enrolled and/or completed the course.

2. Administrative fellowship in patient safety and quality. For the past three years, one fellow per year has participated in experi- ential value-based projects, such as appropriate use of telemetry in hospitalized teaching patients.

3. Enhanced residency curriculum. There has been a deliberate effort to expand the patient safety con- versation in medicine with our

three administrative fellows leading many of these efforts:

• Patient safety discussions at morning report where resi- dents and attending physicians highlight opportunities for system improvement and/or potential patient safety risks.

• Systems-based conferences that bring residents and fac- ulty from medicine and other departments together monthly to discuss complex cases that would benefit from improved care systems.

• Core lectures on patient safety and quality.

• A structured "good catch" program with tiered rewards for residents who file "good catch" reports.

ACPE.ORG 67

4. A practice leadership quality improvement experience in family and community medicine trains residents to be leaders of fam- ily medicine clinical practice care teams and to tackle continuous quality improvement projects. Resident-led projects have included immunization reconciliation to reduce vaccination error and improving patient access through more efficient physician scheduling.

5. Simulation. To practice difficult patient management scenarios and enhance inter-professional communication skills, residents, students and student nurses col- laborate in staged patient care scenarios with guidance from physician and nurse educators.^

Scenario 1

In 2012,69 learners participated in simulated alcohol withdrawal sce- narios. Post simulation, 94 percent noted an improvement in their ability to identify alcohol withdrawal com- pared with 44 percent presimulation, and team behavior analysis scores improved from 55 percent presimula- tion to 81 percent post simulation.

Scenario 2

In 2013, 29 inter-professional pairs of nursing students and resi- dents participated in scenarios for in-hospital acute pain management. After training, the degree of confi- dence in management of acute pain improved at the highest response level (strongly agree) from 7 percent to 23 percent, and at the lowest (dis- agree) falling from 28.1 percent to 12.5 percent. Attitudes toward inter- professional education also improved among 84 percent of respondents.

We also use simulation to teach team-based competencies such as teamwork during rapid responses and procedural competencies. Before performing invasive procedures on

patients, residents undergo standard- ized training using online education- al modules and hands-on sessions in the lab conducted by trained precep- tors.

Before training, residents had a 50 percent first-attempt pass rate for central lines using a validated checklist. After training the pass rate jumped to 100 percent.

Similarly, resident rapid response clinical and team-based competen- cies improved from 50 percent to 70 percent after simulation training, and resident confidence scores increased from 3.44 to 4.13 on a 5-point Likert scale. In total, 89 percent of residents reported that simulation training increased their understanding of rapid response team operations.

6. Experiential, project-based per- formance improvement education. Residents are required to partici- pate in a 12-week, inter-profes- sional/interdepartmental course, initially launched in 2003-2004 with the support of the Robert Wood Johnson Foundation, and subsequently enhanced and sus- tained at our organization.

This course. Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems and Safety, leverages Institute for Healthcare Improvement (IHI) Open School modules and internal subject matter expert faculty, and empha- sizes interdisciplinary, team-based, learner-generated performance improvement projects.

At the end of the course, teams present their projects to peers, proj- ect stakeholders and senior leader- ship before handing them over to system champions. This course repre- sents the earliest effort at Christiana Care to incorporate team-based didactic and experiential learning about patient safety and quality into an interdisciplinary curriculum.

Since 2004,406 learners have participated in ACT courses and have

produced 65 rapid cycle performance improvement projects, many of which resulted in system-wide improvements.

Residents and students also par- ticipate in inter-professional patient hand-offs in the emergency room and on inpatient units. In fiscal years 2012 and 2013, resident-led teams (100 percent) used an admission checklist that lists 14 best practice processes and plans of care to admit 643 patients.

When these synchronized admis- sion teams admitted patients, length of stay (LOS) dropped from 3.54 days to 2.98 days, and there were approxi- mately 50 percent fewer rapid response team calls within the first 24 hours compared with other admissions.

7. Resident leadership elective. In the past year, academic affairs collaborated on a two-week, multi- departmental, intensive elective that combined didactic and inter- active lectures, field trips, discus- sions with system and state-level leaders and ongoing post-course support. In its inaugural year, 23 out of 24 participating residents and fellows "strongly agreed" that they learned new knowledge and skills and "strongly agreed" that the elective will improve career opportunities.

Overall outcomes The use of interdisciplinary,

team-based projects in combina- tion with a didactic curriculum has been effective in achieving residents' awareness of Christiana Care efforts to enhance patient safety and quality.

Among residents responding in 2013 to Accreditation Council for Craduate Medical Education surveys, 97 percent of internal medicine and 100 percent of emergency medicine residents indicated that Christiana Care has a culture that emphasizes the importance of patient safety.

68 PEJ MAY-JUNE/2014

Looking forward Our experience has shown us

that interdepartmental didactic and experiential curricula to teach faculty and residents about patient safety and quality can be developed using internal instructional resources with support from external professional organizations such as the IHI.

Resident participation and leadership in innovative health care delivery projects are useful vehicles to impart important knowledge about aspects of patient safety and quality.

As a result of our multipronged approach, our residents have not only achieved a high degree of aware- ness of Christiana Care's culture of patient safety, but they are better equipped to incorporate these skills into their daily work, not only during their residencies, but hopefully for the duration of their careers.

Acknowledgements: We are grateful for our

residents and fellows, essential to the refine-

ment of our curriculum, and for the work

of our many colleagues who shared their

expertise in the development, teaching and

assessment of the various aspects of our pro-

gram. Thanks to Lois Torgerson, MS, for her

assistance in preparing this manuscript.

Robert M. Dressier, MD, MBA, is the vice chair of

medicine and director of

patient safety and quality

for medicine at Christiana

Care Health System in

Delaware.

Loretta Consiglio-Ward is quality and safety educa-

tion specialist at Christiana

Care Health System in

Delaware.

Carol Moore, MS, RN,

APRN-BC, is quality and

safety education specialist

at Christiana Care Health

System in Delaware.

M a r g o t Savoy, M D ,

M P H , FAAFP, is medical

director of the family medi-

cal centers at Christiana

Care Health System in

Delaware.

Brian M. Aboff, MD, FACP, is program director

of internal medicine resi-

dency at Christiana Care

Health System in Delaware.

Tabassum Salam, MD, FACP, is associate program

director - curriculum at

Christiana Care Health

System in Delaware.

References

1. Unmet Needs: Teaching Physicians Safe Patient Care. National Patient Safety Foundation, Boston, MA. 2010.

2. Tabassum S, Collins M, Baker AM. All the World's a Stage: Integrating Theater and Medicine for Interprofessional Team Building in Physician and Nurse Residency Programs. The Ochsner Journal: Winter 2012, Vol. 12, No. 4, pp. 359-362.

Janine Jordan, MD, is director of care transitions

and resource management

for Christiana Care Health

System.

Virginia U. Collier, MD, MACP, i s t h e H u g h R .

Sharpjr. chair of medicine

at Christiana Care Health

System in Delaware.

ACPE.ORG 69

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