Thomas H. Gallagher, MD University of Washington

 Curricular deficiencies ◦ Curriculum focused mostly on history-taking  Ignores MD communication with other healthcare providers ◦ Communication training insufficiently intense ◦ Failure to recognize communication as skill  “Bedside manner”--can’t be taught (or measured)  Communication discounted as “soft,” “touchy-feely”  Little opportunity to practice, get feedback  Learners struggle to apply general skills to specific situations  Culture of medicine values technical proficiency over interpersonal skills

 Patient satisfaction  Ethics, professionalism  Complaints, malpractice claims  Health outcomes  Safety culture, transparency; disclosure and reporting of adverse events and errors

 Allows learner to practice complex communication skills, receive feedback in safe environment  Allows learners to confront communication dilemmas that are important but uncommon  Types of simulations ◦ (role plays, interactive computer cases, rehearsal) ◦ Standardized patients

 Standardized patients are individuals trained to: ◦ Present consistent scenario ◦ Be reliable observers of behavior ◦ Offer feedback  Extensively validated as assessment tool ◦ Now used in high-stakes certifying exams  Increasingly used as research methodology

 Recognize communication as a skill ◦ Can be learned, practiced, improved, discussed with colleagues ◦ Worthy of learner’s attention  Need cases that take learners out of their comfort zone without overwhelming them  Ability to practice, receive feedback on key skills

 Creating high-fidelity cases  Identifying key observable skills ◦ Communication incredibly complex task  Easy for learners to express socially desirable behaviors

 Designed to assess whether simulation improves healthcare workers’ knowledge, attitudes, and skills in two areas: 1.Team communication about error 2.Error disclosure to patient

 Growing experimentation with disclosure approaches  New standards  State laws re disclosure, apology  Increased emphasis on transparency in healthcare generally

 Many harmful errors not disclosed to patients  When disclosure does take place, it often falls short of meeting patient/family expectations

 What do team members owe one another? ◦ Absolute loyalty? ◦ Falling on sword?  What are roles of different team members in the disclosure process?

 Practicing physicians & nurses ◦ 40 nurse-physician teams (½ surgeons and OR nurses; ½ medical physicians and nurses) ◦ 40 control group teams  Actors ◦ 1 standardized team member per team  Plays role of hospital administrator  Helps team progress through simulation, think out loud ◦ 1 standardized patient per case, 2 cases per simulation  12 Risk Manager “Coaches”

Error Disclosure Simulation 1 Coaching Error Disclosure Simulation 2 Coaching

 1. Team discussion and planning for disclosure ◦ Team discusses what happened, responsibility for the error, and plan what they will disclose to the patient  2. Team Error Disclosure ◦ The team discloses the error to a standardized patient

 Acknowledge error occurred  Offer facts regarding error  Solicit and respect team members’ views of what happened  Negotiate differences respectfully  Avoid blaming; respond appropriately to blaming behavior  Respond empathetically to team members’ emotions

 Plan roles for disclosure discussion  Advocate for full disclosure  Identify core content of full disclosure ◦ Explicit statement that error occurred ◦ What happened, implications for patient health ◦ Why it happened ◦ How will recurrences be prevented  Explicit apology  Anticipate patient questions and emotions and plan team responses  Negotiate differences respectfully

 Team member introductions  Empathetic disclosure of core content ◦ Ask patient what they know about error ◦ Explicitly state that error occurred ◦ Implications for patient health ◦ Solicit patient questions, respond truthfully  Make explicit apology  Explain how recurrences will be prevented  Avoid blaming team members; resist patient’s attempts to fix blame  Empathetic communication with patient  Plan for future meetings

Team Anticipate patient reactions; planning response Solicit multiple views Respond to team member emotions Disclosure Early Explicit Apology Respond to patient emotion Empathetic presentation of core content

 Web assessment ◦ Case-based: 2 cases, 2 different team approaches ◦ Knowledge, skills, attitudes assessed tied to coaching priorities and simulations ◦ Participants complete web-based assessment pre and post training ◦ Controls take web assessment (pre and post) but without the training  Other data sources ◦ Videos of simulations ◦ Debriefing interviews with participants

 Patient admitted to ICU with recurrent seizures  Given loading dose of Dilantin (300 TID), then switched to 300 QD  Physician writing transfer orders to floor mistakenly writes for larger loading dose  Error not noticed by nursing, pharmacy  Patient falls, hits head; Dilantin level 29. Head CT normal  Patient thinks another seizure caused her fall

 Simulation design ◦ Maximizing learning potential of simulation  Skilled coach essential ◦ Maximizing case fidelity  Nature of events  Choice of case  Actor training  Interprofessional interaction  Role of standardized team member in simulation  Especially important in engaging “Silent team member”  Simulation implementation  Managing logistics of recruitment, scheduling a major undertaking  Coordinate schedules of two clinically active subjects, 3 actors, risk manager coach, at least two team members for each session

 Immersive simulation around communication possible outside simulation center ◦ Even senior clinicians found experience educational  Providing expert coaching, feedback is key  Logical challenges can be substantial  Multiple opportunities for communication simulations on other interprofessional topics

 Thomas Gallagher (PI) – Medicine  Lynne Robins-Medical Education  Sarah Shannon – Nursing  Peggy Odegard – Pharmacy  Sara Kim – Medical Education  Doug Brock – Medical Education  Carolyn Prouty – Project Manager  Odawni Palmer – Support Staff  Andrew Wright-Surgery