Using Quality Improvement Tools to Improve Interprofessional Education Performance Improvement Leadership Development Program University of Missouri – Columbia February 19, 2010

Team Members Carla Dyer, MD School of Medicine Deepti Vyas, PharmD UMKC School of Pharmacy Dena Higbee, MS Shelden Simulation Center Gretchen Gregory, MSN School of Nursing Sue Boren, PhD Health Management and Informatics Rusty McCulloh, MDBrown School of Medicine Team Sponsor: Linda Headrick, MD Coaches: Julie Brandt, PhD and Christina Vollrath, MSN

Interprofessional Education in Quality, Safety and Teamwork Focus: Patient safety, QI, and teamwork/communication Four week Curriculum: 7 hours total Began in 2003 Five disciplines: Medicine, Nursing, Respiratory Therapy, Health Administration, and Pharmacy

2010 Participants N=274

2008 Curriculum Introductory Lecture –Quality and safety basics –Local and national context Small Group Sessions—six hours –Interprofessional Roles –Modified root cause analysis –Brainstorming solutions; effort vs. yield Final Group Presentations

Background: 2008 Curriculum Post-course evaluations, on average, demonstrated a decrease in the perceived value of the interprofessional experience and its benefit to their future careers % Students who felt experience would benefit future career

Flow of the Curriculum in 2009 Introductory Lecture QI and Safety Basics Local and National Context National Safety Goals (1 hour) Small Group Sessions --Professional Roles --Case Discussion --Modified Root Cause Analysis --Brainstorming Solutions (3 hours) IP Simulation Emphasizing Teamwork and Safety ( 1 1/2 hours )

Simulation Scenario Semi-urgent setting 5-6 patients/group of students Variable acuity and ages Communication and teamwork issues National Patient Safety goals incorporated 8

2010 National Safety Goals National Patient Safety Goals 2010 Identify patients correctly Report critical results of tests Use medicine safely Prevent errors with invasive procedures Check patient meds Prevent falls Involve patients in their care Identify patient safety risks Prevent surgical site infections

N=171

Case Patient Safety Hazards* % recognized by students ** Patient 1 Inappropriate home meds 50% Verbal Order read back 79% Patient 2 Needle in bed 21% Wrong ID on arm band 25% Patient 3 Category X home meds 53% Patient 4 Drug Allergy 94% Allergy band incorrect 17% Patient 5 Unlocked bed 6% Wrong Dose Medication 50% 2009 Simulation Cases — Integrating Teamwork and Safety 11 **Based on 18 small groups

Aim Statement To increase interprofessional students’ recognition of selected patient safety threats by 25% from baseline by February 2010 through improved student preparation and modification of measurement process.

Why choose safety? MU SOM Key Characteristics of our graduates: “committed to improving care” MU SON Core Curriculum Concepts: Patient Safety Similar accreditation requirements for other programs Institution: Closely related to Quality, Service, People, and Finance

Flow Diagram-IPC 2009

Ishikawa Diagram

Stakeholders Students Faculty school of medicine, nursing, pharmacy and health professions Shelden Simulation Center Staff Office of Clinical Effectiveness Senior education leaders and Administrators at the University Hospital Patients– “downstream”

Effort vs. Yield -Revise simulation to decrease chaos. Changing the setting from the mass calamity to H1N1 coverage? To decrease student stress -Adding safety to introductory lecture -Clarify instructions to students -Clarify goals/learning objectives -Clarify roles of students -Clarify faculty schedules -Revise Sim Pre/Post Survey with Identifiers -Back up system for ensuring identifiers- faculty double check? -Create a leadership role in the scenario/debrief for HMI to integrate QI concepts in debrief - Revise observer checklist -Increasing number of faculty observers -Hire a research assistant to help with data abstraction - Introduction/Creation of a Safety Scenario -Create a faculty debrief guide -Improve audio/visual equipment -Involve statistician Low Impact High Impact Low Effort High Effort

Timeline of Events to Simulation

Focus Areas for Change Increased emphasis on safety in lecture and small group Measurement tools: –Increasing Faculty Observer Ratio –Simplifying Tool and increasing patient role Improving Audiovisual capabilities to capture encounters for future analysis Introduction of Environmental Assessment (based on Safety Seals)

Team Formation (10 minutes) Team Formation (10 minutes) Simulation (20 minutes) Simulation (20 minutes) Deliverable Report (5 minutes) Debrief Session 30 minutes Debrief Session 30 minutes A “Primer” in Safety 20 Simulation (20 minutes) Simulation (20 minutes) Deliverable Report (5 minutes) Deliverable Report (5 minutes) Debrief Session 30 minutes Debrief Session 30 minutes Team Formation (10 minutes) Team Formation (10 minutes) Environmental Assessment Exercise (1/2) Environmental Assessment Exercise (All)

Measuring Change Measured frequency of potential patient safety hazards recognized by students in the interprofessional simulation –Standardized patients –Faculty observers –Order sheets

Measuring Change Outcome Indicators –Potential safety hazards identified –Pre/Post Knowledge, Skills, Attitude survey –Course Evaluation Process Indicators –Qualitative feedback from students/faculty during dry runs –Qualitative feedback from surveys Students and Faculty

Safety Item % Detected 2009 % Detected 2010 % Detected 2010 with Primer Inappropriate home meds 50%42%17% Verbal Order Read 79%42%25% Needle in Bed 21%25%50% Wrong Arm Band 25%67% Category X home meds 53%8%42% Drug Allergy identified 94%92% Recognize incorrect arm band 17%67% Fall risk identified 6%42%50% Medication wrong dose 50%66%55% Preliminary Data Analysis—Based on 24 Groups of Students

Student Feedback Positives: --Enjoyed working in teams --Learned from the other students perspectives, especially from nurses Negatives: Needed more time Perceived value: (5=high) –As individual: 3.79 / 5 –As team: 4.13 / 5

Return on Investment Increased awareness of potential patient safety risks in future health care providers Thousands of dollars potential cost saving to institution –Use of gait belts –Recognition of medication errors –Effective handoffs Decreasing morbidity and mortality of our patients

Costs of Environmental Assessment Standardized patients: > $312 Faculty: 13 faculty and 2 grad students –2 hours / 4 hours –76.5 hrs Manpower Equipment (in kind) Simulation Center space (in kind) Faculty/staff time spent planning and implementing

Other Costs Increased Faculty Observers –24 additional faculty—three hours each Increased Equipment Cost (microphones) --$16,000

Challenges Cycle of improvement is long –Yearly Data collection –Large amounts data/very short time frame –Pressure to improve several areas at one time Logistics of coordination— –274 students --28 standardized patients –>50 faculty/staff Applying QI concepts to education

Lessons Learned Applying QI concepts to improving education is achievable; continuous improvement is critical to curricular success Using technology that supports QI principles Access to resources and mentoring increases success—coaches, sponsors, research faculty Balanced team is key to success—highly invested members; interprofessional representation

Interprofessional Curriculum 2010 Groups of Students: 24 Faculty/Staff: >50 Students in simulation: 274 Environmental safety room encounters: 404 Safety Issues recognized: over 5000 Future impact on their patients: priceless

Summary Continue work regarding effectiveness of “primer” to increase effectiveness of IP simulation Fine tune measurement tools Reinforce patient safety concepts in “real life” setting Emphasize value of interprofessional care and IP education

Questions??? Carla Dyer, University of Missouri School of Medicine Deepti Vyas, Pharm D University of Missouri-Kansas City School of Pharmacy Dena Higbee, MS Simulation Center Director, University of Missouri School of Medicine Gretchen University of Missouri Sinclair School of Nursing 32