Educating Professionals to Improve Health Care April 12, 2007 Leslie W. Hall, MD University of Missouri - Columbia

How Do We Educate for Quality? Key Concepts –Integrate material into curriculum to foster gradual increase in expertise –Connect to the care of patients –Assess outcomes –Offer interprofessional learning opportunities

Quality/Safety Education at University of Missouri Interprofessional undergraduate education in quality/safety 3 rd year med student safety conferences Achieving Competence Today (ACT) interprofessional curriculum Patient safety crew training Faculty Development IHI Health Professions Education Collaborative

Curriculum on Patient Safety & Quality Included in 2 nd year medical curriculum beginning in hours of instruction Didactic lectures & small group sessions Includes simulated root cause analysis of adverse event

Curriculum on Patient Safety & Quality 2006 Medical students Nursing students MHA students RT students

Interprofessional Curriculum 2006 Week 1 – Health Care Team Week 2 – Improving the Health Care System Week 3 – Patient Safety Week 4 – Root Cause Analysis

Course Evaluation Attitudes and self-reported behaviors around patient safety and quality assessed Knowledge – based exam Learner evaluations PreclinicalClinical Year 1 Year 2 Year 3 Year 4 Surveys completed: Curriculum administered

Educational Outcomes Majority of learners felt the interprofessional nature of the training added value Improvements in several patient safety attitudes noted post-training For medical students, by end of third year, some regression in patient safety attitudes occurred. 1 1 Madigosky, W. S., Headrick, L.A., Nelson, K.J., Cox, K.R., & Anderson, T. Changing and Sustaining Medical Student Knowledge, Skills, and Attitudes about Patient Safety and Medical Fallibility. Acad Med 2006; 81:

# # # = Significant Change (Clinical clerkships) 1=Very Uncomfortable, 3=Neutral, 5=Very Comfortable Madigosky W, et al. Academic Medicine; 2006

Adding a Safety “Booster” PreclinicalClinical Patient Safety Curriculum Patient Safety Boosters Year 1 Year 2 Year 3 Year 4 ½ of class – No booster ½ of class – Booster

1=Very Uncomfortable, 3=Neutral, 5=Very Comfortable Comfort in analyzing a case to find the cause of an error… p = 0.03

Interprofessional Curriculum 45 min intro lecture 6 Hours of small group work Final presentation 2007

Small Group Assignments Analyze a case in which an adverse outcome noted Map the process of care Brainstorm system factors contributing to care breakdown Consider system solutions to improve care Create an aim statement and choose a measurement for one proposed improvement Summarize analysis in a brief PowerPoint presentation

Value of IP Experience Percent of students who valued the interprofessional nature of experience

Perceived Benefit to Career Percent of students who felt experience would benefit future career

Potential Outcomes Measurements Learners’ reactions Modification of learners’ attitudes Learners’ acquisition of knowledge or skills Learners’ behavioral change Change in organizational practice Benefits to patients Most common outcomes measured for professional students

Summary of Lessons Learned (offered by students) Interdisciplinary cooperation does work! –Value of different professional perspectives Blaming doesn’t accomplish much “Obvious” problems aren’t always that Obvious There is a systematic way to change systems Don’t bring a knife to a gunfight

Summary of Lessons Learned (offered by students) Small changes in process flow can result in substantial benefits Some problems are simply beyond your ability to control (Macro Issues) There is no “I” in “TEAM”

Safety Competencies after IP Curriculum in Safety/Quality * At the p < 0.05 level

Post-training Differences – 2006 vs Understanding of Other Professions % of respondents from each discipline agreeing with statement: “Involvement of multiple health care disciplines for quality and safety training enhances understanding of different professional perspectives” p < 0.001p = NS

Post-training Differences – 2006 vs Understanding of Other Professions % of respondents from each discipline agreeing with statement: “Involvement of multiple health care disciplines for quality and safety training enhances understanding of different professional perspectives” p < 0.001

Post-training Differences – 2006 vs Teamwork Skill Development % of respondents from each discipline agreeing with statement: “Interprofessional learning is an effective strategy for teamwork skill development” p < 0.001p = NS

Post-training Differences – 2006 vs Teamwork Skill Development % of respondents from each discipline agreeing with statement: “Interprofessional learning is an effective strategy for teamwork skill development” p < 0.001

Message from IP Curriculum 2007 “Teaching” teamwork is neither engaging nor effective Creating an environment conducive to teamwork, and structuring a task that demands teamwork, is effective in development of team skills.

Achieving Competence Today (ACT) Curriculum in QI/patient safety, developed by Partnerships for Quality Education (PQE) : 12 schools used curriculum for interprofessional learners : 13 schools participated : 6 schools funded by RWJF

ACT 2007 Interprofessional model for experiential learning of quality improvement Four “integrated” residents Two attending physicians Two inpatient nurses One pharmacist One MSN student The Internal Med Team

ACT Timeline October November December January February March st Learning Session 2 nd Learning Session 3 rd Learning Session Project Presentations

ACT Timeline October November December January February March st Learning Session 2 nd Learning Session 3 rd Learning Session Project Presentations Ongoing Project Work and Experiential Learning

Learner Feedback Mean score of respondents to statement that the ACT experience helped them to develop greater teamwork skills or QI Skills 1 = Strongly disagree to 5 = Strongly agree

Learner Feedback Mean score of respondents to statement that the ACT experience helped them to understand the contributions made by other professionals and who felt the IP team was an important contributor to the value of ACT 1 = Strongly disagree to 5 = Strongly agree

Tracking Outcomes - ACT Outcomes being analyzed: –Educational: Learner evaluations –Attitudes regarding other professions –Knowledge assessment (QIKAT) –Clinical outcomes of projects

ACT – Lessons Learned Learning and patient care can be optimized simultaneously. Health care learners bring key insights into the process of improving care. Synergy is produced when we combine: –The idealism of health professionals in training with… –The realism of seasoned health care workers… –In the process of improving care

History of CRM Training at MU First class – May, 2003 Since then, appx 1200 trained Feedback very positive

Bringing CRM Concepts to Life at UMHC Med-Neuro ICU AM Pre-briefs Time Out Check-list for OR

Safety Tool Implementation Standardized nurse-to-nurse reports in ICUs Pre-catheterization checklists Post-cath handoffs from cath lab to floor

Safety Tool Implementation One minute nurse-physician phone huddle for Family Medicine admits

Educating for Quality – What Are the Barriers? Scheduling Diversity of students and needs Varying levels of clinical exposure Lack of emphasis on current licensing exams Lack of trained faculty Competing demands on clinical staff More opportunities than time

Faculty Development Faculty champions needed at all levels of curriculum to succeed Multiple concurrent efforts to advance faculty skills in quality/safety: –Revamping of M&M Conferences –Quality & Safety “Fellowships” –Quality Leadership Development Course planned for Fall, 2007 –IHI Health Professions Collaborative

Founded in 2002 Mission – “Committed to the creation of exemplary learning and care models that promote the improvement of health care through both discipline-specific and interprofessional learning experiences.” IHI Health Professions Education Collaborative

U Cincinnati U Connecticut U Chicago U Nebraska U Illinois U Indiana U Minnesota U Missouri U Louisville Case Western U Michigan State U Manitoba U Miami UNC Chapel Hill U South Florida U Tennessee Memphis Vanderbilt Univ Oregon U Dartmouth U Lehigh Valley Mayo Clinic IHI Health Professions Education Collaborative

Involves schools of medicine, nursing, health administration, pharmacy and health professions. Meets twice yearly for learning and sharing Engages national health care leaders to promote education about work of improvement IHI Health Professions Education Collaborative

How Do We Educate for Quality? Key Concepts –Integrate material into curriculum to foster gradual increase in expertise –Connect to the care of patients –Assess outcomes –Offer interprofessional learning opportunities