Improving Patient Safety Jason Zigmont, PhD System Director Experiential Learning

Education does not equal learning Core Beliefs We believe that everyone participating in experiential learning activities is intelligent, well-trained, cares about doing their best and wants to improve. Adapted from the Center for Medical Simulation, Cambridge, MA The goal is to improve outcomes through experiential learning Education does not equal learning

Bloom’s Taxonomy

Learning Outcomes Model Improved Patient Outcomes The Individual Experiences Well-Tuned Learning Orientation Mental Models Analogical Reasoning Challenging Emotionally Charged Mistakes or Errors Improved Patient Outcomes Skilled Mentors Evidence Based Medicine Products and Protocols Environment

Improved Patient Outcomes The Individual Experiences HR – Hiring/Recruitment Orientation Licensure/Certs LMS? Patient Mix Simulation Standardized Patient Improved Patient Outcomes Standardized work Purchasing Six Sigma/Lean Policies New Equipment Research/EBM Posters/Marketing Six Sigma Practice Updates Checklists Joint Commission CMS, ODH, etc. HCAHPS SAQ, AOS RCAs Data Analysis Consultants Environment

Examples Handwashing OR to ICU Handoff TeamSTEPPS

Improving OR to ICU Handoff

TeamSTEPPS training Didactic vs Simulation Unit Based Training In-Situ Training Interdisciplinary Educator Team Nurse Physician Simulation Educator Scheduling… Measurement Process Measures Outcome Measures

Results of the Safety Attitudes Questionnaire Team Training N (%) No Team Training P value In this unit, we discuss ways to prevent errors from happening again 166 82% 127 63.5% 0.001 Mistakes have led to positive changes here 146 72% 119 59.5% 0.007 Staff are not afraid to ask questions when something does not seem right. 153 75.7% 115 57.5% Staff feel free to question the decision of actions of those with more authority. 122 60.4% 81 40.5% Staff will freely speak up if they see something that may negatively affect patient care. 167 82.7% 138 69% We are actively doing things to improve patient safety 185 91% 83% 0.01 We are given feedback about changes put into place based on event reports. 124 61% 99 49% 0.017 We are informed about errors that happen in this unit. 137 67.8% 102 51% When one area in this unit gets really busy, others help 159 78.7% 131 65.5% 0.003

Steps to Success Identify Problem Create Buy-In/Assess Readiness Value/Impact? Individual/Experience/Environment Create Buy-In/Assess Readiness Management Associates Identify the Change Team Define Implementation Plan Plan for Scheduling Sustainment…