1. Preparing to Teach Quality Improvement and Patient Safety
A Workshop in the Teach for UCSF Certificate Program
Henry Crevensten, MD Associate Professor of Clinical Medicine
San Francisco Veterans Affairs Medical Center
April 2016

2. Workshop Outline In the next two hours: Review learning objectives
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5/6/2018
Workshop Outline
In the next two hours:
Review learning objectives
Perform Introductions, goals
Review the Pre-test
Experiential session: groups will go over learning objectives and role model a student interaction. Then pair share about a QI/PS issue.
Project session: groups/pairs will discuss their QI/PS issues and how they might design a project.
Skills assessment and evaluation
Preparing to Teach Quality Improvement and Patient Safety
April 2016

3. [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
5/6/2018
Learning Objectives
By the end of this workshop, participants will be able to:
Define Quality Improvement and Patient Safety
Converse using terminology associated with QI/PS such as: quality gap, needs assessment, PDSA, LEAN, six-sigma
Define types of errors in medical practice
Describe how areas for improvement might be identified
Describe a framework for how QI/PS may be taught in a clinical setting
Preparing to Teach Quality Improvement and Patient Safety
April 2016

4. Introductions For each participant, tell us: Your name
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5/6/2018
Introductions
For each participant, tell us:
Your name
Department, specialty/discipline
Your interest in Quality Improvement and Patient Safety (QI/PS)
Any particular issues that have come up with trainees re: QI/PS
In the interest of time, we may select a just a few individuals or topics (some have responded on the pre-test)
Preparing to Teach Quality Improvement and Patient Safety
April 2016

5. Review Pre-Requisite Materials
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Review Pre-Requisite Materials
Readings: what was relevant / useful?
Preparing to Teach Quality Improvement and Patient Safety
April 2016

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QI/PS Terminology
Quality Improvement Systematic, data-guided activities designed to bring about immediate improvement in health care delivery in a particular setting
Patient Safety a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Its goal is to minimize the incidence and impact of, and maximize recovery from, adverse events
Quality Gap The difference between a known effective intervention and its actual implementation
Preparing to Teach Quality Improvement and Patient Safety
April 2016

7. [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
5/6/2018
QI/PS Terminology
Root Cause Analysis (RCA)  a technique used to identify trends and assess risk that can be used whenever human error is suspected with the understanding that system, rather than individual factors, are likely the cause of most problems
PDSA Cycle A cyclical process that uses small changes to systems before proceeding to larger interventions
Six Sigma A strategy to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. This involves measuring process outcomes, calculating a defect metric, and attempting to reduce process variation.
LEAN A strategy to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. This involves measuring process outcomes, calculating a defect metric, and attempting to reduce process variation.
Preparing to Teach Quality Improvement and Patient Safety
April 2016

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5/6/2018
Types of Error
Medical Error The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Ex: diagnostic error, procedural error
Adverse Event An injury caused by medical management rather than the patient’s medical issue
Error of Omission A procedure or intervention that failed to be undertaken lead to patient morbidity or mortality
Preventable Adverse Event An adverse event that was the result of an error or system design flaw
Preparing to Teach Quality Improvement and Patient Safety
April 2016

9. Experiential Session Group discussion:
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Experiential Session
Group discussion:
We can use a case from one of you or example case: You are provider in clinic precepting a student. The student is seeing a woman who is worried she might be pregnant and your plan is to send off a urine sample. The patient provides a urine sample but in the process of sending it to the lab notices that it is not labeled and that there are several other urine samples waiting. The student is concerned that the urine samples might get mixed up.
Discussion: - Loop this case back to the learning objectives: is this a quality or safety issue? what type of error is this? How might other errors of this type be identified? What is the quality gap? - discuss professionalism and bad/good role modeling
Preparing to Teach Quality Improvement and Patient Safety
April 2016

10. Experiential Session Small Group discussion:
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5/6/2018
Experiential Session
Small Group discussion:
Use the case/example you brought to the workshop, and discuss in pairs. Try to make this inter-professional if possible
Activity guide:
one participant acts as the student and one (or more) participants act as the instructor
student should bring up QI/PS issue (i.e. possibility for mislabeled specimen)
instructor should model professionalism in responding AND how to address the error with the patient (i.e. because the specimen might be mislabeled, we need a new specimen)
instructor should teach some aspect of QI/PS re: the incident (i.e. what type of error, is it a systems issue/provider issue)
instructor should go over framework for addressing the issue: process mapping, driver diagrams, incorporating other disciplines, LEAN/6-sigma
Preparing to Teach Quality Improvement and Patient Safety
April 2016

11. Presentation of Findings
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Presentation of Findings
Small Group discussion:
Groups/pairs should present a brief synopsis of their case, what they felt during the role play and what they learned, and any conclusions they can share with the rest of the group.
Preparing to Teach Quality Improvement and Patient Safety
April 2016

12. Wrap-Up Review learning objectives once more.
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Wrap-Up
Review learning objectives once more.
Have your goals been met?
Future workshops
Post Test
Preparing to Teach Quality Improvement and Patient Safety
April 2016

13. Additional Resources IHI
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Additional Resources
IHI
For additional readings, see suggested list from the UCSF Department of Medicine here:
Preparing to Teach Quality Improvement and Patient Safety
April 2016