1. Improving Patient Safety
Jason Zigmont, PhD
System Director
Experiential Learning

3. 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

4. Bloom’s Taxonomy

5. 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

6. 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

7. Examples
Handwashing
OR to ICU Handoff
TeamSTEPPS

8. Improving OR to ICU Handoff

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

11. 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

12. 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…