Rhonda A. Sparks, M.D.

Medical Director Clinical Skills Education and Testing Center

University of Oklahoma – College of Medicine

 Why is the time right for change in clinical education?

 What are the obstacles to instituting multidisciplinary simulation?

 How can we design the most effective multidisciplinary simulation activities?



Changes in Clinical Education

 Curriculum Reform  Competency Evaluation 

Patient Safety

 Demand for Improved Safety and Quality  Healthcare Reform  Increased Access and Cost Containment

 Revolutions in Medical Education    Flexner Report – 1910  Quackery to Credible Scientists Case Western Reserve University – 1952   Increased Integration of BS and CS Increased Clinical Relevance McMaster University – 1969    Social Unrest/Time of Experimentation…Educationally!

Canadian Universal Healthcare Clinician Shortage

 95% of Medical Schools are Expanding Class Size  The Nurse Education, Expansion, and Development Act of 2009  Macy Foundation 2008 - Urgent Need to Bring Medical Education into Better Alignment with Societal Needs    Foster greater inter-professional teamwork and collaboration Increase curricular focus on knowledge and skills for improving the quality and safety of patient care Foster inter-professional, team based education and patient care

 Theory and Practice of Teams and Teamwork  Knowledge   Skills Attitudes  Miller’s Pyramid of Competency     Knows - information Knows How – to use information Shows – how to use information ***** Does – performs in clinical setting

The 20 th Century Physician

      Accumulate Knowledge Individual Scholarly Work Autonomous Cooperative Individual Achievements Solo Expert

The 21 st Century Physician

 Acquire and Use Knowledge  Interdisciplinary Research  Collaborative  Share Accountability  Interdisciplinary Teams  Coordination of Care

 1999 – Institute of Medicine Report “To Err is Human: Building a Safer Health System”  Medical Error 8 th Leading Cause of Death      99,000 Deaths Annually Non-technical Errors System Errors 7% Inpatients subjected to a medical error Cost – 8 to 29 Billion Annually

 1999 - AHRQ directed by the Healthcare Research and Quality Act to:    Identify the causes of preventable health care errors and patient injury in health care delivery Develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety Disseminate effective strategies throughout the health care industry

 2003 – JCAHO – National Patient Safety Goals    3 of 7 Goals Non-technical skills Instituted Safety Practices Clinical Effectiveness of “Safe Practices”  2004 – The 100K Lives Campaign     Rapid Response Teams AMI Guidelines Prevent Adverse Drug Events (ADE) Prevent Central Line Infections  2005 – Resident Work Hour Limits

 2005 – Patient Safety and Quality Improvement Act  Patient Safety Organizations (PSO)   Limits Use of Reported Adverse Event Information Established a Network of Patient Safety Databases (NPSD)  2005 – TeamSTEPPS  2006 – Keystone Project  Team Approach to Decreasing Line Infections

 2006 – AHRQ – Improving Patient Safety through Simulation Research Grants  2008 – CDC Data Suggests that HAIs effect 2 million patients  2008 – Project RED “Re-Engineered Hospital Discharge Program”  2009 – PSOs Refined and Consumer Avenue for Reporting Developed



H.R. 3590 - Patient Protection and Affordable Care Act 3/23/2010

  Expand health care coverage to 31 million currently uninsured Americans through a combination of cost controls, subsidies and mandates.

It is estimated to cost $848 billion over a 10 year period, but would be fully offset by new taxes and revenues and would actually reduce the deficit by $131 billion over the same period  What will this look like?

 Increase Access - Yes

 Beginning in October 2012, non-rural acute care hospitals that meet or exceed performance standards established by the Secretary of Health and Human Services (HHS) for at least five measures will receive higher Medicare payments from a pool of money collected from all hospitals  Starting in October 2012, hospitals with high readmission rates for patients with these conditions will have their Medicare payments reduced

 What we know  Microsystems over a define period of time  What we don’t know  Long-term outcomes 17

2.4

Length of ICU Stay After Team Training 2.2

2 1.8

50 % R ed ucti on 1.6

1.4

1.2

1 June July August Sept Oct Nov Dec Jan Feb March April May (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine Adverse Outcomes 18 16 2 0 6 4 14 12 10 8 OR Teamwork Climate and Postoperative Sepsis Rates

(per 1000 discharges)

Group Mean AHRQ National Average Low Teamwork Climate Mid Teamwork Climate High Teamwork Climate Teamwork Climate Based on Safety Attitudes Questionnaire Low



High (Sexton, 2006) Johns Hopkins 50% Reduction 10 5 0 25 20 15 Indemnity Experience Pre-Teamwork Training Post-Teamwork Training 20 50% Reduction 11 Malpractice Claims, Suits, and Observations (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN

18

 Change is Hard  Culture of “Silos”  Culture of “Innovation”  Lack of Transparency  Error reporting systems

 Utilize Group Training for Tasks  Define Our Teams  “Micro-environments”  Use Patient Safety Data to Drive Team Training Initiatives  Clearly Define Team Objectives  Use Established Team Training Methodology  TeamSTEPPS

 Department of Defense – DoD and AHRQ  Research Based and Field Tested (MHS)  Four Core Competency Areas     Team Leadership Situation Monitoring Mutual Support Communication

Eight Steps of Change

Team Strategies & Tools to Enhance Performance & Patient Safety

John Kotter

Allan S. Frankel, M.D.

Tulsa

Y’all come back now, ya hear?

Oklahoma City

Tulsa High Rise

OKC High Rise

Yacht on Grand Lake

Yacht on Lake Hefner - OKC

Tulsa Speed Boat

OKC Speed Boat

Typical Tulsa Swimming Pool

Typical OKC Swimming Pool

      Neville AJ, Norman GR. PBL in the Undergraduate MD Program at McMaster University: Three Iterations in Three Decades. Acad Med. 2007;82:370-374 Morrison G, et al. Team Training of Medical Studnets in the 21 st Century:Would Flexner Approve? Acad Med. 2010;85:254-259 Hamman WR. The Complexity of team training: what we have learned from aviation and its applications to medicine. QualSaf Health Care. 2004;13:i72-i79 Issenberg B, et al. Features and uses of high-fidelity medical simulation that lead to effective learning: a BEME Systematic Review. Medical Teacher. 2005;27:10-28 Morey JC. Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training:Evaluation Results of the MedTeams Project. Health Services Research. 2002;37:1553-1581 Nishisaki A, et al. Does Simulation Improve Patient Safety?: Self-efficacy, Competence, Operational Performance, and Patient Safety. Anesthesiology Clinics. 2007;25:225-236

       Miller G. The Assessment of Clinical Skills/Competence/Performance. Acad Med. 199 ;63: 563-567 Beckett M, Fussum D, et al. A Review of Current State Level Adverse Event Reporting Practices: Toward National Standards. AHRQ Report. 2007 LeapeL,Berwick DM. Five Years After to Err is Human: What have We Learned?. JAMA. 2005;293:2384-2390 The Patient Safety and Quality Improvement Act of 2005. Overview, June 2008. Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/qual Institute of Medicine (IOM).(2000). To err is human: Building a safer health system. L. T. Kohn, J. M. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academy Press Clancy CM, Tornberg D. TeamSTEPPS:IntegratingTeamwork Principles into Healthcare Practice. Patient Safety and Quality Healthcare. 2006 http://www.psqh.com