“Quality and Patient
Safety 2008-09”
A UF COM Educational Initiative
Curriculum Committee
June 10, 2008
UF COM Patient Safety Task Force
 Lou Ann Cooper
 Rick Davidson
 Marvin Dewar
 Tim Flynn
 Laura Gruber
 Nancy Hardt
 Heather Harrell
 Omayra Marrero, MS-3
 Eric Rosenberg
 Amy Stevens
 Bob Wears
Themes
 Why develop a UF Patient Safety/Quality
Improvement Course…
• Now?
• For medical students?
 How did we go about drafting a curriculum?
 What are we proposing to do in each year –
and especially the 3rd year?
Why a Patient Safety/QI
Course for Students… now?
 Institutional momentum
• Ferrero Case
• Influence of faculty trained in QI/safety to
organize existing “bits and pieces”
 Organizational momentum
• AAMC – “improving patient safety is our
responsibility” (2004)
• NSPF (VA), AMA, ACGME
 National momentum
• CMS (“non-payment for non-performance/error”)
(some) Preliminary Efforts
 Sub-I Introductory Lecture and Observed
Case reporting (Heather Harrell, Eric
Rosenberg)
 EBM, Clerkship Introductory talks
(Rosenberg)
 Simulation Exercises (Armstrong, others)
Students “get it”
 “my patient came into the ED for presyncope; she
was getting Clonidine instead of “Klonipin” for her
anxiety”
 “my patient refused to go to radiology to get a
dialysis catheter placed; she was right to refuse -they had come for the wrong patient”
 “my patient told the team he was on the ‘same med
list’ as before… we didn’t review his medications
with him, we just recopied the old ones. He didn’t tell
us that his cholesterol medication had been
changed because he’d had rhabdomyolysis
recently… he again developed rhabdomyolysis while
on our service.”
Table 2. Perceived Importance of Proposed Causes for Adverse Events by
Student Discipline and Occasion.
Medical
Nursing (ABN)
Potential Cause of Medical Error
Pre
(p1)
Post
(p2)
p2-p1
Pre
(p1)
Post
(p2)
p2-p1
Overwork, stress, or fatigue on the part of
health professionals.
83.0
81.1
-1.9
74.1
59.3
-14.8
Failure of health professionals to work
together or communicate as part of a team.
64.2
69.8
5.7
44.4
37.0
-7.4
Understaffing of nurses in hospitals.
54.7
58.5
3.8
59.3
85.2
25.9*
Complexity of medical care.
43.4
30.2
-13.2
3.7
7.4
3.7
Insufficient time spent by doctors with
patients.
32.1
13.2 -18.9* 18.5
14.8
-3.7
Mistakes made by health professionals.
11.3
17.0
5.7
29.6
29.6
0.0
Poor training of health professionals.
7.5
1.9
-5.7
33.3
44.4
11.1
Poor supervision of health professionals.
1.9
1.9
0.0
3.8
0.0
-3.8
Uncaring health professionals.
1.9
0.0
-1.9
14.8
0.0
-14.8*
Poor handwriting by health professionals.
0.0
26.4
26.4*
18.5
22.2
3.7
.
Rosenberg, Cooper, Harrell, Menzel, Davidson (2008).
How did we go about drafting
a curriculum?
 8 Task Force Meetings: 12/07 – 5/08
 Surveyed published curricula
 Agreed on multi-year course integrated into
existing courses, but with distinct identity,
course directors
 Developed goals and objectives for each year
 Developed specific activities, options, and
themes for each year
Curriculum Goals: MS-1, MS-2
 Understand patient safety fundamentals including
the importance of an organizational culture that
promotes teamwork and safety, the public focus on
patient safety and adverse events, patient safety
terminology, and the human impact of adverse
events.
 Understand key aspects of methods to improve
patient safety and clinical quality as well as the
interaction between quality improvement efforts in
the medical malpractice tort system.
Curriculum Goals: MS-3
 Recognize and describe adverse event and
patient safety challenges unique to different
specialties and be able to apply strategies
and techniques designed to prevent or
mitigate those events.
Objectives: MS-3
 Identify and analyze common clinical adverse
events.
 Differentiate the impact of system failures and
human factors in the development of adverse
events and discuss approaches to preventing and
mitigating those events.
 Identify and describe system level improvements
which will improve patient safety and reduce
adverse events.
 Identify and be able to apply individual strategies
and approaches to improve patient safety and
reduce adverse events.
Curriculum Goals: MS-4
 Demonstrate competence in key patient
safety and quality improvement skills and
conduct an individual project related to
patient safety in the student’s specialty
choice area.
Patient safety curriculum to be incorporated
longitudinally into existing curriculum
Pre-orientation
Pre-orientation
assigned
readings on the
importance of
developing a
culture of safety
in health care
Year 1
• Quality and Safety Grand
Rounds on the impact of
medical errors on
patients and families
• Culture of safety
workshop at the
beginning of the EPC
course to discuss the preorientation reading
materials and follow up
on the discussion
questions handed out at
the first Quality and
Safety Grand Rounds
• Epidemiology of medical
error online module
• Online module on
national quality
improvement and patient
safety organizations
• Quality and Safety Grand
Rounds on the impact of
medical errors on
providers
Year 2
• QI/PI workshops (at least two)
on the application of
common performance
improvement techniques to a
standard problem, including
problem statement, process
mapping and solution
generation.
• Multidisciplinary panel
discussion on teamwork and
communication issues.
• Communication workshop that
includes a focus on difficult
communications and roleplaying around the use of
structures communications
(i.e., SBAR).
• Panel discussion on safety
lessons from other disciplines
• Lecture on the effectiveness
(or lack of effectiveness) of the
medical malpractice system as
a patient safety tool.
• Portfolio reflections on quality
and safety observations during
the preceptorship experience.
Year 3
• Pre-reading (examples of•
residents, medical
students who have
successfully completed •
patient safety
interventions)
• Clerkship CPCs devoted •
to quality and safety
topics
• Workshops on QI
•
methods
• Over time develop a
•
threaded hypothetical
case to be used for
•
quality CPC across
clerkships
• Student reflection on
errors seen on clerkship •
with course
directors/quality directors
• Student maintains
registry of opportunities
for clinical improvement •
to be discussed with
departmental quality
directors
Year 4
Pre-reading (i.e. How
Doctors Think by Jerome
Groopman, M.D.)
Simulator session:
teamwork and spot the
error
Multi-disciplinary
workshops re:
communication SBAR
Role playing exercise re:
delivering bad news
Root cause analysis
workshop
Self-directed individual
learning project on future
specialty patient safety
issues
Seminar to reflect on
curriculum and identify
opportunities to take
leadership roles in quality
and safety
Seminar to reflect on
gaps between ideal and
optimal care systems vs.
actual performance
“Quality and Patient Safety: I – IV”
 Four, year-long segments (analogous to the EPC
semester series)
 Lecture, seminar, online/independent study,
reflective writing, clinical simulation activities
integrated into existing preclinical and clinical
coursework.
 Collaboration on quality improvement projects
aligned with their specialty areas.
 https://medinfo.ufl.edu/courses/php/content.php
Course Directors
 Eric Rosenberg – UF G’ville Internal Medicine
• ACP Patient Safety (2002) – yearly CME program
• DOM Physician Director for QI
• Medication Safety
 Bob Wears – UF Jax Emergency Medicine
• 1st presentations in 1998
• Faculty in U Wisconsic Human Factors & Engineering in Pt
Safety short course X 4 years
• Faculty in NWU Master's program in pt safety x 2 years
• Multiple funded safety research efforts.
• Multiple research publications and book chapters on
subject
• Editor of Patient Safety in Emergency Medicine
Quality and Patient Safety I
 Online Module I: “The scope and gravity of
adverse events” (A. Stevens)
 Online Module II: “The scope of quality
problems in the U.S. medical system” (E.
Rosenberg)
 Quality and Safety Student Grand Rounds I:
“The Impact of Medical Harm on Patients and
Families” (EPC-1)
 Workshop I: “Review of Readings and Grand
Rounds I” (EPC-1)
• “Executive Summary: To Err is Human” (IOM 1999)
• “When Doctors Make Mistakes” (Atul Gawande)
• Excerpts from executive summaries of IOM/Quality
Chasm Reports
• “The Nature and Frequency of Medical Errors”
(Wachter, Ch 1)
QPS I (cont’d)
Quality and Safety Student Grand Rounds
II: “The Impact of Medical Harm on
Physicians and other Medical
Professionals” (EPC)
Workshop II: “Reflective Writing on
Quality/Safety” (EPC-2)
Clinical Skills Exam Module
Quality and Patient Safety II
 Online Module III: “Introduction to Root Cause
Analysis”
 Online Module IV: “Introduction to Quality
Improvement”
 Workshop III: “Root Cause Analysis Exercise” (EBM)
 Workshop IV: “Quality Improvement Concepts”
 Workshop V: “The Hidden Patient Safety
Curriculum: Current Reality on the Wards and in
Clinic” / Ethical Issues Surrounding Safety (MS-4,
residents, faculty) (Clerkship Orientation 2009;
Ethics)
QPS II (cont’d)
 Workshop VI: “Improving Interdisciplinary Communication”
(Winter/Crawford)
 Workshop VII: “Improving Patient Communication: Assessing
Barriers to Care” (EPC-3)
 Lecture I: “The Tort System and its Impact on Quality
Improvement” (Ethics; J. Osgard SUF Self Insurance Trust Fund)
 Quality and Safety Student Grand Rounds III: “Interdisciplinary
Communication and Teamwork Challenges” (outside speaker)
 Quality and Safety Student Grand Rounds IV: “Lessons from
Industry” (outside speaker)
 Clinical Skills Exam
Quality and Patient Safety III
 Students may consider a menu of options to choose
from during the year to satisfy requirements
 We want to encourage a high degree of flexibility.
 4 Multidisciplinary “Themes”
• Role of Hospital Quality Depts.
• Role of Nursing in QI
• Avoidance of Medication Errors
• Laboratory / Radiographic Errors
QPS III
 Inter-Clerkship Seminar Series: “Case
Studies in Patient Safety”
• Presentation of Actual/Averted Errors with mock
root cause analyses
• Presentation/Analyses of Quality Data with
discussion of methods of performance
improvement
 Patient Safety Rounds at GAVAMC
 Clinical Skills Exam
Clerkship Directors’
Proposals: June 6, 2008
 ER (Jacksonville)
•
Daily shift-change w/ more student involvement -- focus on safety problems/hand off
issues
 Family Medicine/Neurology
•
Root cause analysis case conference using errors reported by students on
 Medicine
•
Likely to incorporate root cause analysis into existing "doc in box" sessions
 Surgery
•
•
•

Day 1 orientation lecture focusing on surgical complication prevention
M&M to focus on root cause analyses
Increased involvement of subspecialty rotations
OB/GYN
•
•
Creating CPC series on quality/error prevention
Incorporate TeamSTEPPS
(http://dodpatientsafety.usuhs.mil/index.php?name=News&file=article&sid=31)
 Pediatrics
•
Students may identify errors and include as part of portfolio) or work through scenarios
in conference geared towards specific pediatrics issues (wt. based dosing, etc.)
 Psychiatry
•
Ethics Case Conference series to focus on error prevention
Quality and Patient Safety IV
 Workshop VIII: “Clinical Decision Making: “How
Doctors Think”
 Online Module V: “Disclosing Errors to Patients”
 Online Module VI: “Anticipating Error to Avert Harm”
 Simulation Exercises
• Harrell Professional Development and Assessment Center
• “Disclosing Errors to Patients and Families”
• “Discussion of Errors on Rounds”
• Operating Room Simulation
• “Spot the Error” Exercise (John Armstrong, Jane Carthy)
• Anesthesiology simulators
• Bedside Procedure Simulation
QPS IV (cont’d)
 Workshop IX: “The Hidden Patient Safety
Curriculum (cont’d)
 Development of CQI Project (with input from
Physician Quality Directors)
• Research/Write about quality of care issues
surrounding a disease, procedure, patient
population
• Adopt a CQI project; participate in data collection,
analysis of ongoing research at SUF
Methods of Evaluation
 Non-credit, required course
 Attendance at all required course activities
 Final exam at close of 1st, 2nd, 3rd, (and 4th)
year (incorporate into clinical skills exam
series if possible)
 Completion of writing assignments
 Completion of Quality Improvement Project
Who will teach it?
 We all will.
 We need more faculty development in this
area, but a wide variety of “open source”,
practical, case-based materials
 Many key concepts are intuitive for the
experienced clinician
• For example, to do a “root cause analysis”:
describe the event, identify the immediate cause
of the adverse event, identify the contributing
causes (latent errors), create an action plan.
How will we know if this is
effective?
 Plan continuing evaluation, evolution of the
curriculum
 Administration of surveys to gauge changes
in attitudes, knowledge, skills
 Establishment of more formal curricula in UF
residency training programs
 Impact on institutional culture, patient
satisfaction, quality
Is it safe to speak up?
 Speak up scripts “I need clarification” to avoid confrontational speech
 People may ignore you
•
Can’t change the world even though the world needs changing
 There are specific avenues to explore in the longer term – even if
people are ignoring you in the short term
•
We can put you in touch with people interested in fixing this problem – it
won’t be business as usual forever
 There are others to talk to in the hierarchy (dean, chairs, QI directors,
clerkship directors)
 We can ask departments to make a general commitment to respond to
those who report problems
•
•
“We’ve made a general commitment to respond in a certain way”
“We will engage and not attack people
Wears: “perhaps the best test of whether safety culture exists is what happens
when a lower status hierarchy person brings up a problem – and they’re
mistaken about whose patient it is… if they don’t get beat up, that’s a healthy
culture…”
Quality is not just meeting
Performance Measures
 “a hospital can be seen as a high quality
organization – receiving awards for being a
stellar performer and oodles of cash from
P4P programs – if all of its “pneumonia”
patients receive the correct antibiotics, all its
“CHF” patients are prescribed ACE inhibitors,
and all its “MI” patients get aspirin and beta
blockers. Even if every one of the diagnoses
was wrong.” – Bob Wachter