improving patient safety jason zigmont, phd system director experiential learning

Improving Patient Safety

Jason Zigmont, PhDSystem Director

Experiential Learning

22

33

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

44

Bloom’s Taxonomy

55

Learning Outcomes Model

The Individual Experiences

Environment

•Well-Tuned Learning Orientation

•Mental Models

•Analogical Reasoning

•Challenging

•Emotionally Charged

•Mistakes or Errors

•Skilled Mentors

•Evidence Based Medicine

•Products and Protocols

Improved Patient

Outcomes

66

The Individual Experiences

Environment

•HR – Hiring/Recruitment

•Orientation

•Licensure/Certs

•LMS?

•Patient Mix

•Simulation

•Standardized Patient

•Six Sigma/Lean

•Policies

•New Equipment

Improved Patient

Outcomes

•Research/EBM

•Posters/Marketing

•Six Sigma

•Data Analysis

•Consultants

•Joint Commission

•CMS, ODH, etc.•HCAHPS

•SAQ, AOS

•RCAs

•Practice Updates

•Checklists

•Standardized work

•Purchasing

77

Examples • Handwashing• OR to ICU Handoff• TeamSTEPPS

88

Improving OR to ICU Handoff

99

TeamSTEPPS training

• Didactic vs Simulation

• Unit Based Training

• In-Situ Training

• Interdisciplinary Educator Team

– Nurse– Physician– Simulation Educator

• Scheduling…

• Measurement– Process Measures– Outcome Measures

1010

1111

QuestionTeam

TrainingN (%)

No Team Training

N (%)P value

In this unit, we discuss ways to prevent errors from happening again

16682%

12763.5%

0.001

Mistakes have led to positive changes here 14672%

11959.5%

0.007

Staff are not afraid to ask questions when something does not seem right.

15375.7%

11557.5%

0.001

Staff feel free to question the decision of actions of those with more authority.

12260.4%

8140.5%

0.001

Staff will freely speak up if they see something that may negatively affect patient care.

16782.7%

13869%

0.001

We are actively doing things to improve patient safety 18591%

16683%

0.01

We are given feedback about changes put into place based on event reports.

12461%

9949%

0.017

We are informed about errors that happen in this unit. 13767.8%

10251%

0.001

When one area in this unit gets really busy, others help 15978.7%

13165.5%

0.003

Results of the Safety Attitudes Questionnaire

1212

Steps to Success

• Identify Problem– Value/Impact?– Individual/Experience/Environment

• Create Buy-In/Assess Readiness– Management– Associates

• Identify the Change Team

• Define Implementation Plan

• Plan for Scheduling

• Sustainment…