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…