introduction leading change to improve quality and · 2012-08-03 · leading change to improve...

Leading Change to improve QuaLity and patient Safety A Practical Workshop for Clinicians and Educators

RegisteR eaRly

enRollment

is limited!

Hilton Boston Back BayThursday, November 3 and Friday, November 4, 2011

Jointly Sponsored / Co-Provided By:

aCgme/aBmS Competency: Systems-Based practice | earn risk management credits

Learn from Experienced Clinicians and Faculty

Referenced in Rosalie Phillips' Introduction

Patients expect safe, high quality care; and as health care professionals we recognize the need to strive constantly and systematically to improve quality, reduce errors, and enhance patient safety. Changing the culture, structures and processes in care delivery

settings to achieve these goals is especially beneficial when practitioners are also teachers.

At this two-day course you will learn from experienced clinical leaders and faculty how they address specific aspects of quality and safety in their institutions and practices. Workshops will consider opportunities for improvement, barriers to change, strategies for action, and the impact on patient care. They will also highlight opportunities to engage trainees to develop competence in quality improvement.

The course is hosted by Tufts University School of Medicine and led by faculty from affiliated hospitals, recognized for their high levels of quality and their outstanding and innovative training programs. We hope that you will join us for this important educational opportunity.

Course Goal: The overall course goal is to provide practical approaches to enhance patient safety, reduce the risk of medical error, and improve health care quality in the clinical setting, and to review methods for teaching these skills to professionals-in-training.

eduCational objeCtives: At the conclusion of this course, learners should be able to:

• Describe the challenges and emerging strategies to improve quality and reduce medical errors in the U.S. health care system.

• Identify specific methods and approaches to improve quality and patient safety that hospitals, medical groups and other care delivery settings have adopted.

• Articulate approaches to lead and implement improvement strategies, taking into account barriers to change, such as systems issues, professional resistance, and resource constraints.

• Identify opportunities and practical approaches to teach quality and patient safety in a clinical environment, including inpatient and ambulatory practice settings.

Who should attend: This course will be of special interest to: practicing physicians, nurses, pharmacists and other clinical professionals; faculty in these professions; clinical practice leaders; hospital and health system administrators; and patient safety officers.

Course direCtorEvan M. Benjamin, MD, FACP Senior Vice President, Healthcare Quality, Baystate Health, Inc. Associate Professor, Tufts University School of Medicine

Course Co-direCtorDoug Salvador, MD, MPH Associate Chief Medical Officer/Patient Safety Officer, Maine Medical Center Assistant Professor, Tufts University School of Medicine

Course ConvenerScott Epstein, MD Dean for Educational Affairs Professor of Medicine, Tufts University School of Medicine


Course AgendA Thursday, November 3, 2011

7:30 a.m. registration and Continental Breakfast

8:00 a.m. Welcome, introductions and Course overview

8:15 a.m. LeadingChangetoImproveQualityandSafety

10:00 a.m. Break

10:15 a.m. FundamentalsofthePatientSafetyCulture

12:00 noon Lunch

1:00 p.m. WorkshopSession1

group 1: diagnostic error group 2: medication Safety

2:15 p.m. Break


group 1: using team training and Communication to reduce patient harm group 2: the aftermath of adverse events: apology and disclosure

3:45 p.m. ClosingCommentsandReflections:ImplicationsforPracticeandTeaching

4:15 p.m. day 1 adjourns

Friday, November 4, 2011

7:30 a.m. registration and Continental Breakfast

8:00 a.m. overview of day 2

8:15 a.m. SucceedingatHighRiskQualityImprovement

10:00 a.m. Break

10:15 a.m. WorkshopSession1

group 1: measures and tools for improvement group 2: Learning from error

12:00 noon Lunch


group 1: the use of Checklists to improve Quality and Safety group 2: teaching Quality through modeling Behavior

2:15 p.m. Break


group 1: transparency and pay-for-performance as Strategies to improve Care

group 2: driving Waste out of the System

3:45 p.m. ClosingCommentsandReflections:ImplicationsforPracticeandTeaching

4:15 p.m. Conference adjourns


Teaching the Next Generation of Healthcare Providers to be Leaders in Quality—

The Tufts Experience

Referenced in the presentation by:

Douglas Salvador, MD, MPH

Susan Curtis, RN, CPHQ

Maine Medical Center

National Quality Colloquium Wednesday, August 15, 2012

1:30 p.m. – 2:15 p.m.

SFSBM: Health Systems, Quality, Patient Safety

Thursday, April 261:30pm4:30

Teamwork Exercise Mike Lyle, Robert Trowbridge, Doug Salvador

Learning Objectives

Upon completion of the Teamwork Exercise portion of the curriculum medical students will:

be able to describe multiple negotiating styles [KNOWLEDGE] be capable of planning for a negotiating session [SKILL]

Reading Assignment

- None


Monday, May 78:00am 9:00am

How Physicians are Compensated

William Williams

Learning Objectives

Upon the completion of the Health Systems/Finance portion of the curriculum medical students will be able to describe how physicians are compensated [KNOWLEDGE]

Reading Assignment:

- None


Monday, May 79:00 10:00am

How Society Pays for Healthcare Al Swallow

Learning Objectives

Upon the completion of the Health Systems/Finance portion of the curriculum medical students will be able to describe how society pays for healthcare [KNOWLEDGE]

Reading Assignment:

- None SFSBM: Health Systems, Quality, Patient Safety

Thursday, May 178:15am 10:00am

Shared Decisionmaking Conference plenary

Jack Wennberg, “epatient Dave” Debronkart

Learning Objectives

Upon completion of the Shared Decisionmaking portion of the curriculum medical students will:

Appreciate the importance of engaging patients and families as full members of the healthcare team (ATTITUDE)

Reading Assignment

None


Thursday, May 1710:30 12:30pm

Small Area Variations David Wennberg Learning Objectives

Upon completion of the Small Area Variations portion of the curriculum medical students will:

be able to describe small area variations in healthcare [KNOWLEDGE] be able to describe potential modifiable causes of small area variations in

healthcare [KNOWLEDGE]

Reading Assignment:

- None


Thursday, May 171:30 2:15 pm

Introduction to Patient Safety Doug Salvador Learning Objectives

Upon completion of the Patient Safety portion of the curriculum medical students will:

be capable of describing basic principles of Human error theory and human factors (KNOWLEDGE)

have internalized the idea that the practice of medicine requires safety systems to catch human errors before they reach and harm patients (ATTITUDE)

be able to describe the principle of ‘just culture’ (KNOWLEDGE) Reading Assignment:

- Reason J. Human error: models and management. BMJ 2000;320:768‐70. - Leape L, Berwick D, Clancy C et al. Transforming Healthcare: A Safety Imperative. Qual Saf

Health Care 2009;18:424‐428.


Thursday, May 172:15 4:30 pm

Root Cause Analysis Exercise Cynthia Bridgham, Julia Dalphin Learning Objectives

Upon completion of the Patient Safety portion of the curriculum medical students will:

have contributed to a root cause analysis (SKILL) discern the importance of reporting errors (ATTITUDE)

Reading Assignment:

- None


Friday, May 188:00am9:45am

Introduction to Healthcare Quality

Neil Korsen

Learning Objectives

Upon completion of the Healthcare Quality portion of the curriculum medical students will:

be aware of the quality problem in U.S. healthcare. (KNOWLEDGE) develop a willingness to change their own behavior and practice and take

accountability for the results of those changes. [ATTITUDE]

Reading Assignment:

Read each of these as the content will form the basis for a group discussion during

this session.

- Berwick D. A User’s Manual for the IOM’s Quality Chasm Report. Health Affairs 2002;21(3):80‐90.

- Berwick D, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs 2008;27(3):759‐769.


Friday, May 1810:15am12:00noon

Model for Improvement Exercise Neil Korsen MD Learning Objectives

Upon completion of the Quality portion of the curriculum medical students will: Be capable of describing the steps in the Plan‐Do‐Study‐Act cycle and their

application to healthcare [KNOWLEDGE] be capable of applying process improvement methods in a group exercise

(SKILL) Reading Assignment

- http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

(Read this short description of the Model for Improvement)


Monday, May 211:00 4:30pm

Standardized Patient Scenarios Neil Korsen, Julia Dalphin, Doug Salvador

Learning Objectives

Upon completion of the Quality/Patient Safety portions of the curriculum medical

students will:

develop a willingness to change their own behavior and practice and take accountability for the results of those changes. [ATTITUDE]

discern the importance of reporting errors [ATTITUDE]

Reading Assignment:

- None SFSBM: Health Systems, Quality, Patient Safety

Tuesday, May 226:00 9:00pm (Dinner)

Healthcare Reform Roundtable Doug Salvador, Frank Chessa

Disclosure of Adverse Events

February 2012

Learning Objectives

• Identify process steps for disclosure [Knowledge]

• Identify three things patients want after avoidable harm [Knowledge]

• Provide honest, timely, effective communication about the facts of the adverse event [Skill]

• Accept the obligation to disclose the occurrence of adverse events [Attitude]

A Story of Patient Harm

How Often Do We Disclose?

• 2/3 of residents admitted making a fatal mistake• Only 50% disclosed to attending• Only 25% were disclosed to the patient• 2/3 of physicians did not even feel comfortable

discussing a medical error with a close friend

• More recent studies show that fewer than half of adverse events due to preventable errors are disclosed to patients and their families.

Wu, AW et al: Do House Officers Learn from Their Mistakes? JAMA 1991, 265(16):2089-94.

Barriers to Disclosure

• Fear of Litigation

• Harm to Reputation

• Discomfort with handling emotional response

• Lack of training in communication

• Belief that patients and families cannot understand the full complexity of events

Wu AW et al, Emer Med Clin N Am, 24(2006):703-714.

Loren DJ et al, Jt Comm J Qual Patient Saf, 36(2010): 101-108.

Disclosure

• Ethical Imperative

• Professional, Legislative, and Regulatory support for the practice

• Anecdotal evidence for no increase in litigation risk

• No evidence base for best practice methods

• Impact of disclosure on outcomes is unclear

Gallagher TH et al, N Engl J Med, 2007, 356:2713

When should we disclose?

• After preventable harm caused by medical error

• NOT:– After known complications of standard medical care

• Optional:– After medical error that does not cause harm

What Do Patients Want After a Medical Error?

• An honest explanation

• An apology

• A guarantee it won’t happen to anyone else

• (To be part of the solution?)

Initial Disclosure Content

• What happened, implications: Include everything that you are certain of at the time of the discussion – don’t speculate

• Was event preventable (due to error)• Why event happened• How recurrences will be prevented• Apology

– Expression of sympathy for all adverse events– Full apology when adverse event due to error

• Plans for follow-up

How to disclose

• Who: health care professional whom the patient perceives as being responsible for his/her care

• Communication advice:– Opening statement: forthright

– Determine extent of patient’s knowledge first

– Do not rush the disclosure, pause frequently, ask questions

– Be explicit

– Expect strong emotions and manage your emotions – don’t become defensive or angry

– Validate the strong reactions and empathize

– Allow the patient to direct the conversation

Before You Walk in the Room

• Remember:

This conversation is for the patient and family, not primarily for YOU!

Don’t expect forgiveness.

References

• When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; March 2006

• Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org)

• Kachalia A., et al.: Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Ann Intern Med 153:213-221, August 17, 2010.

• Gallagher T. H., et al.: Disclosing Harmful Medical Errors to Patients. N EnglJ Med 356:2713, Jun 28, 2007.

Update: 2012-02-16 Page 1 of 4

Marie Gagnon Internal Medicine Case of Harm to family Member (2).doc

Internal Medicine: Medical Error Disclosure

Key Objective(s) and Competencies

• Identify the process steps for disclosure [Knowledge] • Identify three things patients want after avoidable harm

[Knowledge] • Provide honest, timely effective communication about the

facts of the adverse event [Skill] • Accept the obligation to disclose the occurrence of adverse

events [Attitude] Supporting Literature

N/A

Role Name, Gender, Age Range

SP: Male or female (pt’s child) b/t 40-60 years old David Gagnon, 40 year old male Patient: Marie Gagnon, 83 year old female (David’s biological mother)

Appearance, Behavior, Attitude

• Still grieving loss of his mother and unsettled. • Well- dressed, business man. • Confused about his mother’s death, but not confrontational

initially.

Setting In the physician’s office or in a consult room

Presenting Situation & History of Present Illness

Your mother was an 82 year woman cared for over the past four years for her chronic kidney disease. She had congestive heart failure and had several hospital admissions over the last 18 months of her life. On one of these admissions 10 months ago, this resident was on her inpatient team when she was admitted for acute kidney injury. The renal ultrasound ordered by this doctor revealed an abnormality. This result was followed up by contrast CT of the abdomen. The CT scan revealed a 3 cm mass in the right kidney suspicious for renal cell carcinoma. This doctor made the active decision to delay discussion of the findings until the next clinic appointment since mom had been tearful when the doctor discussed the possibility of dialysis and she was quite short of breath from her exacerbation of congestive



heart failure. It was believed that she would refuse dialysis treatment if her kidney function worsened. Unfortunately the resident was pulled away on clinic day as “jeopardy” to cover for a sick colleague in SCU, so the Nurse Practitioner saw your mom. The dictated discharge summary had not yet been completed, so the NP didn’t know about, or speak with the patient (who was feeling better) about the mass. NRP suggested a 3-month follow-up appointment at the clinic. Unfortunately, the patient “no showed” for the 3 month visit due to a scheduling error she made and her appointment was never rescheduled. Mom called 6 months later following the missed visit with back pain and weight loss. Admitted to the hospital - on imaging is found to have a large renal mass with spine lesions suspicious for metastases. A biopsy is done confirming metastatic renal cell carcinoma and your mom opts to go to hospice care and passes away peacefully one week later. You made an appointment to see her doctor because you have questions about your mother’s illness. You reported this error in communication of a critical imaging study result to the medical center’s risk management department. A root cause analysis is scheduled in the next week to identify and fix any systems associated with the reporting process. A radiologist and another attending reviewed the case and it is clear that the cancer was curable 10 months ago, but the lack of follow-up led to cancer progression and your mom’s death.

Opening Statement

The physician should begin the conversation by saying “Mr. Gagnon, I have some important information to share with you about your mother’s death.”

Pertinent Patient History Past Medical History Family Medical History Social History Sexual History Medications

N/A



Allergies Recent Lab Results

Scripted Questions/ Answers

• How could this have happened? • What are you going to do to prevent this from happening in

the future? OR What are you going to do to prevent this from happening to someone else’s family?

• Has this ever happened before?

Task(s) for learner • Disclose the medical error to Mr. Gagnon and apologize.

Exam Room Needs • Consult room or physician’s office

Designed for (e.g. 3rd yr student, intern, etc)

3rd year IM Resident

Case Authors D. Salvador, J. Dalphin, J. Erickson, C. Mallar

Date Created/ Updates February 1, 2012

Glossary •



Original Documentation

SP Apology and Disclosure Scenario 2 The patient was an 82 year old woman that you cared for over the past four years for her chronic kidney disease. She had congestive heart failure and had several hospital admissions over the last 18 months of her life. On one of these admissions, 10 months ago, you saw her in consultation for acute kidney injury. The renal ultrasound you ordered revealed an abnormality that was followed up by contrast CT of the abdomen. The CT scan revealed a 1.5 cm mass in the right kidney suspicious for renal cell carcinoma. You decide to reveal this information to your patient in an outpatient follow up visit. She has been tearful as you discussed the possibility of dialysis and is quite breathless from her exacerbation of congestive heart failure. She believes that she will refuse dialysis treatment if her kidney function worsens. She is ultimately discharged to home off of dialysis. You are pulled away to an important meeting in Bangor, ME on the day of your patient’s follow up appointment and your partner sees her in follow up. He is not aware of the CT scan results. Your patient returns to the hospital 9 months later with back pain and on imaging is found to have a large renal mass with spine lesions suspicious for metastases. A biopsy is done confirming metastatic renal cell carcinoma and she opts to go to hospice care and passes away peacefully one week later. Your patient’s son, David, made an appointment to see you because he has questions about his mother’s illness. You reported this error in communication of a critical imaging study result to the medical center’s risk management department. A root cause analysis is scheduled in the next week to identify and fix any systems associated with the reporting process. A radiologist and one of your colleagues reviewed the case and it is clear that the cancer was curable 10 months ago, but the lack of follow up led to cancer progression and your patient’s death.

Update: 2012-02-19 Page 1 of 2 Marie Gagnon - Door accepted track changes.doc

Internal Medicine 3rd Year Residents: Medical Error Disclosure Event

Patient Name: Marie Gagnon, 83 year old female

Setting: Consult Room

Vital Signs: N/A

Patient Information:

You cared for Mrs. Gagnon over the past four years for her chronic kidney disease. She had congestive heart failure and had several hospital admissions over the last 18 months of her life. On one of these admissions, 10 months ago, you saw her in consultation for acute kidney injury. The renal ultrasound you ordered revealed an abnormality that was followed up by contrast CT of the abdomen. The CT scan revealed a 1.5 cm mass in the right kidney suspicious for renal cell carcinoma. Since Mrs. Gagnon was tearful as you discussed the possibility of dialysis, and quite breathless from her exacerbation of congestive heart failure you decided to reveal this information to your patient in an outpatient follow-up visit. She is ultimately discharged to home off of dialysis. You are pulled away to an important meeting in Bangor, ME on the day of your patient’s follow-up appointment and your partner sees her in follow-up. He is not aware of the CT scan results. Your patient returns to the hospital 9 months later with back pain. Imaging reveals a large renal mass with spine lesions suspicious for metastases. A biopsy confirms metastatic renal cell carcinoma. Mrs. Gagnon opts to go to hospice care and passes away peacefully one week later. You reported this error in communicating the critical finding to the medical center’s risk management department. A root cause analysis is scheduled in the next week to identify and fix any systems associated with the reporting process. A radiologist and one of your colleagues reviewed the case and it is clear that the cancer was curable 10 months ago, but the lack of follow-up led to cancer progression and Mrs. Gagnon’s death. Meanwhile, Mrs. Gagnon’s son David, made an appointment to see you because he has questions about his mother’s illness.

Update: 2012-02-19 Page 2 of 2 Marie Gagnon - Door accepted track changes.doc

Instructions: You have up to 15 minutes to answer David’s questions surrounding his mother’s illness and death, explain her death was the result of a medical error and apologize.

When you have finished with your patient, please wait outside the room until the standardized patient calls you in for feedback.

PHYSICIAN/RESIDENT/NP/PA-C

Team Briefing/IDCR Exercise Read your role in the group exercise Leader opens the briefing Role play the briefing at your table

Include key briefing elements All team members contribute

LEADER sets the stage:

• Disavow Perfection (remove your ego)to flatten hierarchy and encourage speaking up • Team members state name and role • Leader engages every participant using eye contact and people’s names • Explicitly ask for input about concerns or issues • Provide information and talk about next steps, shared mental model • Encourage ongoing monitoring and cross-checking • Seek useful information • Update as needed – build into procedure

Be ready to role play the Briefing to the whole room

Pediatrics Tommy is an 18 year-old admitted 4 days ago for a CF cleanout and CF related diabetes. His hgb A1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is asking for more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. The plan is for him to be discharged home on IV antibiotics in two days. He lives with his disabled father and has limited resources for medications. Pharmacist met with him yesterday and is not compliant with his medications at home. Attending/Resident/NP/PA-C-you were just told by xxx that they are concerned the patient is taking pain medication for anxiety, he also admits to smoking pot on a regular basis. Adult Medical #1 Mr T. is a 44-year-old man admitted 4 days ago for a DVT. He is also diabetic, hgbA1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is demanding more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. His lab work indicates he will be anticoagulated and estimated discharge is in two days. He lives alone and has limited resources for medications. Pharmacist met with him yesterday and suspects he is not taking his medications at home as prescribed due to cost. The CNA noted a stage 1 area on his coccyx this am, he refuses to turn because of his pain. (Team members not mentioned make up something you know about the patient to contribute to the briefing). Attending/Resident/NP/PA-C- you just got in report from the night coverage that patient has a history of Narcotic drug abuse related to a chronic back issue from a work injury. ED Mr. G is an 82 year-old who has just arrived by ambulance from a restaurant He was out to lunch with his family and began coughing after eating some meat. He presents with chief complaint of “something is stuck in my throat”. He has a significant medical history: A-Fib, COPD, HTN, GERD, Parkinson’s, and CAD. His medications include: Digoxin 0.125mg, Coumadin 2.5 daily, Nexium 20 mg, Metoprolol 50 mg, Lasix 20 mg, Sinemet 25/100, Spiriva, and Albuterol.

His vital signs are T-37.7 P-110 R-22 BP 168/98. O2 Sat= 93% on 2 liters nasal cannula Weight=66 kg Height= 163 cm He is extremely anxious. Attending/Resident/NP/PA-C- You see from the chart that his patient was discharged 2 weeks ago for an exacerbation of CHF. You have just ordered a Stat CBC, Chem. Panel, PT/INR, and Dig level. Surgery/Operating Room A 32-year-old male, Mr T, who sustained extensive injuries in a motor cycle accident 10 days ago, is scheduled for a dressing change under anesthesia. He has a history of bipolar disorder, ETOH & tobacco abuse. He has a left chest tube, a central line IV and two peripheral IVs. He is on 3 liters nasal oxygen. Security has been called a couple of times because he has gotten angry with the staff for “not giving me enough pain medication”. He is currently on oxycontin 20 mg p.o. Q12hr and Oxycodone 5mg p.o. Q2hr PRN. Attending/Resident/NP/PA-C- You were involved with the dressing change in the OR last week and remember that the patient awoke from the procedure and required frequent morphine doses for the first 90 minutes. He dropped his BP to 70’s/30s as a result but recovered quickly with a fluid bolus. OB/NICU A 38 yo G4P1 woman with 32 week triplets is laboring with a fetal monitor in place. Most recent cervical check of 3 cm and thick. She has received an epidural anesthetic, but has been uncomfortable and progressing slowly. The primary nurse tells you that she is worried about the tracing. You look at it and have concerns about repeated decelerations. The team is pulled together and the decision is made to take this woman to a stat C-section. Team from OB, Family Center, and NICU hold a briefing just prior to surgery. Attending/Resident/NP/PA-C- you have spoken to the father, he is frantic over this emergency situation with his wife and babies. You are concerned that although he wants to be at the delivery he is not coping well and could require one on one support if he goes to OR with his wife.

NURSE

Team Briefing/IDCR Exercise BBCH

Read your role in the group exercise Leader opens the briefing Role play the briefing at your table





____________________________________________________________________________________ Pediatrics Tommy is an 18 year-old admitted 4 days ago for a CF cleanout and CF related diabetes. His hgb A1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is asking for more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. The plan is for him to be discharged home on IV antibiotics in two days. He lives with his disabled father and has limited resources for medications. Pharmacist met with him yesterday and is not compliant with his medications at home. Nurse-You have taken care of this patient on several admissions and are concerned that he is showing signs of depression. H has decreased appetite, is sleeping a lot, and hasn’t responded once to your attempts to get him to laugh-which has always worked in past admissions Adult Medical #1 Mr T. is a 44-year-old man admitted 4 days ago for a DVT. He is also diabetic, hgbA1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is demanding more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. His lab work indicates he will be anticoagulated and estimated discharge is in two days. He lives alone and has limited resources for medications. Pharmacist met with him yesterday and suspects he is not taking his medications at home as prescribed due to cost. The CNA noted a stage 1 area on his coccyx this am, he refuses to turn because of his pain. (Team members not mentioned make up something you know about the patient to contribute to the briefing). Nurse- Patient’s fasting blood glucose was 260 this am. You suspect that his friends are bringing him food that he is keeping at the bedside.

ED Mr. G is an 82 year-old who has just arrived by ambulance from a restaurant He was out to lunch with his family and began coughing after eating some meat. He presents with chief complaint of “something is stuck in my throat”. He has a significant medical history: A-Fib, COPD, HTN, GERD, Parkinson’s, and CAD. His medications include: Digoxin 0.125mg, Coumadin 2.5 daily, Nexium 20 mg, Metoprolol 50 mg, Lasix 20 mg, Sinemet 25/100, Spiriva, and Albuterol. His vital signs are T-37.7 P-110 R-22 BP 168/98. O2 Sat= 93% on 2 liters nasal cannula Weight=66 kg Height= 163 cm He is extremely anxious. Nurse-Patient’s vital signs are now BP 182/96 and P-90. He denies pain and refuses any medication, but keeps asking what is going to happen to me? Surgery/Operating Room A 32-year-old male, Mr T, who sustained extensive injuries in a motor cycle accident 10 days ago, is scheduled for a dressing change under anesthesia. He has a history of bipolar disorder, ETOH & tobacco abuse. He has a left chest tube, a central line IV and two peripheral IVs. He is on 3 liters nasal oxygen. Security has been called a couple of times because he has gotten angry with the staff for “not giving me enough pain medication”. He is currently on oxycontin 20 mg p.o. Q12hr and Oxycodone 5mg p.o. Q2hr PRN. Nurse-The nurse from the unit just called to report the patient has developed a fever of 39.2 and concern is he is developing pneumonia. He has not been compliant with use of incentive spirometer. A stat chest x-ray has been ordered. The surgeon says we will await the wet reading before sending patient for dressing change. OB/NICU A 38 yo G4P1 woman with 32 week triplets is laboring with a fetal monitor in place. Most recent cervical check of 3 cm and thick. She has received an epidural anesthetic, but has been uncomfortable and progressing slowly. The primary nurse tells you that she is worried about the tracing. You look at it and have concerns about repeated decelerations. The team is pulled together and the decision is made to take this woman for a stat C-section. Team from OB, Family Center, and NICU hold a briefing just prior to surgery. Nurse-NICU is full and needs to transfer two patients to CCN and discharge another before triplets can be admitted.

C.N.A./NUS/PCR/Tech Roles

Team Briefing/IDCR Exercise






Pediatrics Tommy is an 18 year-old admitted 4 days ago for a CF cleanout and CF related diabetes. His hgb A1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is asking for more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. The plan is for him to be discharged home on IV antibiotics in two days. He lives with his disabled father and has limited resources for medications. Pharmacist met with him yesterday and is not compliant with his medications at home. C.N.A./NUS/PCR/Tech - The father came in this am and you could smell alcohol on his breath. You have known him for many years as his son has had numerous admissions and this has never been a concern. You also notice that he looks like he isn’t eating and has lost probably 10 lbs. Adult Medical #1 Mr T. is a 44-year-old man admitted 4 days ago for a DVT. He is also diabetic, hgbA1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is demanding more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. His lab work indicates he will be anticoagulated and estimated discharge is in two days. He lives alone and has limited resources for medications. Pharmacist met with him yesterday and suspects he is not taking his medications at home as prescribed due to cost. The CNA noted a stage 1 area on his coccyx this am, he refuses to turn because of his pain. C.N.A./NUS/PCR/Tech-The patient told you that he is afraid he is going to lose his job and his apt. ED Mr. G is an 82 year-old who has just arrived by ambulance from a restaurant He was out to lunch with his family and began coughing after eating some meat. He presents with chief complaint of “something is stuck in my throat”. He has a

significant medical history: A-Fib, COPD, HTN, GERD, Parkinson’s, and CAD. His medications include: Digoxin 0.125mg, Coumadin 2.5 daily, Nexium 20 mg, Metoprolol 50 mg, Lasix 20 mg, Sinemet 25/100, Spiriva, and Albuterol. His vital signs are T-37.7 P-110 R-22 BP 168/98. O2 Sat= 93% on 2 liters nasal cannula Weight=66 kg Height= 163 cm He is extremely anxious. C.N.A./NUS/PCR/Tech-You just left the patient and he is complaining of ‘a little short of breath” which he was not complaining about on admission. Surgery/Operating Room A 32-year-old male, Mr T, who sustained extensive injuries in a motor cycle accident 10 days ago, is scheduled for a dressing change under anesthesia. He has a history of bipolar disorder, ETOH & tobacco abuse. He has a left chest tube, a central line IV and two peripheral IVs. He is on 3 liters nasal oxygen. Security has been called a couple of times because he has gotten angry with the staff for “not giving me enough pain medication”. He is currently on oxycontin 20 mg p.o. Q12hr and Oxycodone 5mg p.o. Q2hr PRN. C.N.A./NUS/PCR/Tech-Pt had a wound culture done with the last dressing change in the OR two days ago but you don’t see the results in the computer. OB/NICU A 38 yo G4P1 woman with 32 week triplets is laboring with a fetal monitor in place. Most recent cervical check of 3 cm and thick. She has received an epidural anesthetic, but has been uncomfortable and progressing slowly. The primary nurse tells you that she is worried about the tracing. You look at it and have concerns about repeated decelerations. The team is pulled together and the decision is made to take this woman for a stat C-section. Team from OB, Family Center, and NICU hold a briefing just prior to surgery. C.N.A./NUS/PCR/Tech-You just spoke with the parents for the baby going home today. They are ready to leave but have one more question for the doctors.

PT/OT/RT/SW/Care Coordinator/Other

Team Briefing/IDCR Exercise






Pediatrics Tommy is an 18 year-old admitted 4 days ago for a CF cleanout and CF related diabetes. His hgb A1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is asking for more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. The plan is for him to be discharged home on IV antibiotics in two days. He lives with his disabled father and has limited resources for medications. Pharmacist met with him yesterday and is not compliant with his medications at home. PT/OT/RT/SW/Care Coordinator/Other--patient is always asleep when you try to see them. You caught him awake this am but he said he didn’t feel well enough to work with you. You told him you would check back after lunch. Adult Medical #1 Mr T. is a 44-year-old man admitted 4 days ago for a DVT. He is also diabetic, hgbA1C was 5.6 on admission and his finger sticks are ranging 200-300. This morning he is demanding more pain medication, stating he is having severe back pain 8/10 (has chronic back pain and takes oxycodone PRN at home) none has been ordered. PT began seeing patient yesterday. His lab work indicates he will be anticoagulated and estimated discharge is in two days. He lives alone and has limited resources for medications. Pharmacist met with him yesterday and suspects he is not taking his medications at home as prescribed due to cost. The CNA noted a stage 1 area on his coccyx this am, he refuses to turn because of his pain. (Team members not mentioned make up something you know about the patient to contribute to the briefing). PT/OT/RT/SW/Care Coordinator/Other—You tried to do an initial assessment with the patient this am but he said he was in too much pain and to come back tomorrow.

Continued on BACK

ED Mr. G is an 82 year-old who has just arrived by ambulance from a restaurant He was out to lunch with his family and began coughing after eating some meat. He presents with chief complaint of “something is stuck in my throat”. He has a significant medical history: A-Fib, COPD, HTN, GERD, Parkinson’s, and CAD. His medications include: Digoxin 0.125mg, Coumadin 2.5 daily, Nexium 20 mg, Metoprolol 50 mg, Lasix 20 mg, Sinemet 25/100, Spiriva, and Albuterol. His vital signs are T-37.7 P-110 R-22 BP 168/98. O2 Sat= 93% on 2 liters nasal cannula Weight=66 kg Height= 163 cm He is extremely anxious. PT/OT/RT/SW/Care Coordinator/Other-You are the resp therapist, the ED attending just asked you to give Mr G an albuteral nebs treatment Surgery/Operating Room A 32-year-old male, Mr T, who sustained extensive injuries in a motor cycle accident 10 days ago, is scheduled for a dressing change under anesthesia. He has a history of bipolar disorder, ETOH & tobacco abuse. He has a left chest tube, a central line IV and two peripheral IVs. He is on 3 liters nasal oxygen. Security has been called a couple of times because he has gotten angry with the staff for “not giving me enough pain medication”. He is currently on oxycontin 20 mg p.o. Q12hr and Oxycodone 5mg p.o. Q2hr PRN. . PT/OT/RT/SW/Care Coordinator/Other-you have been following the patient for three days and did his resp assessment this am, he had been maintaining an O2 Sat of 94-95% on 2 liter nasal oxygen, but this am you changed him to 3 liters and just 30 min ago increased it to 4 liters. OB/NICU A 38 yo G4P1 woman with 32 week triplets is laboring with a fetal monitor in place. Most recent cervical check of 3 cm and thick. She has received an epidural anesthetic, but has been uncomfortable and progressing slowly. The primary nurse tells you that she is worried about the tracing. You look at it and have concerns about repeated decelerations. The team is pulled together and the decision is made to take this woman for a stat C-section. Team from OB, Family Center, and NICU hold a briefing just prior to surgery. PT/OT/RT/SW/Care Coordinator/Other-The family being discharged needs to have a home visit today to ensure they understand how to use the equipment set up yesterday for the baby’s discharge. You are waiting to hear back from the home health agency.

Patient Safety Concern Pathway

Follow the 4 pathway steps to managea situation when you have a patient safety concernThe patient and their safety come

first.

Each of us has an absolute

Say “I’m Concerned…” to invoke the pathway

Use SBAR to explain1

CODE OF CONDUCT

obligation to speak up if patient safety is a concern.

Each of us has an absolute obligation to listen/respond if someone speaks up

Use SBAR to explainResponse is to act on concernTeach the concerned caregiver something

they didn’t know, or modify the patient care plan as needed

Say “I’m still Concerned…” if concern persists

R i t k l dg d f th 2

Response is to acknowledge and further explore the persistent concern

Modify care plan as neededProvide rationale for the plan along with

evidence base if availableGo to the literature together

Say “We need to collaborate…” if still a

USING THE PATHWAYPathway should be invoked when

anyone has a patient safety concern.

3 Say We need to collaborate… if still a concern

Response should be: “ I will call… Will you call…”

Task of both parties is to bring one or more knowledgeable persons into the discussion to guide decision-making

Summon one or several knowledgeable, f i id / /

Pathway should not be invoked for personal education or convenience in the absence of a patient safety concern.

If unsure whether to invoke the pathway it is always acceptable to

3

often more senior, resident/s, nurse/s, or attending colleague/s

Invoke “Chain for Resolution” if still not resolved

Initiate if one or more parties fails/refuses to engage in the PSC Pathway or there is still a safety concern

pathway, it is always acceptable to confer and get advice from another member of the team.

There is a rare occasion when a decision is so time-critical that the team will have to defer to the senior

4

a safety concernIdeally, usage of the chain of command

step will be verbalized to the involved parties before the end of the communication interaction

Chain for Resolution is outlined below

WHEN Steps 1-3 Fail Use “CHAIN for RESOLUTION”

person.

Patterns of conflict will be addressed by the Chain for Resolution

Director NURSES Charge

RESIDENT/STUDENT

Manager AVP

Chief Resident Program Director Dept ChiefPatient SafetyOfficer

p

ATTENDINGS Division Director/Program Medical Director

NP/PA-C Manager

Teaching the Next Generation of Healthcare Providers to be Leaders in Quality—

The Tufts Experience

Referenced in the presentation by

Joseph Rencic, MD

Tufts Medical Center

National Quality Colloquium Wednesday, August 15, 2012

1:30 p.m. – 2:15 p.m.

1

Explicit Reasoning

The course

Nine weeks, pass-fail structure

Pre-class assignments Web-based interactive case with team

Selected readings in clinical reasoning

Weekly quiz1

Video lecture series

Two-hour, small group, symptom-based learning exercises One common symptom per week

Two different cases (e.g. ACS, aortic dissection) per session2

Goal-oriented facilitation 1 Larsen DP et al. Test-enhanced learning in medical education. Med Educ. 2008.2 Proctor RW and Vu KL. In: Ericsson KA, Charness N, Feltovich P, and Hoffman R, eds., The Cambridge Handbook of Expertise and Expert Performance. New York, NY: Cambridge University Press, 2006.

2

Challenges of designing the course

Recall/retention of material

Team-based learning/peer teaching

Faculty development

Assessment

Post-course challenges/feedback

AssessmentNo control group

Lack of standard experience across facilitators

Length of pre-class cases

Peer learning/teaching

3

Assessment

Extended matching, short answer final exam

OSCE: One station with

clinical reasoning short answer

Participation

Complex representation of cognition in problem-solving

Croskerry P. Adv Health Sci Edu 2009; 14(supp 1):27-35.

4

The utility of tests

How valuable is a nuclear stress test for ruling in coronary artery disease?

How valuable is a physical exam finding of egophony for ruling in pneumonia?

Disease probability and testing

The utility of a test for a given patient can not be determined without disease probability

Bayes theorem: Pre-test odds x

likelihood ratio = post-test odds

Note: Stress test has likelihood ratio of 3.3

5

Representative case

Week 3. Chest pain

7

Expert answer

Data from metacognition studies

The following slides review data from the metacognitive studies The next slide reviews the instructions for how to

use “conscious thought” in the two studies cited

The follow up slides show the effect on this “conscious thought” procedure on diagnostic accuracy for simple and complex cases

8

Instructions for “conscious thought” read the case write down the diagnosis previously given for the case list the findings in the case description that support this

diagnosis list the findings that speak against this diagnosis list the findings that would be expected to be present if

the diagnosis were true but were not described in the case

list alternative diagnoses assuming that the initial diagnosis generated for the case had proved to be incorrect to follow the same procedure(steps3-5 above)for each alternative diagnosis

draw a conclusion by ranking the diagnoses in order of likelihood and selecting their final diagnosis for the case

Conscious thought more accurate

Expert accuracy

9

But not for students

Novice accuracy

introduction leading change to improve quality and · 2012-08-03 · leading change to improve...

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