Rhonda A. Sparks, M.D.Medical Director

Clinical Skills Education and Testing CenterUniversity 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 EducationCurriculum ReformCompetency Evaluation

Patient SafetyDemand for Improved Safety and Quality

Healthcare ReformIncreased Access and Cost Containment

Revolutions in Medical EducationFlexner Report – 1910

Quackery to Credible ScientistsCase Western Reserve University – 1952

Increased Integration of BS and CSIncreased Clinical Relevance

McMaster University – 1969Social Unrest/Time of Experimentation…

Educationally!Canadian Universal HealthcareClinician 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 NeedsFoster greater inter-professional teamwork and

collaborationIncrease curricular focus on knowledge and skills for

improving the quality and safety of patient careFoster inter-professional, team based education and patient

care

Theory and Practice of Teams and TeamworkKnowledgeSkillsAttitudes

Miller’s Pyramid of CompetencyKnows - informationKnows How – to use informationShows – how to use information *****Does – performs in clinical setting

The 20th Century Physician

Accumulate KnowledgeIndividual Scholarly WorkAutonomousCooperativeIndividual AchievementsSolo Expert

The 21st Century Physician

Acquire and Use Knowledge

Interdisciplinary Research

CollaborativeShare AccountabilityInterdisciplinary TeamsCoordination of Care

1999 – Institute of Medicine Report “To Err is Human: Building a Safer Health System”Medical Error 8th Leading Cause of Death99,000 Deaths AnnuallyNon-technical ErrorsSystem Errors 7% Inpatients subjected to a medical errorCost – 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 deliveryDevelop, demonstrate, and evaluate strategies

for reducing errors and improving patient safety

Disseminate effective strategies throughout the health care industry

2003 – JCAHO – National Patient Safety Goals3 of 7 Goals Non-technical skills Instituted Safety PracticesClinical Effectiveness of “Safe Practices”

2004 – The 100K Lives CampaignRapid Response TeamsAMI GuidelinesPrevent Adverse Drug Events (ADE)Prevent Central Line Infections

2005 – Resident Work Hour Limits

2005 – Patient Safety and Quality Improvement ActPatient Safety Organizations (PSO)Limits Use of Reported Adverse Event InformationEstablished a Network of Patient Safety

Databases (NPSD)

2005 – TeamSTEPPS

2006 – Keystone ProjectTeam 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 3/23/2010Expand 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 knowMicrosystems over a define period of time

What we don’t knowLong-term outcomes

17

18

Indemnity Experienc e

20

11

0

5

10

15

20

25

Malpractice Claims, Suits, and Observations

Pre-Teamwork Training Post-Teamwork Training

A dverse Outcomes

50%Reduction

50%Reduction

(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN

1

1.2

1.4

1.6

1.8

2

2.2

2.4

June July August Sept Oct Nov Dec Jan Feb M arch April M ay

Avg

. Len

gth

of S

tay

(day

s)

Length of ICU Stay After Team Training OR Teamw ork Climate and P ostoperative Seps is Rates (per 1000 discharges)

Group Mean

Low Teamwork Climate

Mid Teamwork Climate

High Teamwork Climate

0

2

4

6

8

10

12

14

16

18

AHRQ National A verage

Teamwork Climate Based on Safety Attitudes Questionnaire

Low High

(Sexton, 2006)Johns Hopkins

(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine

Change is HardCulture of

“Silos” Culture of

“Innovation”Lack of

TransparencyError

reporting systems

Utilize Group Training for TasksDefine Our Teams

“Micro-environments”Use Patient Safety Data to Drive Team

Training InitiativesClearly Define Team ObjectivesUse Established Team Training Methodology

TeamSTEPPS

Department of Defense – DoD and AHRQResearch Based and Field Tested (MHS)Four Core Competency Areas

Team LeadershipSituation MonitoringMutual SupportCommunication

John Kotter

Team Strategies & Tools to Enhance Performance & Patient Safety

Eight Stepsof Change

Allan S. Frankel, M.D.

Oklahoma City

Y’all come back now, ya hear?

Tulsa

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 21stCentury: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