Multidisciplinary Simulation Moving Clinical Education from Group Training

Multidisciplinary Simulation Moving Clinical Education from Group Training to Team Training Rhonda A. Sparks, M. D. Medical Director Clinical Skills Education and Testing Center University of Oklahoma – College of Medicine

Where are we going? 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?

Time for Change “The Perfect Storm”

Time for Changes in Clinical Education Curriculum Reform Competency Evaluation Patient Safety Demand for Improved Safety and Quality Healthcare Reform Increased Access and Cost Containment

Changes in Clinical Education How We Teach Revolutions in Medical Education Flexner Report – 1910 Quackery to Credible Scientists Case Western Reserve University – 1952 Increased Integration of BS and CS Increased Clinical Relevance Mc. Master University – 1969 Social Unrest/Time of Experimentation…Educationally! Canadian Universal Healthcare Clinician Shortage

Changes in Clinical Education What We Teach 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 Needs Foster greater inter-professional teamwork and collaboration Increase curricular focus on knowledge and skills for improving the quality and safety of patient care Foster inter-professional, team based education and patient care

Changes in Clinical Education – Evaluation/Competency Theory and Practice of Teams and Teamwork Knowledge Skills Attitudes Miller’s Pyramid of Competency Knows - information Knows How – to use information Shows – how to use information ***** Does – performs in clinical setting

Changes in Physician Culture 1910 - 2010 The 20 th Century Physician The 21 st Century Physician Accumulate Knowledge Acquire and Use Knowledge Individual Scholarly Work Interdisciplinary Research Autonomous Cooperative Individual Achievements Solo Expert Collaborative Share Accountability Interdisciplinary Teams Coordination of Care

Patient Safety 1999 – Institute of Medicine Report “To Err is Human: Building a Safer Health System” Medical Error 8 th Leading Cause of Death 99, 000 Deaths Annually Non-technical Errors System Errors 7% Inpatients subjected to a medical error Cost – 8 to 29 Billion Annually

Patient Safety 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 delivery Develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety Disseminate effective strategies throughout the health care industry

Patient Safety 2003 – JCAHO – National Patient Safety Goals 3 of 7 Goals Non-technical skills Instituted Safety Practices Clinical Effectiveness of “Safe Practices” 2004 – The 100 K Lives Campaign Rapid Response Teams AMI Guidelines Prevent Adverse Drug Events (ADE) Prevent Central Line Infections 2005 – Resident Work Hour Limits

Patient Safety 2005 – Patient Safety and Quality Improvement Act Patient Safety Organizations (PSO) Limits Use of Reported Adverse Event Information Established a Network of Patient Safety Databases (NPSD) 2005 – Team. STEPPS 2006 – Keystone Project Team Approach to Decreasing Line Infections

Patient Safety 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

Healthcare Reform H. R. 3590 - Patient Protection and Affordable Care Act 3/23/2010 Expand 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

Healthcare Reform 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

How Effective is Team Training? What we know Microsystems over a define period of time What we don’t know Long-term outcomes 17

(Sexton, 2006) Johns Hopkins (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN 18

What are the obstacles to wider utilization of multidisciplinary simulation? Change is Hard Culture of “Silos” Culture of “Innovation” Lack of Transparency Error reporting systems

Making It Work Utilize Group Training for Tasks Define Our Teams “Micro-environments” Use Patient Safety Data to Drive Team Training Initiatives Clearly Define Team Objectives Use Established Team Training Methodology Team. STEPPS

Team. STEPPS Department of Defense – Do. D and AHRQ Research Based and Field Tested (MHS) Four Core Competency Areas Team Leadership Situation Monitoring Mutual Support Communication

Eight Steps of Change John Kotter Team Strategies & Tools to Enhance Performance & Patient Safety

“We can assure our patients that their care is always provided by a team of experts, but we cannot assure our patients that their care is always provided by expert teams” Allan S. Frankel, M. D.

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Bibliography Neville AJ, Norman GR. PBL in the Undergraduate MD Program at Mc. Master University: Three Iterations in Three Decades. Acad Med. 2007; 82: 370 -374 Morrison G, et al. Team Training of Medical Studnets in the 21 st. Century: 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. Qual. Saf Health Care. 2004; 13: i 72 -i 79 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 Med. Teams 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

Bibliography 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 Leape. L, 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. Team. STEPPS: Integrating. Teamwork Principles into Healthcare Practice. Patient Safety and Quality Healthcare. 2006 http: //www. psqh. com