Quality & Patient Safety
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1 QHI INTEGRATED CURRICULUM Quality & Patient Safety INTEGRATED CURRICULUM April 2015
2 QUALITY & PATIENT SAFETY INTEGRATED CURRICULUM Table of Contents Introduction QHI Integrated Curriculum Certificates... 5 AIW Yellow Belt Certificate...5 Alberta Health Services Improvement Way (AIW) Fundamentals...6 Patient Safety Certificate...5 Disclosing Unanticipated Medical Outcomes (DUMO)...8 Fundamentals of Patient Safety...9 Immediate and Ongoing Management of Clinically Serious Adverse Events Introduction to Human Factors Reporting & Learning System: How to Submit a Report AHS Systems Analysis Methodology (SAM) Teamwork at Times of Transition Patient Safety Online Learning Suite for Managers... 5 Appropriate Accountability Decision Support Tool...7 Immediate and Ongoing Management of Clinically Serious Adverse Events Managing Patient Concerns for Leaders: Patient Relations - ReLATE ReSPOND Reporting & Learning System: How to Submit a Report Reporting & Learning System Advanced User: How to Generate Data Reporting & Learning System Advanced User: Reading, Processing and Sharing Reports AHS Systems Analysis Methodology (SAM) Partnering with Patients Certificate...5 Patient & Family-Centred Care Patient Engagement Annual Continuing Education (ACE): Patient Relations - ReLATE ReSPOND Quality is Everyone s Business Certificate... 5 Alberta Health Services Improvement Way (AIW) Fundamentals...6 Fundamentals of Patient Safety...9 Living a Just Culture video Annual Continuing Education (ACE): Patient Relations - ReLATE ReSPOND Quality is Everyone s Business video Reporting & Learning System: How to Submit a Report Targeting Teams Certificate...5 Teamwork at Times of Transition Advanced Learning AIW Green Belt...24 AHS Systems Analysis Methodology (SAM)...25 Workshop in Simulation Education (WISE)...26 Meaning from Evidence Mini-Modules Patient Safety Snapshot Education Pyramid Appendix A Obtaining Continuing Medical Education (CME) Credits
3 QUALITY & PATIENT SAFETY INTEGRATED CURRICULUM Introduction The core quality and patient safety capabilities provide a framework for the Quality & Patient Safety Integrated Curriculum designed for all AHS staff and medical staff. The intent of the curriculum is to engage and support AHS employees and to incorporate and apply quality and patient safety principles into their respective roles - so that together we can transform our organization and improve healthcare outcomes for Albertans. Getting Started It is recommended that all new AHS employees fulfill the online AHS orientation and passport to Quality & Healthcare Improvement (QHI) through MyLearningLink, and then pursue the Quality & Patient Safety Integrated Curriculum. All AHS Staff are encouraged to complete the Quality is Everyone s Business module The learner is encouraged to collaborate with their leader/manager to build an individualized quality and patient safety learning plan, based on the course descriptions, learning outcomes and target audience guidelines provided. Quality & Patient Safety Education Certificates help the learner to target quality and patient safety education as it applies to their role. The learner can expect to complete a brief pre- and post-knowledge assessment at the time of the session, and may be contacted 4-6 weeks thereafter via survey to assess how they have applied their learning into their role within the organization. The course outline offers: course title and description target audience learning outcomes registration details next steps core capabilities the session addresses Questions about the Quality & Patient Safety Curriculum, and requests for targeted sessions or continuing education credits can be directed to: QPSE@albertahealthservices.ca RETURN TO TABLE OF CONTENTS 3
4 QUALITY & PATIENT SAFETY INTEGRATED CURRICULUM Throughout the Curriculum, are identified to capture the knowledge, skills, attitudes and behaviours required to support and enhance quality and patient safety within AHS. As you browse through the course descriptions, you will note that all are listed, however only those highlighted in BOLD are applicable to that course. CORE CAPABILITIES 1. Advocating and demonstrating patient centred care 2. Practicing effective communication and teamwork 3. Applying complex adaptive systems theory to patient safety 4. Participating in Continuous Quality Improvement 5. Modelling safe and ethical behaviour 6. Advancing evidence informed practice 7. Improving patient safety through maximizing human factors 8. Managing, reporting, analyzing, disclosing and learning from hazards, close calls and adverse events DEFINITIONS Actively engaging and partnering with patients and families in their care Collaborating with team members, demonstrating mutual respect, appropriately sharing accountabilities, and interdependent decision-making Anticipating and recognizing that a constellation of dynamic, interdependent factors within the healthcare system may contribute to patient outcomes and unexpected events Applying the AHS Improvement Way (AIW) as a common organization-wide approach for increasing efficiency, decreasing waste, managing variation, and measuring change Consistently demonstrating behaviours and attitudes in accordance with our AHS values, code of conduct and just culture principles Practice in accordance with professional codes of conduct and ethical principles Disseminating leading practices and applying evidence to safe and effective care Employing situational awareness, recognizing our collective human fallibility, and appreciating how the humanenvironment interface influences our cognition and behavior Preventing adverse events, employing risk awareness, recognizing and appropriately responding to hazards, close calls and adverse events RETURN TO TABLE OF CONTENTS 4
5 QHI CURRICULUM Certificates Quality & Healthcare Improvement offers Quality & Patient Safety Education Certificates to Alberta Health Services staff and Medical staff for quality & patient safety learning QUALITY IS EVERYONE S BUSINESS CERTIFICATE Foundational Learning in Quality Improvement & Patient Safety COMPONENTS:  ÂQuality is Everyone s Business: 10-minute video  ÂLiving a Just Culture: 3-minute video  ÂFundamentals of Patient Safety (FPS): 4-hour facilitated learning course  ÂAlberta Health Services Improvement Way (AIW) Fundamentals: 4 or 8 hour facilitated learning course  ÂAnnual Continuing Education (ACE): Patient Relations ReLATE ReSPOND : elearning  ÂReporting & Learning System (RLS): How to Submit a Report: elearning Time Commitment: 12 Hours All AHS staff and Medical staff PATIENT SAFETY CERTIFICATE Systems thinking and just culture principles informing reporting, disclosing, analyzing, learning and improving relative to hazards, close calls and adverse events COMPONENTS:  ÂFundamentals of Patient Safety (FPS): 4-hour facilitated learning course  ÂIntroduction to Human Factors (HF): 4-hour facilitated learning course  ÂTeamwork at Times of Transition (T3): 4-hour facilitated learning course  ÂReporting & Learning System (RLS) How to Submit a Report: elearning  ÂImmediate and Ongoing Management of Clinically Serious Adverse Events (IOM): elearning  ÂAHS Systems Analysis Methodology (SAM): elearning  ÂDisclosing Unanticipated Medical Outcomes (DUMO): 4-hour facilitated learning course Time Commitment: 20 Hours AHS Clinical staff, Operational Leadership, Medical staff and Patient Safety staff PATIENT SAFETY ONLINE LEARNING SUITE FOR MANAGERS Just in Time Patient Safety Learning for the Operational Manager COMPONENTS:  ÂReporting & Learning System (RLS) How to Submit a Report: elearning  ÂReporting & Learning System (RLS) Advanced User Module - Reading, Processing and Sharing Reports: elearning  ÂReporting & Learning System (RLS) Advanced User Module - Generating Data Summaries: elearning  ÂImmediate and Ongoing Management of Clinically Serious Adverse Events (IOM): elearning  ÂAHS Systems Analysis Methodology (SAM): elearning  ÂAppropriate Accountability Decision Support Tool: elearning  ÂPatient Relations - ReLATE ReSPOND Managing Patient Concerns for Leaders: elearning Time Commitment: 4 to 6 Hours Operational Managers and Leaders AIW YELLOW BELT CERTIFICATE Foundational performance improvement learning leading to an AHS Green and Black Belt Certificate COMPONENTS:  ÂAlberta Health Services Improvement Way (AIW) Fundamentals: 4 hour/8 hour facilitated learning course  ÂAIW Yellow Belt Module 1: Process Mapping  ÂAIW Yellow Belt Module 2: 5S Workplace Organization  ÂAIW Yellow Belt Module 3: Standard Work Time Commitment: 10 Hours All AHS staff and Medical staff PARTNERING WITH PATIENTS CERTIFICATE Partnering with Patients and Families is key to positive outcomes, patient satisfaction and Patient Safety COMPONENTS: ÂÂPatient Engagement 101: elearning  ÂPatient & Family-Centred Care 101: elearning  ÂAnnual Continuing Education (ACE): Patient Relations ReLATE ReSPOND : elearning Time Commitment: 3 Hours All AHS staff TARGETING TEAMS CERTIFICATE Teamwork contributes to system efficiencies, shared mental models and Patient Safety COMPONENTS:  ÂTeamwork at Times of Transition (T3): 4-hour facilitated learning course Time Commitment: 4 Hours AHS Clinical teams (CLICK ON EACH COURSE TITLE TO HYPERLINK TO THE PAGE FOR COURSE DESCRIPTION) 5
6 Alberta Health Services Improvement Way (AIW) Fundamentals All AHS staff and Medical staff This eight-hour course (which can also be offered as a four-hour targeted session) provides an overview of the Alberta Health Services Improvement Way, with particular focus on immediate problem-solving opportunities for quick wins and activities that will allow participants to directly apply their learning using a simulated process. Participants will learn about the Alberta Health Services Improvement Way, practice AIW thinking and methods and will be equipped to apply learning solutions to every day problem-solving opportunities. To obtain a Yellow Belt certificate, participants must also complete three AIW online sessions on key aspects of improvement: Process Mapping, 5S Workplace Organization Methodology, and Standard Work. The modules are available on MyLearningLink. All three modules are required to receive a Yellow Belt certificate. Demonstrate understanding of key quality improvement principles, via post-knowledge assessment by: Awareness of AIW tools and principles to make improvements in work area Identifying a quick win upon returning to the workplace 6
7 Appropriate Accountability Decision Support Tool Clinical leads, Supervisors, Managers, Medical staff, and Senior Administrative staff The AHS Appropriate Accountability Decision Support Tool is a module designed to provide a consistent, standardized approach to assessing the need for an individual accountability review when the unexpected or unanticipated occurs in the system. Best used after the unexpected occurs, the manager considers if the situation warrants an Administrative Review, employing the AHS just culture principles. This does not impact whether a Systems Review would occur and both would be conducted independently. Demonstrate understanding of complex adaptive systems theory and just culture in relation to appropriate accountability by: Distinguishing between when care is reasonable and when care is not reasonable as evidenced by professional standards of practice and codes of conduct, organizational policies and procedures, the substitution test of what a similarly trained and experienced, and what the prudent and ethical practitioner would do in these circumstances Making the distinction between a Patient Safety Systems Review and a Quality Administrative Review Recognizing that in exceedingly rare circumstances is there intent to harm Relate application of just culture, via follow-up electronic surveys, as evidenced by: Appreciating that although we are all accountable for our own actions, we cannot control system deficiencies Valuing human fallibility in that holding one person responsible for an error does not prevent the error from recurring in the system 7
8 Disclosing Unanticipated Medical Outcomes Healthcare professionals such as Nurses, Managers and Medical staff who will be involved in disclosure conversations with patients and families This powerful four-hour facilitated course provides the participant with insight into the patient and family experience following an unanticipated outcome; how expectations are created and what happens when the organization s response does not meet these expectations. The class provides the opportunity to learn about and discuss disclosure as a large group and to practice disclosure discussions in small groups. The significance of an apology, the ALEE Technique when care is reasonable, and the TEAM Technique when care is not reasonable, are all employed. Demonstrate understanding of disclosure principles, via pre- and post-knowledge assessment by: Differentiating between the appropriate information to be shared in the initial phase of disclosure and the stages of disclosure thereafter Understanding how patients and families experience adverse outcomes, how expectations develop, and how not meeting expectations can result in disappointment Relate application of disclosure principles by managing disclosure with a patient and family through to resolution, via follow-up electronic surveys by: Acknowledging and apologizing Participating in disclosure meetings with the patient and family Offering practical and/or emotional support Investigating and committing to disclosure of findings 8
9 Fundamentals of Patient Safety All AHS staff and Medical staff This four-hour facilitated course introduces patient safety principles, illustrated through healthcare examples and participant activities. The following key principles serve as a framework for the course: Complex adaptive systems theory Identifying and reporting hazards, close calls and adverse events Defining just culture Optimizing human factors The value of inter-professional and collaborative teamwork, and the significance of the patient and family s role in patient safety Demonstrate understanding of key patient safety science principles, via pre- and post-knowledge assessment by: Differentiating hazards, close calls and adverse events Identifying aspects of how patients want to be involved in their care Recognizing characteristics of a just culture Relate recognition and application of patient safety processes via follow-up electronic surveys, as evidenced by: Reporting of hazards, close calls and adverse events via the Reporting and Learning System for patient safety Modeling patient safety practices with peers, teams, patients and their families Providing examples of a shift to systems thinking from person thinking Advocating and encouraging an active role for patients and families in the promotion of patient safety 9
10 Immediate and Ongoing Management of Clinically Serious Adverse Events (IOM) Module Clinical leads, Supervisors, Managers, Medical staff, and Senior Administrative staff When the unexpected happens, a clear understanding of roles and responsibilities becomes even more important. This 30-minute interactive elearning module provides just-in-time learning of the prioritized steps involved in the Immediate and Ongoing Management of Clinically Serious Events guideline, embedded in the Just Culture Guiding Principles and complex adaptive systems theory. Demonstrate understanding of responding appropriately when an adverse event has occurred by: Defining a clinically serious adverse event Describing the immediate and ongoing roles and responsibilities of AHS staff, Medical staff and leaders when a clinically serious adverse event occurs Defining the acronym RESPOND as it relates to the Immediate and Ongoing Management of a Clinically Serious Adverse Event Relate application of responding appropriately to an adverse event, via electronic surveys by: Conducting an initial assessment as the Accountable Leader, or referring to the Accountable Leader to determine the appropriate immediate and ongoing organizational response Demonstrating compassion and empathy to patient, family and staff in the immediate response and management of a clinically serious adverse event Citing adherence to the Immediate and Ongoing Management of Clinically Serious Adverse Events guideline 10
11 Introduction to Human Factors Frontline healthcare professionals interfacing with devices, equipment and complex environments This four-hour facilitated course applies human capabilities and human limitations to the interaction between people, equipment and environments. The history of human factors and how it transitioned into healthcare, the principles of human factors as they relate to healthcare, as well as specific human factors projects instituted within AHS are presented. Exercises in the course help participants to discover our shared human fallibilities. The course concludes with practical tips on how to recognize potential human factors-related complications in the workplace and strategies to address them. Demonstrate understanding of human factors, via pre- and post-knowledge assessment by: Recognizing how human factors is applied in healthcare Categorizing types of error Identifying ways to apply human factors to practice Relate application of optimizing human factors, via follow-up electronic surveys by: Reporting and removing faulty equipment and devices from practice setting Referring unsafe work-arounds and variable processes to appropriate educator or leader 11
12 Living a Just Culture Video All AHS staff and Medical staff An engaging three-minute video that defines what living a just culture looks like within Alberta Health Services (AHS). This video serves as an introduction to and promotion of the AHS Just Culture Guiding Principles. After viewing this video you will: Describe what a just culture is Describe the seven Just Culture Guiding Principles Identify why a just culture is important Demonstrate what a just culture looks like Describe what you can do to promote a just culture 3. Applying complex adaptive systems theory to patient safety 6. Advancing evidence informed practice 12
13 Managing Patient Concerns for Leaders: Patient Relations - ReLATE ReSPOND Supervisors, Managers and Medical staff The resolution of patient concerns is the responsibility of all AHS staff, Management and Medical staff, and contributes to continuous system improvements in the delivery of quality care. This 30-minute self-paced elearning module uses a case study to prepare managers and leaders to work through the patient feedback review process and to manage patient concerns, as outlined in the AHS Patients Concerns Resolution policy and procedure. Demonstrate understanding of the role and responsibilities of the leader in managing concerns, via electronic surveys by: Describing a leader s responsibilities as it relates to patient concerns Identifying how to respond to a complainant in an effective manner Applying the appropriate steps to take when managing a concern 13
14 Patient & Family-Centred Care 101 All AHS staff with patient and family encounters A 30-minute elearning module that demonstrates how, when we listen and value patient and family perspectives and choices, patients and families are encouraged to actively participate in the process of, and decision-making in their care. Demonstrate understanding of practicing Patient & Family-Centred Care by: Differentiating between patient engagement and Patient & Family-Centred Care Describing why Patient & Family-Centred Care applies to collaborative practice Identifying the four principles of Patient & Family-Centred Care Describing what Patient & Family-Centred Care looks, sounds and feels like for each guiding principle Relate application of effective Patient & Family-Centred Care, as evidenced by follow-up electronic surveys by: Demonstrating how we listen and value the patient and family s perspectives and choices, by encouraging them to actively participate in decision-making relative to their care Describing how to apply Patient & Family-Centred Care to practice by implementing tools and practices to improve the patient experience 14
15 Patient Engagement 101 All staff with patient and family encounters A 30-minute elearning module that introduces the concept of patient engagement to AHS staff and Medical staff, designed to improve quality outcomes by effectively engaging patients at all levels of decision making across the organization. Demonstrate understanding of effectively engaging patients and families by: Differentiating between patient engagement and Patient & Family-Centred Care Identifying five factors to consider for successful patient engagement Describing the levels of patient engagement Defining leading practices for patient engagement Relate application of effective patient engagement, as evidenced by follow-up electronic surveys by: Appreciating the importance of involving patients and families through all aspects of the healthcare system Actively seeking input and feedback from patients and families Determining a team s readiness when working with a patient advisor 15
16 Annual Continuing Education (ACE): Patient Relations - ReLATE ReSPOND All AHS staff with patient and family encounters Managing the feedback presented by patients is a component of delivering quality care and is an important learning resource for care issues and service improvements. The Patient Relations online videos review the Patient Relations - ReLATE ReSPOND processes: Uneasy Listening Part 1: Patient Relations - Understanding and Using the Patient Concerns Resolution Uneasy Listening Part 2: Using ReLATE to engage patients and families Uneasy Listening Part 3: Using ReSPOND to resolve concerns as they arise Uneasy Listening Part 4: When Patient Relations becomes involved Demonstrate understanding of effective communication with patients and families through: Accessing the AHS Patient Concerns Resolution Process policy Supporting patients and families on how to make a complaint Awareness of some potential reasons as to why patients complain Relate application of effective communication with patients and families, as evidenced by follow-up electronic surveys by: Anticipating, actively listening, acknowledging and responding to patient and family expressed needs Advocating for, and engaging patients and families, in collaboratively defining and achieving care goals 16
17 Quality is Everyone s Business All AHS staff and Medical staff A 10-minute video that defines the dimensions of quality, as well as patient safety science, Patient & Family-Centred Care principles, and performance improvement methodologies. This module serves as an introductory gateway to the Quality & Patient Safety Integrated Curriculum. Demonstrate an understanding of how quality influences healthcare providers at the frontline by: Describing key quality principles, as defined under the HQCA Dimensions of Quality Identifying the core capabilities that underlie the Quality & Patient Safety Integrated Curriculum Recognizing services provided through Quality & Healthcare Improvement are represented in the Quality & Patient Safety Integrated Curriculum 3. Applying complex adaptive systems theory to patient safety 17
18 Reporting & Learning System (RLS): How to Submit a Report All AHS staff and Medical staff This 20-minute module was designed to help AHS staff and Medical staff become proficient in submitting an RLS Report for adverse events, close calls and hazards as well as understand how reporting improves patient safety. Demonstrate an understanding of how a just culture informs reporting of adverse events, close calls and hazards, contributing to organizational learning, via electronic surveys by: Applying reporter responsibilities as outlined in the Alberta Health Services Reporting of Clinical Adverse Events, Close Calls and Hazards policy Gaining proficiency in submitting reports into the Reporting & Learning System (RLS) 18
19 Reporting & Learning System (RLS): Advanced Users - Generating Data Summaries RLS Advanced Users This 20-minute elearning module was designed to support Advanced Users, including managers and administrative leaders, to become proficient in using the analysis functions in the Reporting & Learning System (RLS) by generating graphical data analysis based on RLS Reports received from the area(s) of responsibility. This is the second of two modules developed for Advanced Users. You are encouraged to review the module - Reporting & Learning System (RLS): Advanced Users - Reading, Processing and Sharing Reports. Demonstrate an understanding of how a just culture informs reporting of adverse events, close calls and hazards, contributing to organizational learning, via electronic surveys by: Gaining proficiency in creating data summaries from Reporting & Learning System (RLS) reports and applying results to system improvements Gaining awareness of the following Reporting & Learning System (RLS) functions: My Reports New Search Design a Report Dashboards 19
20 Reporting & Learning System (RLS): Advanced Users - Reading, Processing and Sharing Reports RLS Advanced Users This 30-minute elearning module was designed to support Advanced Users, including managers and administrative leaders, to become proficient with their accountabilities as outlined in the Alberta Health Services Reporting of Clinical Adverse Events, Close Calls and Hazards policy. This module guides Advanced Users on how to read, process and share reports received from these area(s) of responsibility. This is the first of two modules developed for Advanced Users. You are encouraged to review the next module - Reporting & Learning System (RLS): Advanced Users - Generating Data Summaries. Demonstrate an understanding of how a just culture informs reporting of adverse events, close calls and hazards, contributing to organizational learning, via electronic surveys by: Differentiating between the three types of permissions in the Reporting & Learning System (RLS) Gaining proficiency in reading, processing and sharing Reporting & Learning System (RLS) reports Adding attachments Setting and changing passwords 20
21 AHS Systems Analysis Methodology (SAM) elearning Module Clinical Safety leaders, Clinical Quality Improvement consultants, Supervisors, Managers, Medical staff and Senior Administrative staff Reviewing and learning from adverse events is essential to improving patient safety. This one-hour elearning module was developed to prepare managers and leaders to conduct or participate in a patient safety review using the AHS Systems Analysis Methodology (SAM). As the participant applies the methodology to an online case, the importance of considering the complexities of the healthcare system (considering the equipment, environment, team, etc.) that may have contributed to an adverse event, using a team approach, becomes evident. Demonstrate understanding of analyzing adverse events and the application of the AHS Systems Analysis Methodology via electronic surveys by: Describing the four foundational principles of the Systems Analysis Methodology Identifying when to conduct a Patient Safety Review, or a Quality Assurance Review under Section 9 of the Alberta Evidence Act Differentiating concise, comprehensive and aggregate review methods Applying the Systems Analysis Methodology to conduct a case study review 21
22 Teamwork at Times of Transition Frontline healthcare professionals who work in inter-professional teams This four-hour facilitated course is primarily comprised of experiential learning opportunities to practice and apply structured communication and critical language tools. Effective teams work collaboratively and respectfully, employing shared decision-making and shared mental models. Communication strategies such as: briefings, debriefings; using structured language tools such as isobar; using critical language tools, such as CUS ( I am concerned, I am uncomfortable, and this is a safety issue ); closing communication loops; using checklists and team huddles are all addressed in this course. Demonstrate understanding of effective teamwork, via pre- and post-knowledge assessment by: Recognizing structured communication tools offer a framework for conversations addressing what is working well and what may need improvement to ensure quality care Defining structured communication tools, such as SBAR, isobar, NOD and CUS Defining situational awareness and shared mental model as they relate to effective teamwork Identifying strategies to ensure optimal communication and to reduce the potential for error Relate application of structured communication, via follow-up electronic surveys, by: Standardizing team processes and communication creating interdependent decision making and actions Using structured communication tools to optimize communication Using critical language tools to speak up and seek clarity Participating in briefings or debriefings Using check-back or read-back strategies to create a shared mental model Advocating for the patient and family to be active participants in team communication and processes 22
23 QHI CURRICULUM Advanced Education Quality & Healthcare Improvement Advanced Learning Programs AIW GREEN BELT CERTIFICATE Advanced performance improvement learning for a Green Belt Certificate, demonstrating skill on improvement opportunities COMPONENTS: ÂÂObtain an AIW Yellow Belt Certificate  ÂComplete 5-day AIW Greenbelt Training workshop /OR self-study  ÂRegister for and pass AIW Green Belt exam (exam prep course recommended) ÂÂComplete AIW Project ÂÂProject review by Review Panel Time Commitment: Approximately 3-6 months / complete AIW Project All AHS staff or Medical staff who meet the prerequisites AHS SYSTEMS ANALYSIS METHODOLOGY (SAM) Demonstrate understanding of analyzing adverse events and application of the AHS Systems Analysis Methodology (SAM) COMPONENTS:  ÂIdentify internal and external resources for information and data gathering  ÂRecognize characteristics of and conduct interviews using supportive interviewing techniques  ÂDevelop a Timeline and describe the difference between Timelines 1 and 2  ÂIdentify components of a Constellation Map and complete a Safer Matrix and/or Constellation Map  ÂDevelop recommendations relative to a SAM analysis Time Commitment: 8 Hours Clinical Safety Leaders, Supervisors, Managers, Physician Quality leads, and Senior Administrative staff WORKSHOP IN SIMULATION EDUCATION (WISE) Workshop in Simulation Education (WISE) is a foundational course designed to introduce participants to the techniques behind using simulation as an educational modality COMPONENTS:  ÂThrough experiential learning participants will learn how to integrate the theory behind designing, delivering, and debriefing into a successful simulation session Time Commitment: 2 Days AHS staff with educational responsibilities using simulation (CLICK ON EACH CERTIFICATE TITLE TO HYPERLINK TO THE PAGE FOR COURSE DESCRIPTION) 23
24 Alberta Health Services Improvement Way (AIW) Green Belt Certification All AHS staff or Medical staff who meet the prerequisites An AIW Green Belt is a proven practitioner of improvement methods who is skilled at explaining the value/role of the AIW and guiding individuals and teams in applying it to real AHS improvement opportunities. A Green Belt Certificate is a significantly more advanced level of achievement, and requires demonstration of knowledge and ability to use AIW skills on real improvement opportunities. An examination and improvement project review are key elements of the assessment. Steps to Green Belt Certification 1. Obtain an AIW Yellow Belt Certificate 2. Complete 5-day AIW Greenbelt Training workshop /OR self-study the materials 3. Register for and pass AIW Green Belt exam (exam prep course recommended) 4. Complete AIW Project Review (submitted project will be reviewed by the review panel and should be complete ) Demonstrate understanding of effective teamwork via pre-/post-knowledge assessment by: Clearly defining opportunities (What is wrong? Why is it important?) and establishing goals for improvement Documenting current-state and future-state work processes; using process knowledge to analyze and evaluate Selecting and supporting appropriate measures, gauge current (baseline) performance and evaluate improvement Applying creative and analytical stills to develop, test and validate improvement actions and results Developing effective change management plans and actions to build support for improvement projects and solutions Documenting and sharing learning of improvement experiences, including successes and challenges RETURN TO QHI CURRICULUM ADVANCED EDUCATION CERTIFICATES OVERVIEW 24
25 AHS Systems Analysis Methodology (SAM) Clinical Safety leaders, Supervisors, Managers, Physician Quality leads, and Senior Administrative staff Reviewing and learning from adverse events is essential to improving patient safety. This blended learning opportunity builds on concepts learned in the SAM elearning module through experiential learning, including group work, role play and simulation. Participants will work through the AHS Systems Analysis Methodology, with the support of expert facilitators, developing both individual skills and working with other participants on developing capability in the team approach. Demonstrate understanding of effective teamwork via pre-/post-knowledge assessment by: Identifying two internal and two external resources for information and data gathering Recognizing characteristics of supportive interviewing Identifying the components of a Constellation Map Describing the difference between Timeline 1 and Timeline 2 Demonstrate understanding of analyzing adverse events and application of the AHS Systems Analysis Methodology via electronic surveys by: Developing a Timeline Conducting interviews using supportive interviewing techniques Completing a Safer Matrix and a Constellation Map Developing effective recommendations 3. Applying complex adaptive systems theory to patient safety RETURN TO QHI CURRICULUM ADVANCED EDUCATION CERTIFICATES OVERVIEW 25
26 Workshop in Simulation Education (WISE) AHS personnel with educational responsibilities that are using, or wish to use simulation as an educational modality. WISE is a two-day foundational course designed to introduce participants to the techniques behind using simulation as an educational modality. Through experiential learning, participants will integrate the theory behind designing, delivering, and debriefing into a successful simulation session. By the end of the course, participants will design and run their own simulation and facilitate the debriefing that follows. Participants will: Understand the essential elements of a simulation session Identify principles of effective teamwork skills (such as SCore - Simulation Core Curriculum) Learn and apply tools for effective debriefing Participate in scenario development and facilitate a simulation scenario Clinical managers or Physicians interested in improving team performance should contact the Provincial simulation program, esim (educate, simulate, innovate, motivate) and Workshops in Simulation Education (WISE). For further information: esim.booking@albertahealthservices.ca Call Provincial esim Booking: RETURN TO QHI CURRICULUM ADVANCED EDUCATION CERTIFICATES OVERVIEW 26
27 QUALITY & PATIENT SAFETY JUST-IN-TIME LEARNING Just-in-Time Learning (JIT) Just-in-Time learning provides staff and medical staff access to education that can be immediately applied to their practice setting. We offer three modes of just-in-time learning: 1. One hour awareness sessions that are amenable to staff meetings, committee meetings, and webinars; 2. A series of interactive webinars through ilearning that showcase powerful stories exemplifying quality and patient safety principles (search webinar in MyLearningLink): and 3. Mini-modules or short elearning modules that are about five minutes in length providing Meaning from Evidence to inform improvement. Meaning from Evidence Mini-Modules The following mini-modules are available through MyLearningLink. Meaning from Evidence: Histograms After viewing this module you will be able to: 1. Describe a Histogram and how it is used to interpret data 2. Describe if a process is consistent by examining the distribution 3. Interpret a Histogram using AHS data Meaning from Evidence: Pareto Charts After viewing this module you will be able to: 1. Describe a Pareto Chart and how it is used to interpret data 2. Describe the 80/20 Rule 3. Interpret a Pareto Chart using AHS data Meaning from Evidence: Scatter Plots After viewing this module you will be able to: 1. Describe a Scatter Plot and how it is used to interpret data 2. Describe the various types of correlations 3. Interpret a Scatter Plot using AHS data Meaning from Evidence: Run & Control Charts After viewing this module you will be able to: 1. Describe a Run Chart and how it is used to interpret data 2. Describe a Control Chart and how it is used to interpret data 3. Identify Common Cause Variation and Special Cause Variation RETURN TO TABLE OF CONTENTS 27
28 QUALITY & PATIENT SAFETY JUST-IN-TIME LEARNING Just-in-Time Learning (JIT) Just-in-Time learning provides staff and medical staff access to education that can be immediately applied to their practice setting. We offer three modes of just-in-time learning: 1. One hour awareness sessions that are amenable to staff meetings, committee meetings, and webinars; 2. A series of interactive webinars through ilearning that showcase powerful stories exemplifying quality and patient safety principles (search webinar in MyLearningLink): and 3. Mini-modules or short elearning modules that are about five minutes in length providing Meaning from Evidence to inform improvement. Patient Safety Snapshot The following 1-hour sessions offer an opportunity to learn about a Patient Safety topic in a quick snapshot with opportunity for questions and discussion. Moving from a Person Approach to a Systems Approach After attending this session, you will be able to: 1. Describe the scope of the patient safety problem 2. Define close calls, hazards and adverse events 3. Describe the difference between the person approach and the systems approach to error 4. Describe a Patient Safety Culture in the context of four attributes Understanding Human Error (in development) After attending this session, you will be able to: 1. Describe how human limitations can contribute to error in a complex adaptive system, such as healthcare 2. Recall some specific human limitations that can impact healthcare providers 3. Describe ways in which Human Factors is applied in AHS Disclosure of Harm After attending this session, you will be able to: 1. Recall key aspects of the AHS Disclosure of Harm policy 2. Describe two types of apology and their appropriate use 3. Define the AID technique 4. Define the second victim Introduction to Structured Communication & Critical Language After attending this session, you will be able to: 1. Advocate for the patient and family to be active participants in team communication and processes 2. Define situational awareness and shared mental model as they relate to effective teamwork 3. Define examples of structured and critical language communication tools 4. Identify strategies to ensure optimal communication and reduce the potential for error These are offered by Targeted Session via the below. General Inquiries: Please QPSE@albertahealthservices.ca RETURN TO TABLE OF CONTENTS 28
29 QUALITY & PATIENT SAFETY INTEGRATED CURRICULUM QHI Quality & Patient Safety Education Pyramid ORGANIZATIONAL ROLES ALL AHS STAFF AND MEDICAL STAFF Making Improvements Everyday CLINICAL PROVIDERS Partnering with Patients to Improve our System CHAMPIONS Leading Improvement MANAGERS SITE, SECTION, PROGRAM MEDICAL LEAD Coaching Improvement EXECUTIVE & SENIOR LEADERS SENIOR MEDICAL DIRECTORS ZONE MEDICAL DIRECTORS Sponsoring Improvement LEARNING OPPORTUNITIES BY ROLE Quality is Everyone s Business Certificate Prosci Participant Partnering with Patients Certificate Targeting Teams Certificate AIW Yellow Belt Certificate Prosci Participant AIW Green Belt Certificate Prosci Adviser or Influencer Partnering with Patients Certificate Targeting Teams Certificate AIW Green Belt Certificate Patient Safety Certificate Online Patient Safety Learning Suite Prosci Leading Change Leadership Bootcamp Prosci Executive Sponsor GREEN BLUE Learning for everyone within the organization Additional learning that best aligns with your role RETURN TO TABLE OF CONTENTS 29
30 QUALITY & PATIENT SAFETY INTEGRATED CURRICULUM Appendix A Obtaining Continuing Medical Education Credits for Courses within the Quality & Patient Safety Integrated Curriculum Royal College of Physicians and Surgeons of Canada All courses offered through the Quality & Patient Safety Integrated Curriculum may be applied toward Maintenance of Certification (MOC). In-person facilitated courses Online courses Exception: Disclosing Unanticipated Medical Outcomes Apply under Section 1 Group Learning (0.5 credits/hour) Apply for 0.5 credits per course under Section 2: Self-Learning under scanning This 4 hour AHS/IHC-C course is credited for Section 2 Self-learning CPD credits Certificates for completion are available from AHS Quality & Safety Education. While not usually needed for credit validation, the certificates may be useful to keep in your continuing professional development files. The College of Family Physicians Canada All courses offered through the Quality & Patient Safety Integrated Curriculum may be applied toward Maintenance of Certification (MOC). In-person facilitated courses Online courses Exception: Disclosing Unanticipated Medical Outcomes Apply for Mainpro M2 credits Apply for Mainpro M2 credits This 4 hour AHS/IHC-C course is credited for 4 Mainpro-M1 credits. Additional Mainpro-C credits are available if a linking learning to practice form is completed and submitted. Once logged in, proceed to the CPD area, select other related links and then select individual consideration form. Alternatively, you can submit a linking learning to practice form for Mainpro-C credits. Certificates for completion are available from AHS Quality & Safety Education. While not usually needed for credit validation, the certificates may be useful to keep in your continuing professional development files. RETURN TO TABLE OF CONTENTS 30
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