How To Improve Patient Safety And Quality Improvement In Pgme

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1 How to effectively incorporate patient safety and quality improvement into PGME Amy Nakajima University of Ottawa/Bruyère Continuing Care Sherissa Microys University of Ottawa/The Ottawa Hospital Li Peckan Children s Hospital of Easter Ontario Saturday, October 25, 2014

2 I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. J ai (ou j ai eu) une affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Amy Nakajima speaker for Canadian Patient Safety Institute (Canadian Patient Safety Officer course) Date: Saturday, October 25, 2014

3 I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. J ai (ou j ai eu) une affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Sherissa Microys Received a speakers honorarium from Roche Site P.I. on a study for Bayer Date: Saturday, October 25, 2014

4 I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Li Peckan Date: Saturday, October 25, 2014

5 Incorporating PS/QI into PGME Nakajima, Peckan & Microys Learning Objectives At the end of this session, participants will be able to: 1. Describe The Safety Competencies framework 2. Link Safety Competencies to CanMEDS Roles 3. Construct a teaching encounter that incorporates a safety competency or an opportunity for quality improvement 4. Consider an appropriate method of assessment The International Conference on Residency Education La Conférence internationale sur la formation des résidents 5

6 Goal of this session: Consider how to teach PS and QI competencies to our trainees using an approach that: Is meaningful and engaging Highlights the PS/QI content of your current teaching, both formally and informally The International Conference on Residency Education La Conférence internationale sur la formation des résidents 6

7 The Six Steps The International Conference on Residency Education La Conférence internationale sur la formation des résidents

8 Step 1: Define the Problem Determine What is Meaningful

9 What is keeping you awake at night?

10 The problem named is the problem solved Clearly state the problem articulate the gap between the current reality and the behaviour that should be demonstrated Activity: 2 min write down your patient safety or quality problem 3 min share with a colleague how well did you formulate the issue? 3 min Debrief on challenges and helpful hints

11 Step 2: Describe the Background & the Current Conditions How do you know that there is a problem?

12 How do you know that it s a problem?

13 What are you seeing, hearing or reading that indicates a patient safety or quality issue exists? Clearly state the problem articulate the gap between the current reality and the behaviour that should be demonstrated Activity: 2 min describe the qualitative or quantitative data that points towards the patient safety or quality problem 3 min share with a colleague how clearly did you provide a context for the issue? Does the background information lead you to re-define the safety or quality issue that needs addressed? 3 min Debrief on challenges and helpful hints

14 Step 3: Drill Down to the Root Cause(s) of the Problem

15 Root Cause Fishbone Diagram Cause(s) Effect Process Policy Place Adverse Impact Provider Patient Physical Equipment

16 Root Cause S.H.E.L. Malloy, O Boyle. The SHEL Model: A Useful Tool for Analyzing and Teaching the Contribution of Human Factors to Medical Error. Acad Med 2005: 80: Hardware: Machines Instruments Software: Procedures Protocols Training Environment: Physical Political Cultural Financial Liveware: Patient/Family Team Other Providers

17 Middle of the night, very busy call, very busy weekend 3rd year pediatrics resident Young boy, post-op Ventricular tachycardia Defibrillated Called to see another patient Receives STAT call back to see this patient Patient is in ventricular tachycardia with BP Resident applies paddles and defibrillates

18 BUT The defibrillator is set at adult settings Child has received 5 X amount of joules He is in sinus rhythm No burns Machine had been turned off after initial defibrillation When turned back on, automatic reset to factory settings

19 And then I felt physically ill after this happened I stated that I needed to call the attending to let him know what happened, and to complete an incident report. I was told very firmly by the charge nurse that I was not permitted to do so. She stated that we would all be in a lot of trouble for being so careless.

20 The child is fine. This was very stressful and resulted in much lost sleep and guilt worrying that someone would find out. I felt I was being extremely dishonest and was ashamed about the error and not admitted to it. As well, the parents were not present at the time and were never told of the event. Hartfield D. Defibrillator Misadventure Case. Curriculum-on-the-Go, KEN, CAPHC website. CurriculumontheGo/Domain+1+Lesson+Plan%28s%29

21 Back to the case Child defibrillated with 5x more joules than indicated; No harm done Nurse in charge tells resident not to disclose to anyone Resident feels extremely guilty What are the root causes of the patient safety or quality improvement concern that you can identify from this scenario?

22 What is causing the problem? Use the fishbone or S.H.E.L model to drill down to the root-causes of the safety or quality problem that must be addressed Activity: 3 min Brainstorm & drill down on the root causes of the issue with a partner 7 min Debrief on the root causes as a group How would you prioritize the issues to be addressed? 4 min drill down on the root causes of your own issue

23 Step 4: Determine the Learning Objectives

24 What Does Good Look Like? What is the problem or issue? Refer to clinical standards and expectations: Clinical Practice Guidelines Institutional protocols/policies Required Organization Practice In the context of an educational framework:

25 Drivers Consider your stakeholders in creating your educational encounter: Educational Organizational Medico-legal/Regulatory

26

27

28 QI Leadership

29

30 How do the Patient Safety Domains map to CanMEDS Roles?

31 Copyright 2009 The Royal College of Physicians and Surgeons of Canada. Reproduced with permission.

32 Domain 1: Contribute to a Culture of Patient Safety A commitment to applying core patient safety knowledge, skills & attitudes to everyday work

33 Domain 2: Work in Teams for Patient Safety Working within interprofessional teams to optimize both patient safety and quality of care

34 Domain 3: Communicate Effectively for Patient Safety Promoting patient safety through effective health care communication

35 Domain 4: Manage Safety Risks Anticipating, recognizing & managing situations that place patients at risk

36 Domain 5: Optimize Human & Environmental Factors Managing the relationship between individual & environmental characteristics to optimize patient safety

37 Domain 6: Recognize, Respond to & Disclose AE Recognizing the occurrence of an AE / CC & responding effectively to mitigate harm to the patient, ensure disclosure and prevent recurrence Photo courtesy of the Canadian Medical Protective Association

38 Triple C Competency-based Curriculum 38

39 Triple C Competency-based Curriculum 39

40 Work collaboratively with your Residents to define specific improvements in their performance Activity: 5 min describe what good performance would look like as if you were watching this skill or competency being demonstrated on a video Link the improvement to the CANMeds Roles & safety competencies that you are targeting 3 min Debrief on challenges and helpful hints

41 Step 5: Design the Learning Encounter

42 WHO, is going to do WHAT, by WHEN? Spectrum of teaching: Formal Informal Incidental Match the teaching modality to the moment

43 Formulate the main actions that will be taken to develop the competencies of your Residents Activity: 5 min list the specific steps that you and your resident(s) will take to close the gap in their performance regarding the patient safety or quality improvement issue 3 min share your plan with your colleague

44 Step 6: Choose The Assessment Method Follow-up & follow-though

45 Choice of Assessment Method Depends on: 1. The original safety or quality issue 2. The purpose of the teaching 3. Teaching modality and your relationship with the Trainee

46 How to Assess: Incidental Conversational feed-back Teach-backs Role-play / just-in-time coaching Informal Direct observation with patient Encounter Cards Portfolios and Logbooks Formal Simulation Based Assessment Standardized Patients Written: essay, multiple-choice questions Structured Oral Examinations (SOEs) Multi Source Feedback (360-degree evaluation) OSCE Objective Structured Clinical Examinations OSPRE Objective Structured Performance Related Exam

47 Determine how you will assess your Trainee(s) Activity: 3 min list the range of possible assessment methods that you will utilize for this learning encounter 5 min Open group discussion what are the challenges that you face when it comes to assessing your Residents?

48 Help us improve. Your input matters. Download the ICRE App, Visit the evaluation area in Pre-function Hall B, near Registration, or Go to: icreevaluations to complete the session evaluation. Aidons-nous à nous améliorer. Votre opinion compte. Téléchargez l application de la CIFR Visitez la zone d évaluation, au vestibule de la salle B, près du kiosque d inscription, ou Visitez le afin de remplir une évaluation de la séance. You could be entered to win 1 of 3 $100 gift cards. Vous courrez la chance de gagner l un des trois chèques-cadeaux d une valeur de 100 $.

49 Thank you for your time and attention! If you have any questions, or curiosities, then please contact: Amy at Sherissa at or Li at

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