peer to peer education: improving knowledge transfer

1. Peer to Peer Education: Improving Knowledge Transfer Helen Fernandez, MD, MPH Associate Professor Mount Sinai School of Medicine

2. Webinar Objectives By the end of this session, learners will: Discuss the impact of peer to peer education Define communication skills Define knowledge transfer Name 3 characteristics of effective communication to improve knowledge transfer Discuss barriers to effective communication

3. Case Scenario Margaret is a second-year family medicine resident During a case conference, she is presenting a follow-up case who was discharged from the hospital from the clinic to your team. �This is an 74 year old woman who came today to the clinic. She has a history of atrial fibrillation and hypertension. She was discharged from the hospital 2 weeks ago but I am unsure what they did. She was discharged on an antibiotic and her usual dose of coumadin. No one has checked her anticoagulation (INR) level in 2 weeks.�

4. Case Debrief Was her presentation helpful to others? Why or why not? What is missing from her presentation? How could she improve her presentation? What feedback would you provide Margaret? How will you fill in the gaps?

5. Patient safety Number of deaths that occur annually due to medical errors? 44,000 to 98,000 Total cost of these errors in 1997 17 to 29 billion dollars Key Content /Instructions (Time: 1 min) �How many deaths occur annually from medical errors?� Ask participants for their best guess, then click to show answer. �What was the total cost of these errors in 1997?� Ask participants for their best guess, then click to show answer. Medical errors are more common than we realize. 0.2-2% of hospitalized patients experience major permanent injury or death from their medical care, not due to underlying illness; extrapolating from this data: the annual number of deaths from medical errors is 44,000-98,000. These findings were first published in 1991! To emphasize the large proportion of deaths, it may be helpful to compare this number to the population of a town or university. Educational purpose History of patient safety and activism to create attitudinal shift/ buy-in. Background information for the facilitator Two studies of large samples of hospital admissions, one in NY using 1984 data and another in Colorado and Utah using 1992 data, found that the proportion of hospital admissions experiencing an adverse event, defined as injures caused by medical management, were 3.7 and 2.9 percent respectively. Methods: Records reviewed by specially trained nurses and medical records administrators Independent review by =2 board-certified physicians Presence of adverse events (kappa = 0.61) Presence of negligent care (kappa = 0.24) The proportion of adverse events attributable to errors (preventable adverse events) was 58% in NY and 53% in Colorado and Utah When extrapolated to the over 33.6 million admissions in 1997, the results of these two studies imply that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Total national costs (lost income, lost household productions, disability, healthcare costs) are between 37.6 billion and 50 billion for adverse events and between 17 and 29 billion for preventable adverse events. Healthcare costs account for over � of the total costs. *These studies were conducted on hospitalized patients -- a fraction of the total populations. These studies may underestimate the number of errors because they: Considered only those patients whose injuries resulted in a specified level of harm Maintained a high threshold in determining whether an adverse event was preventable or negligent (concurrence of two reviewers) 3. Only included errors documented in patient records. Thomas. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Medical care. 2000;38(3):261. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care. Apr 2004;13(2):145-151; discussion 151-142. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. Feb 7 1991;324(6):377-384. Key Content /Instructions (Time: 1 min) �How many deaths occur annually from medical errors?� Ask participants for their best guess, then click to show answer. �What was the total cost of these errors in 1997?� Ask participants for their best guess, then click to show answer. Medical errors are more common than we realize. 0.2-2% of hospitalized patients experience major permanent injury or death from their medical care, not due to underlying illness; extrapolating from this data: the annual number of deaths from medical errors is 44,000-98,000. These findings were first published in 1991! To emphasize the large proportion of deaths, it may be helpful to compare this number to the population of a town or university. Educational purpose History of patient safety and activism to create attitudinal shift/ buy-in. Background information for the facilitator Two studies of large samples of hospital admissions, one in NY using 1984 data and another in Colorado and Utah using 1992 data, found that the proportion of hospital admissions experiencing an adverse event, defined as injures caused by medical management, were 3.7 and 2.9 percent respectively. Methods: Records reviewed by specially trained nurses and medical records administrators Independent review by =2 board-certified physicians Presence of adverse events (kappa = 0.61) Presence of negligent care (kappa = 0.24) The proportion of adverse events attributable to errors (preventable adverse events) was 58% in NY and 53% in Colorado and Utah When extrapolated to the over 33.6 million admissions in 1997, the results of these two studies imply that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Total national costs (lost income, lost household productions, disability, healthcare costs) are between 37.6 billion and 50 billion for adverse events and between 17 and 29 billion for preventable adverse events. Healthcare costs account for over � of the total costs. *These studies were conducted on hospitalized patients -- a fraction of the total populations. These studies may underestimate the number of errors because they: Considered only those patients whose injuries resulted in a specified level of harm Maintained a high threshold in determining whether an adverse event was preventable or negligent (concurrence of two reviewers) 3. Only included errors documented in patient records. Thomas. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Medical care. 2000;38(3):261. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care. Apr 2004;13(2):145-151; discussion 151-142. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. Feb 7 1991;324(6):377-384.

6. Why Do Errors Occur? Workload fluctuations Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following a protocol Excessive professional courtesy Hidden agenda Complacency High-risk phase Strength of an idea Task fixation

7. Institute of Medicine Report Medical errors are the leading cause More Americans die from medical errors than from breast

8. How hazardous is health care? Key Content /Instructions (Time: 1 min) You would have to fly continuously for 438 years on 8 million flights before you would be die in a plane crash, yet much more publicity is focused on plane crashes than on medical errors. The risk of dying as a result of a medical error far surpasses the risk of dying in an airline accident, but more public attention is focused on improving safety in the airline industry. Americans also have a very limited understanding of healthcare safety issues. Educational purpose Puts the danger of health care into perspective. Background information for the facilitator www.ihc.com patient safety presentation Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. Feb 7 1991;324(6):377-384. Key Content /Instructions (Time: 1 min) You would have to fly continuously for 438 years on 8 million flights before you would be die in a plane crash, yet much more publicity is focused on plane crashes than on medical errors. The risk of dying as a result of a medical error far surpasses the risk of dying in an airline accident, but more public attention is focused on improving safety in the airline industry. Americans also have a very limited understanding of healthcare safety issues. Educational purpose Puts the danger of health care into perspective. Background information for the facilitator www.ihc.com patient safety presentation Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. Feb 7 1991;324(6):377-384.

9. A snapshot of recent news in the patient safety movement Key Content /Instructions (Time: 2 mins) Patient safety is a relatively young movement. In 1905, a case came before the Supreme Court, involving a female epileptic who sued her surgeon for removing her uterus and ovaries without telling her his intentions in advance. The surgeon argued that he had deceived the patient so that she would not resist having the �needed� procedure. The court ruled in favor of the patient, asserting that even the most �eminent� physician or surgeon cannot violate a patient�s body without prior consent. Researchers did not report the problem of patient safety in medical literature until the mid-1950s, nearly fifty years after this case. In the early 1970s, courts began forcing physicians to disclose to their patients not only the procedures to be performed, but the benefits and possible negative side effects. The 1980s and early 1990s were speckled with more and more patient safety and medical error horror stories. In more recent news, [Review slide]. Ask, �Is it surprising that only FIVE years ago the Joint Commission began requiring hospitals to disclose errors to patients? Is it surprising that many of us feel unskilled and/or uncomfortable with error disclosure?� Bob Wachter says the problem of medical errors was discovered in 1999. Why is that? This was not the first time a medical error occurred, rather, a number of prominent events placed errors in the public eye. (Include example of NY Times reporter receiving an overdose of chemotherapy.) Educational purpose Provide background on the history of the patient safety movement in order to assist with the attitudinal shift that will take place with our participants. Background information for the facilitator 2003: ABMS and the Council of Medical Specialty Societies convene panel of patient safety experts (ABMS: American Board of Medical Specialities was developed in 1933 out of concern for the quality of medical care delivered by doctors and maintains its mission to improve the quality of medical care in the US. The ABMS can make recommendations but does not mandate the actions that boards must take. Individual medical specialty boards set the standards required to achieve certification status. Nevertheless, the ABMS assists its member boards in developing professional and educational standards for the evaluation and certification of physicians) Kachalia A, Johnson JK, Miller S, Brennan T. The incorporation of patient safety into board certification examinations. Acad Med. Apr 2006;81(4):317-325. Key Content /Instructions (Time: 2 mins) Patient safety is a relatively young movement. In 1905, a case came before the Supreme Court, involving a female epileptic who sued her surgeon for removing her uterus and ovaries without telling her his intentions in advance. The surgeon argued that he had deceived the patient so that she would not resist having the �needed� procedure. The court ruled in favor of the patient, asserting that even the most �eminent� physician or surgeon cannot violate a patient�s body without prior consent. Researchers did not report the problem of patient safety in medical literature until the mid-1950s, nearly fifty years after this case. In the early 1970s, courts began forcing physicians to disclose to their patients not only the procedures to be performed, but the benefits and possible negative side effects. The 1980s and early 1990s were speckled with more and more patient safety and medical error horror stories. In more recent news, [Review slide]. Ask, �Is it surprising that only FIVE years ago the Joint Commission began requiring hospitals to disclose errors to patients? Is it surprising that many of us feel unskilled and/or uncomfortable with error disclosure?� Bob Wachter says the problem of medical errors was discovered in 1999. Why is that? This was not the first time a medical error occurred, rather, a number of prominent events placed errors in the public eye. (Include example of NY Times reporter receiving an overdose of chemotherapy.) Educational purpose Provide background on the history of the patient safety movement in order to assist with the attitudinal shift that will take place with our participants. Background information for the facilitator 2003: ABMS and the Council of Medical Specialty Societies convene panel of patient safety experts (ABMS: American Board of Medical Specialities was developed in 1933 out of concern for the quality of medical care delivered by doctors and maintains its mission to improve the quality of medical care in the US. The ABMS can make recommendations but does not mandate the actions that boards must take. Individual medical specialty boards set the standards required to achieve certification status. Nevertheless, the ABMS assists its member boards in developing professional and educational standards for the evaluation and certification of physicians) Kachalia A, Johnson JK, Miller S, Brennan T. The incorporation of patient safety into board certification examinations. Acad Med. Apr 2006;81(4):317-325.

10. Definition of Communication Skills A communication skills is a discrete mode by which a healthcare professional can further the clinical dialogue and thus achieve a strategy

11. Professionalism is the habitual and judicious use of � Communication Knowledge Technical skills Clinical reasoning Emotions Values Reflection in daily practice

13. Impact of Effective Communication Skills Enhances diagnostic efficiency, clinical outcomes, utilization of services and patient and healthcare professional satisfaction Decreases patient anxiety Improves team�s relationship and work output Decrease medical errors and increase patient safety

14. Better Communication=Better Knowledge Transfer

15. Knowledge Transfer Effective methods to introduce and implement more effective patient care based on evidence-based medicine

16. Standards of Effective Communication Complete Contains all important information Clarity Information can be plainly understood Concise Communicate the information in a brief manner Timely Offer and request information in a timely manner

17. Other Basic Skills to Effective Communication Listening Asking open-ended questions Asking closed questions Paraphasing Using Facilitators Assessing non-verbals Silence

18. Methods to Improve Communication with Peers Situation-Background-Assessment-Recommendation (SBAR) Teach-back or check-back Handoff

19. SBAR Communicate Situation�what is happening with the patient? Background�what is the clinical background? Assessment�what do you think is going on (problem identification)? Recommendation---what would I do or recommend?

20. Teach-Back or Check-Back Sender initiates message Receiver accepts message and provides feedback conformation Sender verifies message was received Checks for understanding of message I want to make sure I explained everything clearly Tell me X things I told you today What questions do you have?

21. Hand-off The transfer of information during transitions in care across the continuum; to include an opportunity to ask questions, clarity and confirm

22. �I PASS the BATON� Introduction: introduce yourself, role and patient Patient: identifiers Assessment: present the patient�s case Situation: current status, including treatment regimen, any recent changes Safety: any critical information such as allergies, alerts, laboratory values

23. �I PASS the BATON� The Background: previous medical history, medications Actions: what actions were taken or are required? Why? Timing: level of urgency Ownership: who is responsible? Next; what will happen next? What is plan?

24. More Tips to Improve Peer to Peer Communication Flexibility (your are not always right) Avoid distractions Be honest but with care Be comfortable with areas of gray Have integrity and build trust

25. Peers in Your Life Reflect on your peer group Discuss what you have learned from your peer, both positive and negative

26. Benefits of Peer to Peer Education To enhance intrinsic motivation To socialize and provide role models To alleviate teaching pressures To create a comfortable and safe educational environment To practice peer feedback To train leaderships and confidence

27. Working as a Team Improves Knowledge Transfer and Health Care Effective teams have been shown to: Improve quality, lower costs (Wagner, 2001) Decrease length of ICU stay (Shortell, 1994) Reduce medical errors (Silver, 2000) Improve outcomes for chronic conditions such as diabetes mellitus (Wagner, 2000) Key Content /Instructions (Time: 1 min) These articles show how interdisciplinary teams have impacted contemporary practice. Educational purpose Background information for the facilitator Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. Nov 2004;42(11):1040-1048. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. Feb 2001;27(2):63-80. Silver MP, Antonow JA. Reducing medication errors in hospitals: a peer review organization collaboration. Jt Comm J Qual Improv. Jun 2000;26(6):332-340. Wagner EH. The role of patient care teams in chronic disease management. Bmj. Feb 26 2000;320(7234):569-572.Key Content /Instructions (Time: 1 min) These articles show how interdisciplinary teams have impacted contemporary practice. Educational purpose Background information for the facilitator Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. Nov 2004;42(11):1040-1048. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. Feb 2001;27(2):63-80. Silver MP, Antonow JA. Reducing medication errors in hospitals: a peer review organization collaboration. Jt Comm J Qual Improv. Jun 2000;26(6):332-340. Wagner EH. The role of patient care teams in chronic disease management. Bmj. Feb 26 2000;320(7234):569-572.

28. Future Steps for Increasing Knowledge Transfer Workshops, webcasts, training programs, technical assistance in care delivery settings DVDs, �how to� guides, workbooks Presentations to healthcare operational leadership Live/web-assisted conferences Publications in peer-reviewed and trade journals