Thomas H. Gallagher, MD University of Washington

1. Thomas H. Gallagher, MD University of Washington

2. Curricular deficiencies • Curriculum focused mostly on history-taking • Ignores MD communication with other healthcare providers • Communication training insufficiently intense • Failure to recognize communication as skill • “Bedside manner”--can’t be taught (or measured) • Communication discounted as “soft,” “touchy-feely” • Little opportunity to practice, get feedback • Learners struggle to apply general skills to specific situations • Culture of medicine values technical proficiency over interpersonal skills

3. Patient satisfaction • Ethics, professionalism • Complaints, malpractice claims • Health outcomes • Safety culture, transparency; disclosure and reporting of adverse events and errors

4. Allows learner to practice complex communication skills, receive feedback in safe environment • Allows learners to confront communication dilemmas that are important but uncommon • Types of simulations • (role plays, interactive computer cases, rehearsal) • Standardized patients

5. Standardized patients are individuals trained to: • Present consistent scenario • Be reliable observers of behavior • Offer feedback • Extensively validated as assessment tool • Now used in high-stakes certifying exams • Increasingly used as research methodology

6. Recognize communication as a skill • Can be learned, practiced, improved, discussed with colleagues • Worthy of learner’s attention • Need cases that take learners out of their comfort zone without overwhelming them • Ability to practice, receive feedback on key skills

7. Creating high-fidelity cases • Identifying key observable skills • Communication incredibly complex task • Easy for learners to express socially desirable behaviors

8.  Designed to assess whether simulation improves healthcare workers’ knowledge, attitudes, and skills in two areas: • Team communication about error • Error disclosure to patient

9. Growing experimentation with disclosure approaches • New standards • State laws re disclosure, apology • Increased emphasis on transparency in healthcare generally

10. Many harmful errors not disclosed to patients • When disclosure does take place, it often falls short of meeting patient/family expectations

13. What do team members owe one another? • Absolute loyalty? • Falling on sword? • What are roles of different team members in the disclosure process?

14. Practicing physicians & nurses • 40 nurse-physician teams (½ surgeons and OR nurses; ½ medical physicians and nurses) • 40 control group teams • Actors • 1 standardized team member per team • Plays role of hospital administrator • Helps team progress through simulation, think out loud • 1 standardized patient per case, 2 cases per simulation • 12 Risk Manager “Coaches”

16. 1. Team discussion and planning for disclosure • Team discusses what happened, responsibility for the error, and plan what they will disclose to the patient • 2. Team Error Disclosure • The team discloses the error to a standardized patient

17. Acknowledge error occurred • Offer facts regarding error • Solicit and respect team members’ views of what happened • Negotiate differences respectfully • Avoid blaming; respond appropriately to blaming behavior • Respond empathetically to team members’ emotions

18. Plan roles for disclosure discussion • Advocate for full disclosure • Identify core content of full disclosure • Explicit statement that error occurred • What happened, implications for patient health • Why it happened • How will recurrences be prevented • Explicit apology • Anticipate patient questions and emotions and plan team responses • Negotiate differences respectfully

19. Team member introductions • Empathetic disclosure of core content • Ask patient what they know about error • Explicitly state that error occurred • Implications for patient health • Solicit patient questions, respond truthfully • Make explicit apology • Explain how recurrences will be prevented • Avoid blaming team members; resist patient’s attempts to fix blame • Empathetic communication with patient • Plan for future meetings

21. Web assessment • Case-based: 2 cases, 2 different team approaches • Knowledge, skills, attitudes assessed tied to coaching priorities and simulations • Participants complete web-based assessment pre and post training • Controls take web assessment (pre and post) but without the training • Other data sources • Videos of simulations • Debriefing interviews with participants

22. Patient admitted to ICU with recurrent seizures • Given loading dose of Dilantin (300 TID), then switched to 300 QD • Physician writing transfer orders to floor mistakenly writes for larger loading dose • Error not noticed by nursing, pharmacy • Patient falls, hits head; Dilantin level 29. Head CT normal • Patient thinks another seizure caused her fall

28. Simulation design • Maximizing learning potential of simulation • Skilled coach essential • Maximizing case fidelity • Nature of events • Choice of case • Actor training • Interprofessional interaction • Role of standardized team member in simulation • Especially important in engaging “Silent team member” • Simulation implementation • Managing logistics of recruitment, scheduling a major undertaking • Coordinate schedules of two clinically active subjects, 3 actors, risk manager coach, at least two team members for each session

29. Immersive simulation around communication possible outside simulation center • Even senior clinicians found experience educational • Providing expert coaching, feedback is key • Logical challenges can be substantial • Multiple opportunities for communication simulations on other interprofessional topics

30. Thomas Gallagher (PI) – Medicine • Lynne Robins-Medical Education • Sarah Shannon – Nursing • Peggy Odegard – Pharmacy • Sara Kim – Medical Education • Doug Brock – Medical Education • Carolyn Prouty – Project Manager • Odawni Palmer – Support Staff • Andrew Wright-Surgery