Multidisciplinary Simulation Moving Clinical Education from Group Training to Team Training

1. Multidisciplinary SimulationMoving Clinical EducationfromGroup Training to Team Training Rhonda A. Sparks, M.D. Medical Director Clinical Skills Education and Testing Center University of Oklahoma – College of Medicine

2. 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?

3. Time for Change“The Perfect Storm”

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

5. 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 • McMaster University – 1969 • Social Unrest/Time of Experimentation…Educationally! • Canadian Universal Healthcare • Clinician Shortage

6. 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

7. 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

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

9. Patient Safety • 1999 – Institute of Medicine Report “To Err is Human: Building a Safer Health System” • Medical Error 8th 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

10. 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

11. 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 100K Lives Campaign • Rapid Response Teams • AMI Guidelines • Prevent Adverse Drug Events (ADE) • Prevent Central Line Infections • 2005 – Resident Work Hour Limits

12. 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 – TeamSTEPPS • 2006 – Keystone Project • Team Approach to Decreasing Line Infections

13. 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

15. 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

16. 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

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

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

19. 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

20. 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 • TeamSTEPPS

21. TeamSTEPPS • Department of Defense – DoD and AHRQ • Research Based and Field Tested (MHS) • Four Core Competency Areas • Team Leadership • Situation Monitoring • Mutual Support • Communication

22. Eight Stepsof Change John Kotter Team Strategies & Tools to Enhance Performance & Patient Safety

25. “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.

26. Tulsa Y’all come back now, ya hear? Oklahoma City

27. Tulsa High Rise

28. OKC High Rise

29. Yacht on Grand Lake

30. Yacht on Lake Hefner - OKC

31. Tulsa Speed Boat

32. OKC Speed Boat

33. Typical Tulsa Swimming Pool

34. Typical OKC Swimming Pool

35. Bibliography • Neville AJ, Norman GR. PBL in the Undergraduate MD Program at McMaster University: Three Iterations in Three Decades. Acad Med. 2007;82:370-374 • Morrison G, et al. Team Training of Medical Studnets in the 21stCentury: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. QualSaf Health Care. 2004;13:i72-i79 • 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 MedTeams 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

36. 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 • LeapeL,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. TeamSTEPPS:IntegratingTeamwork Principles into Healthcare Practice. Patient Safety and Quality Healthcare. 2006 http://www.psqh.com