ABMS ® Patient Safety Programs ABMS ® Patient Safety Improvement Program ABMS ® Patient Safety Foundations ABMS ® Qu

1. ABMS® Patient Safety ProgramsABMS® Patient Safety Improvement ProgramABMS® Patient Safety FoundationsABMS® Quality Improvement in Practice

2. ABMS Patient Safety Programs • ABMS has developed three online programs that provide leading edge content in patient safety and quality improvement (QI) • ABMS® Patient Safety Improvement Program • Comprehensive program providing patient safety curriculum, quality improvement fundamentals, performance improvement activities • ABMS® Patient Safety Foundations • Foundation level curriculum in key patient safety areas • ABMS® Quality Improvement in Practice • Quality improvement fundamentals and performance improvement activities • Programs are approved for AMA PRA Category 1 credit • Programs satisfy ABMS Maintenance of Certification® (ABMS MOC) requirements based on individual Member Board criteria

3. Goals and Objectives • The ABMS Patient Safety programs enable healthcare professionals to • Learn essential knowledge, skills and attitudes about patient safety • Apply the principles to improve care in their own clinical environments • Measure individual progress on changes made and provide feedback • Integrate acquired QI skills into local and national patient safety activities • Programs originally developed to satisfy ABMS MOC requirements, but are valuable resources for all healthcare providers regardless of MOC engagement or status

4. ABMS program development; alignment with other initiatives • ABMS program development • Based on current research and best practices • Guided by a blue ribbon advisory panel • Developed by subject matter experts in patient safety and quality improvement • Use evidence-based clinical performance measures • ABMS programs align with major initiatives • Joint Commission National Safety Goals • World Health Organization Patient Safety Solutions • ABMS programs address all six ABMS/ACGME competencies • Medical Knowledge, Professionalism, Communication & Interpersonal Skills, Patient Care, Systems-Based Practice, Practice-Based Learning and Improvement

5. Program Highlights • ABMS programs • Engage the learner using dynamic, Web-based technologies • Are self-contained with resource documents to guide through all exercises and activities • Include documents, sample forms, transcripts and references that may be printed and retained for future reference • Adapt to different learning styles • ABMS programs are applicable to • Clinicians, staff, leadership and administrators across the healthcare continuum • All physician profiles, including • Primary Care, Surgery/Proceduralist, Consultative, Non-Practicing • All clinical environments, including • In-patient, ambulatory, office practice

6. Program modules and options • Four key modules provide specific training and content • Three programs use different combinations of modules

7. Program contents, CME and ABMS MOC 1 - Based on AMA PRA Category 1 Guidelines for Performance Improvement Activities 2 - Based on AMA PRA Category 1 Guidelines for Enduring Activities 3 - Based on individual ABMS Member Board requirements

8. Improvement activities • Clinicians with direct patient care choose from: • Hand Hygiene • Medication Reconciliation • Allergy List • Critical Test Results Communication • Correct Site / Patient / Procedure • Safer Prescription and Order Writing • Discharge Planning • Clinicians not providing direct patient care (e.g. retired; administrators; researchers) choose from: • Safer Prescription and Order Writing (non-practicing version) • Critical Test Results Communication (non-practicing version)

9. Improvement activity structure • Improvement activities include • Case presentation (online) • Initial measurement using de-identified practice data (online) • Results benchmarked against national standards • Immediate feedback provided • Development/ implementation of improvement activity in the clinician’s practice setting (offline) • Re-measurement using de-identified practice data (online) • Results benchmarked against national standards • Immediate feedback provided • All instructions and resources to develop and implement improvement activities are included

10. Thank You. For more information, please contact: HealthStream (800) 521-0574 customer.service@healthstream.com ABMS (312) 436-2600 products@abms.org Patient Safety Improvement Program

11. Appendices • About ABMS • About ABMS Maintenance of Certification(ABMS MOC) • ABMS Patient Safety Programs Appendix • Curriculum Objectives • Improvement Activity Objectives • Sample Errors Illustrated • Contributors • Advisory Committee • Content Development Team Leaders

12. About American Board of Medical Specialties (ABMS) • ABMS… • is a not-for-profit organization comprising 24 medical specialty Member Boards (www.abms.org) • establishes standards for physician specialty certification and Maintenance of Certification (ABMS MOC) • communicates information about these standards to support the public’s quest for safe, high-quality healthcare. • serves as a unique and highly influential voice in the healthcare industry, bringing focus and rigor to issues involving specialization and certification in medicine

13. What is ABMS Maintenance of Certification(ABMS MOC)? • ABMS MOC is a process designed to document that physician specialists, certified by one of the Member Boards of ABMS, maintain the necessary competencies to provide quality patient care. • ABMS MOC assures that the physician is committed to lifelong learning and competency in a specialty and/or subspecialty using a process that is designed to keep certification continuous.

14. Competency Mapping

15. Patient Safety Improvement Program Appendix • Curriculum Objectives • Improvement Activities by Physician Profile • Improvement Activity Objectives • Sample Errors Illustrated

16. Patient Safety Curriculum Objectives • Epidemiology of Safety and Harm • Identify issues creating a national focus on patient safety • List common types, causes of adverse events • Define a system for classifying errors • Systems Approach to Patient Safety • Define a system • Identify workarounds and their effects on system • Identify healthcare system layers that impact care • Distinguish between error mitigation and error recovery

17. Patient Safety Curriculum Objectives • Communication • Recognize role that communication plays in patient safety • Identify barriers that affect patient/practitioner communication • Apply steps for disclosure of adverse events to patients • Improve information transfer from practitioner to practitioner • Safety Culture • Identify safety culture elements (beliefs, attitudes, values, risk and safety) • Identify the value of learning in creating, sustaining patient safety • Recognize relationship between reporting and learning

18. Improvement Activity by Physician Profile

19. ImprovementActivity Objectives • Hand Hygiene • Ensure use of appropriate hand hygiene for every patient encounter. • Medication reconciliation • Ensure that accurate and complete information on all patient medications is updated at every encounter. • Allergy list • Ensure that accurate and complete information on patient allergies is updated at every encounter.

20. Improvement Activity Objectives • Critical Test Results Communication • Improve the timely and effective communication of critical test results, including: • Reporting of information by specialties that provide results • Tracking and follow-up of results by specialties that receive them • Correct Person / Site / Procedure • Implement key changes to improve communication and prevent surgical errors in person, site, or procedure

21. Improvement Activity Objectives • Safer Prescriptions and Medication Orders • Avoid the use of terms from the Joint Commission’s Official “Do Not Use” List when writing prescriptions or medication orders • Discharge Planning • Improve provider-patient communication at the time of discharge from the hospital

22. Sample Errors Illustrated in ScenariosScenario #1 • “Sylvia” • 42-year-old female presented to the emergency department with a two day history of headache, neck pain, and photophobia • Errors illustrated: • HIV testing without informed consent • Delayed diagnosis • Drug prescribed despite known allergy • Wrong medication dosage • Lack of a robust system for lab result follow up

23. Sample Errors Illustrated in ScenariosScenario #2 • “Allison” • 2-year old with a history of prematurity, chronic lung disease and asthma, and congestive heart failure after Tetralogy of Fallot Repair • Errors illustrated: • Medication overdose • Lack of computerized physician order entry to alert the error at initial order • Shortage of trained personnel • Computer system failure (technology)

24. Sample Errors Illustrated in ScenariosScenario #3 • “Joan Morris” • 67-year-old female admitted to the interventional radiology service for cerebral angiography • Errors illustrated: • Wrong patient • Communication failures • Technology (computer) incompatibility between units • Flawed informed consent process

25. Sample Errors Illustrated in ScenariosScenario #4 • “Ms. Sinclair” • 30-year-old woman notices an abnormality on a monthly self-breast exam • Errors illustrated: • Abnormal test report delay • Wrong site surgery • No tumor board presentation • Communication failures • Inadequate test reporting systems and wrong site surgery prevention systems

26. Program Development • Advisory Committee of Patient Safety subject matter experts Peter B. Angood, MD Kerm Henriksen, PhD James P. Bagian, MD, PE John Hickner, MD, MSc Paul Barach, MD, MPH Lucian Leape, MD David W. Bates, MD, MSC Eric Marks, MD Eric Coleman, MD, MPH Marlene Miller, MD, MSc David M. Gaba, MD Niraj Sehgal, MD, MPH Paula Griswold, MS Ajit K. Sachdeva, MD • Content development teams led by curriculum and QI subject matter experts Carole M. Lannon, MD, MPH Julie K. Johnson, MSPH, PhD