Improving Patient Safety
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Transcript of Improving Patient Safety
Improving Patient Safety
Jason Zigmont, PhDSystem Director
Experiential Learning
22
33
Core Beliefs• We believe that everyone participating in
experiential learning activities is intelligent, well-trained, cares about doing their best and wants to improve. Adapted from the Center for Medical Simulation, Cambridge, MA
• The goal is to improve outcomes through experiential learning
Education does not equal learning
44
Bloom’s Taxonomy
55
Learning Outcomes Model
The Individual Experiences
Environment
•Well-Tuned Learning Orientation
•Mental Models
•Analogical Reasoning
•Challenging
•Emotionally Charged
•Mistakes or Errors
•Skilled Mentors
•Evidence Based Medicine
•Products and Protocols
Improved Patient
Outcomes
66
The Individual Experiences
Environment
•HR – Hiring/Recruitment
•Orientation
•Licensure/Certs
•LMS?
•Patient Mix
•Simulation
•Standardized Patient
•Six Sigma/Lean
•Policies
•New Equipment
Improved Patient
Outcomes
•Research/EBM
•Posters/Marketing
•Six Sigma
•Data Analysis
•Consultants
•Joint Commission
•CMS, ODH, etc.•HCAHPS
•SAQ, AOS
•RCAs
•Practice Updates
•Checklists
•Standardized work
•Purchasing
77
Examples • Handwashing• OR to ICU Handoff• TeamSTEPPS
88
Improving OR to ICU Handoff
99
TeamSTEPPS training
• Didactic vs Simulation
• Unit Based Training
• In-Situ Training
• Interdisciplinary Educator Team
– Nurse– Physician– Simulation Educator
• Scheduling…
• Measurement– Process Measures– Outcome Measures
1010
1111
QuestionTeam
TrainingN (%)
No Team Training
N (%)P value
In this unit, we discuss ways to prevent errors from happening again
16682%
12763.5%
0.001
Mistakes have led to positive changes here 14672%
11959.5%
0.007
Staff are not afraid to ask questions when something does not seem right.
15375.7%
11557.5%
0.001
Staff feel free to question the decision of actions of those with more authority.
12260.4%
8140.5%
0.001
Staff will freely speak up if they see something that may negatively affect patient care.
16782.7%
13869%
0.001
We are actively doing things to improve patient safety 18591%
16683%
0.01
We are given feedback about changes put into place based on event reports.
12461%
9949%
0.017
We are informed about errors that happen in this unit. 13767.8%
10251%
0.001
When one area in this unit gets really busy, others help 15978.7%
13165.5%
0.003
Results of the Safety Attitudes Questionnaire
1212
Steps to Success
• Identify Problem– Value/Impact?– Individual/Experience/Environment
• Create Buy-In/Assess Readiness– Management– Associates
• Identify the Change Team
• Define Implementation Plan
• Plan for Scheduling
• Sustainment…