Outpatient Systems Background Analyses: An Interprofessional � 4.5 million ambulatory care visits occur every year due to adverse drug events 1 Curriculum to Teach Patient Safety � 5% of adults in the United States experience a missed or delayed diagnosis each year 2 Presenter: Maya Dulay MD � Educating healthcare trainees in patient safety is a requirement Team: Krista Gager NP, Josue Zapata MD, David Margolius MD, � Promotes the Culture of Safety during a key JoAnne Saxe, NP developmental stage Systems Analysis (SA): � A tool to elucidate individual and systems factors that contribute to adverse events and near misses 1. Sarkar U, Health Serv Res. 2011;46:1517-1533 2. Singh H, BMJ Qual Saf. 2014;23:727-731 2 3/30/2016 Learning Objectives Setting and Participants • San Francisco VA Healthcare System is 1 of 7 VA Centers of Excellence in Primary Care Education (COEPCE), began 2011 1. Identify patient safety problems in ambulatory settings 2. Learn the systems analysis framework to apply to adverse events and near misses 3. Distinguish between individual and systems factors 4. Focus error prevention towards improving processes Interprofessional Sustainable and systems Collaboration Relationships Patient Centered QI/Patient Communication Safety 3 3/30/2016 4 3/30/2016 1 3/30/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Setting and Participants Outpatient SA Curriculum Design • Participants 2011-2015: Prep • 69 medicine residents • 20 NP students • Faculty emails trainee pairs intro and expectations • pharmacy resident (at least 2 weeks prior) • Each learner attends 2-3 one-hour SA sessions in 1yr and • Trainees choose personal case with near miss/adverse event presents 1 case as part of a pair • Mini case review: Trainee pairs prepare SA • Patient Safety Faculty: worksheet • 1 MD, 2 NP, Quality & Safety Chief Residents 4. Classify 1. Collect 2. Construct 3. Identify 5. Propose contributing information timeline key events solutions factors 5 3/30/2016 6 3/30/2016 Outpatient SA Curriculum Design Outpatient SA Curriculum Design Conference Wrap-up • Trainee teams submit final worksheet with updated recommendations • 2-3 Trainee teams present cases during one hour conference • Recommendations communicated to key • Review timeline, key events, identify adverse stakeholders by faculty event(s), sources of error • Small group discussion focuses on sources of • Clinic Leadership, Clinic QI Huddle Board, error and potential solutions Office of Systems Improvement • Faculty guides discussion and highlights learning • Idea generating for future Trainee QI projects points 7 3/30/2016 8 3/30/2016 2 3/30/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
SA Evaluation Results: Curriculum Evaluation 2011-15 SA session ratings by learners (n=160) Usefulness of discussion during the session 4.6 Usefulness of activities/exercises during the 4.6 session Estimated likelihood of making changes in 4.4 practice as a result of the session Overall quality of session 4.6 1 2 3 4 5 Ratings Scale 1= Poor, 2=Fair, 3=Good, 4=Very Good, 5=Excellent 9 3/30/2016 10 3/30/2016 Conclusions and Lessons Learned Conclusions and Lessons Learned • SAs can be a springboard for trainee-led QI projects and a • Highly rated, case-based approach to patient safety source of recommendations for clinic/facility leadership . education for interprofessional trainees in outpatient settings • Experiential learning an ideal medium to teach QI and PS • Communication errors were key contributing factors in our SAs -> helps inform and reinforce the importance of our COEPCE patient and IP communication curriculum 11 3/30/2016 12 3/30/2016 3 3/30/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Acknowledgements • QI & PS Team: • JoAnne Saxe, Krista Gager Questions? • Quality & Safety Chief Residents: ‒ Krishan Soni ‒ Aparna Goel ‒ Emily Gottenborg ‒ David Margolius ‒ Josue Zapata • Jessica Chen, Christine Generans, Gillian Earnest 13 3/30/2016 14 4 3/30/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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