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Improving Patient Safety Jason Zigmont, PhD System Director Experiential Learning.

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Presentation on theme: "Improving Patient Safety Jason Zigmont, PhD System Director Experiential Learning."— Presentation transcript:

1 Improving Patient Safety Jason Zigmont, PhD System Director Experiential Learning

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3 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

4 44 Blooms Taxonomy

5 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

6 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

7 77 Examples Handwashing OR to ICU Handoff TeamSTEPPS

8 88 Improving OR to ICU Handoff

9 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

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11 11 Question Team Training N (%) No Team Training N (%) P value In this unit, we discuss ways to prevent errors from happening again % % Mistakes have led to positive changes here146 72% % Staff are not afraid to ask questions when something does not seem right % % Staff feel free to question the decision of actions of those with more authority % % Staff will freely speak up if they see something that may negatively affect patient care % % We are actively doing things to improve patient safety185 91% % 0.01 We are given feedback about changes put into place based on event reports % 99 49% We are informed about errors that happen in this unit % % When one area in this unit gets really busy, others help % % Results of the Safety Attitudes Questionnaire

12 12 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…


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