Preparing to Teach Quality Improvement and Patient Safety A Workshop in the Teach for UCSF Certificate Program Henry Crevensten, MD Associate Professor of Clinical Medicine San Francisco Veterans Affairs Medical Center April 2016

Workshop Outline In the next two hours: Review learning objectives [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Workshop Outline In the next two hours: Review learning objectives Perform Introductions, goals Review the Pre-test Experiential session: groups will go over learning objectives and role model a student interaction. Then pair share about a QI/PS issue. Project session: groups/pairs will discuss their QI/PS issues and how they might design a project. Skills assessment and evaluation Preparing to Teach Quality Improvement and Patient Safety April 2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Learning Objectives By the end of this workshop, participants will be able to: Define Quality Improvement and Patient Safety Converse using terminology associated with QI/PS such as: quality gap, needs assessment, PDSA, LEAN, six-sigma Define types of errors in medical practice Describe how areas for improvement might be identified Describe a framework for how QI/PS may be taught in a clinical setting Preparing to Teach Quality Improvement and Patient Safety April 2016

Introductions For each participant, tell us: Your name [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Introductions For each participant, tell us: Your name Department, specialty/discipline Your interest in Quality Improvement and Patient Safety (QI/PS) Any particular issues that have come up with trainees re: QI/PS In the interest of time, we may select a just a few individuals or topics (some have responded on the pre-test) Preparing to Teach Quality Improvement and Patient Safety April 2016

Review Pre-Requisite Materials [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Review Pre-Requisite Materials Readings: what was relevant / useful? Preparing to Teach Quality Improvement and Patient Safety April 2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 QI/PS Terminology Quality Improvement Systematic, data-guided activities designed to bring about immediate improvement in health care delivery in a particular setting Patient Safety a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Its goal is to minimize the incidence and impact of, and maximize recovery from, adverse events Quality Gap The difference between a known effective intervention and its actual implementation Preparing to Teach Quality Improvement and Patient Safety April 2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 QI/PS Terminology Root Cause Analysis (RCA)  a technique used to identify trends and assess risk that can be used whenever human error is suspected with the understanding that system, rather than individual factors, are likely the cause of most problems PDSA Cycle A cyclical process that uses small changes to systems before proceeding to larger interventions Six Sigma A strategy to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. This involves measuring process outcomes, calculating a defect metric, and attempting to reduce process variation. LEAN A strategy to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. This involves measuring process outcomes, calculating a defect metric, and attempting to reduce process variation. Preparing to Teach Quality Improvement and Patient Safety April 2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Types of Error Medical Error The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Ex: diagnostic error, procedural error Adverse Event An injury caused by medical management rather than the patient’s medical issue Error of Omission A procedure or intervention that failed to be undertaken lead to patient morbidity or mortality Preventable Adverse Event An adverse event that was the result of an error or system design flaw Preparing to Teach Quality Improvement and Patient Safety April 2016

Experiential Session Group discussion: [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Experiential Session Group discussion: We can use a case from one of you or example case: You are provider in clinic precepting a student. The student is seeing a woman who is worried she might be pregnant and your plan is to send off a urine sample. The patient provides a urine sample but in the process of sending it to the lab notices that it is not labeled and that there are several other urine samples waiting. The student is concerned that the urine samples might get mixed up. Discussion: - Loop this case back to the learning objectives: is this a quality or safety issue? what type of error is this? How might other errors of this type be identified? What is the quality gap? - discuss professionalism and bad/good role modeling Preparing to Teach Quality Improvement and Patient Safety April 2016

Experiential Session Small Group discussion: [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Experiential Session Small Group discussion: Use the case/example you brought to the workshop, and discuss in pairs. Try to make this inter-professional if possible Activity guide: one participant acts as the student and one (or more) participants act as the instructor student should bring up QI/PS issue (i.e. possibility for mislabeled specimen) instructor should model professionalism in responding AND how to address the error with the patient (i.e. because the specimen might be mislabeled, we need a new specimen) instructor should teach some aspect of QI/PS re: the incident (i.e. what type of error, is it a systems issue/provider issue) instructor should go over framework for addressing the issue: process mapping, driver diagrams, incorporating other disciplines, LEAN/6-sigma Preparing to Teach Quality Improvement and Patient Safety April 2016

Presentation of Findings [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Presentation of Findings Small Group discussion: Groups/pairs should present a brief synopsis of their case, what they felt during the role play and what they learned, and any conclusions they can share with the rest of the group. Preparing to Teach Quality Improvement and Patient Safety April 2016

Wrap-Up Review learning objectives once more. [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Wrap-Up Review learning objectives once more. Have your goals been met? Future workshops Post Test Preparing to Teach Quality Improvement and Patient Safety April 2016

Additional Resources IHI [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/6/2018 Additional Resources IHI For additional readings, see suggested list from the UCSF Department of Medicine here: https://medicine.ucsf.edu/safety/resources/ Preparing to Teach Quality Improvement and Patient Safety April 2016