Quality Enhancement Plan Full Report - UT Southwestern · for interprofessional simulation-based team training for handovers. Faculty within our Academic Colleges, Health Professions

Southern Association of Colleges and Schools Commission on Colleges

Page 1 of 73 pages

“Better Communication - Better Care”

The University of Texas Southwestern Medical Center

Quality Enhancement Plan for the Southern Association of Colleges and Schools Commission on Colleges

On-Site Review March 26 – 28, 2019

Team Training for Students to Enhance Communication During Handovers by Putting the Team FIRST

Team FIRST

Face-to-Face

Interprofessional & Interactive

Reliable & Resilient

Safe for Synthesis

Team Training


Table of Contents Page 2 of 73 pages

Tab

Table of Contents

Table of Contents .................................................................................................................... Page 2

Abbreviations and Glossary ..................................................................................................... Page 3

I. Executive Summary ................................................................................................... Page 4

II. Process Used to Develop the QEP ............................................................................. Page 5

III. Identification of the Topic ......................................................................................... Page 8

IV. Desired Student Learning Outcomes ....................................................................... Page 10

V. Literature Review and Best Practice ........................................................................ Page 16

VI. Actions to be Implemented ...................................................................................... Page 21

VII. Timeline ................................................................................................................... Page 34

VIII. Organizational Structure .......................................................................................... Page 37

IX. Resources ................................................................................................................. Page 38

X. Assessment Plan ...................................................................................................... Page 40

XI. Appendices .............................................................................................................. Page 46

Appendix A: Debriefing Best Practices....................................................... Page 46

Appendix B: Content for Educational Experiences .................................... Page 47

Appendix C: Consultants and Team Science Collaborators ....................... Page 52

Appendix D: Assessment Instruments ......................................................... Page 58

Appendix E: Reaffirmation Committees and Subcommittees .................... Page 66

XII. References ................................................................................................................ Page 70


Abbreviations and Glossary Page 3 of 73 pages

Abbreviations Used in This Document

Abbreviation Definition AAMC Association of American Medical Colleges CC Core Competency CEPAER Core Entrustable Professional Activities for Entering Residency EMR Electronic Medical Record EPA Entrustable Professional Activity GSBS Graduate School of Biomedical Sciences HRO High Reliability Organization IDEAL Interprofessional Development, Education & Active Learning IP Interprofessional IPEC Interprofessional Education Collaborative KSAs Knowledge, Skills and Attitudes Med ED Medical Education MS1 1st year student, Southwestern Medical School MS2 2nd year student, Southwestern Medical School RCR Responsible Conduct of Research SHP School of Health Professions SLC Student Leadership Council SMIG Science of Medicine Interest Group SWAT Southwestern Academy of Teachers T2C Transition to Clerkships TeamSTEPPS Team Strategy and tools to Enhance Performance and Patient Safety TJC The Joint Commission UT University of Texas

Glossary of Terms in This Document

Structured Communication The understanding and application of using the SBAR structure to communicate during handover events.

Psychological Safety A belief that it is safe on this team in regards to interpersonal risk taking.

Mutual Trust The shared belief that team members will perform their roles and protect the interests of their teammates.

Closed Loop Communication Team members acknowledge receipt of messages during communication dialogue, usually characterized by a message being sent, acknowledgment of receipt and a follow-up from sender to ensure message was interpreted correctly.

Team Mental Model Organized knowledge structures that have commonalities across team members or complement team members


I. Executive Summary Page 4 of 73 pages

I. Executive Summary

The University of Texas Southwestern Medical Center’s 2019 Quality Enhancement Plan is entitled “Team FIRST.” The name underscores the importance of teams in healthcare by implicitly accepting that humans can and will err, yet resilient teams can be highly reliable. Further, it emphasizes the primacy of team-based communication in providing safer patient care. Since handovers are the ubiquitous teaming event in healthcare, the acronym “FIRST” points to the critical behaviors and conditions that must be present during handovers: 1. Face-to-Face Feedback, 2. Interprofessional and Interactive, 3. Reliable and Resilient, 4. Safe for Synthesis and 5. Team Training. Team FIRST provides a progressive series of interprofessional academic curricula designed to translate team-based communication during handovers into the clinical learning environment. By doing so, Team FIRST not only ensures student competencies in teamwork and communication but makes them active participants in the clinical transformation currently underway at UT Southwestern. Since many of our students will remain here as trainees, staff, and faculty, Team FIRST will help them become role models and local champions in our efforts to advance team-based care at our institution. For others, these experiences will help them influence similar clinical transformations occurring within the U.S. healthcare system. Team FIRST is innovative in several dimensions. Primarily, it is driven by, and for, students. The Offices of Quality, Safety, and Outcomes Education in conjunction with Office of Undergraduate Education has already engaged over 20 students in scholarly activities related to team-based care during handovers. Second, Team FIRST provides opportunities for scholarly activity for both students and faculty by constructing teams comprised of students, faculty scholars, human factors scientists, and executive sponsors within each of the program’s critical components. This ensures programs are acceptable, feasible, and hence likely to achieve widespread adoption locally and nationally. Third, Team FIRST integrates and applies the sciences of experiential learning, human factors, implementation, and safety to a common problem in healthcare. Successful execution of its objectives has the potential to produce national and international leaders in simulation-based education, patient safety, and quality improvement. Team FIRST is an ambitious undertaking that leverages many of the existing and emerging programs at UT Southwestern. Whereas our previous QEP introduced interprofessional curriculum for our students, the Transitions in Training curriculum, recently launched for medical students, is providing us an “on-ramp” for interprofessional simulation-based team training for handovers. Faculty within our Academic Colleges, Health Professions and programs in Nursing and Pharmacy, at other institutions, already involved in inter-professional activities, will be used to support Team FIRST’s expanded curriculum. Most importantly, Team FIRST has the potential to create greater synergy between existing programs within Academic Affairs and the Health System’s clinical learning environments. Team-based communication and care coordination are central to reducing preventable harms and creating joy-in-work for medical teams. The inclusion of experts in organizational psychology and human factors in our proposal facilitates the adaptation of principles successfully used in other high-reliability industries, like aviation, to our healthcare system. Our focus on handovers provides the opportunity to teach and reinforce behaviors critical to teamwork, such as honesty, discipline, humility, curiosity, and creativity. These educational experiences will provide students with the skills and confidence needed to serve as change agents in efforts to reduce harms associated with communication failures. In summary, Team FIRST is a high-impact proposal, which challenges us to utilize the full capabilities of our academic medical center to develop innovative curriculum as well as students and faculty capable of accelerating the clinical transformation occurring within UT Southwestern and around the world.


II. Process Used to Develop the QEP Page 5 of 73 pages

II. Process Used to Develop the QEP: INTRODUCTION The University of Texas Southwestern Medical Center consists of three degree-granting health-related schools: UT Southwestern Medical School, UT Southwestern School of Health Professions and UT Southwestern Graduate School of Biomedical Sciences. Our learners benefit from a faculty renowned for groundbreaking biomedical research, innovative educational programs and the delivery of complex medical care. Our University-based healthcare system has long-standing affiliations with large private, county, children’s, and Veterans hospitals serving the greater North Texas region in conjunction with UT Southwestern’s hospitals and clinics. The faculty is comprised of over 2,000 individuals. Each year we train over 2,200 medical, graduate and health profession students. State of Texas support for education? Ongoing support from federal agencies such as the National Institutes of Health, along with foundations, individuals and corporations provide more than $577 million per year to fund research projects. UT Southwestern has approximately 17,000 employees and a 2017-18 operating budget of $2.817 billion. UT Southwestern Medical Center Mission and Values UT Southwestern’s mission is promoting health and healthy society that enables the achievement of full human potential. We:

• EDUCATE Physicians, scientists, and caregivers optimally prepared to serve the needs of patients and society

• DISCOVER Research that solves for unmet needs by finding better treatments, cures, and prevention with a commitment to ensuring real-world application

• HEAL Best care possible today, with continuous improvement and innovation for better care tomorrow

UT Southwestern’s core values:

• Teamwork: We work collaboratively and with a shared purpose, drawing on our diverse backgrounds, talents, and ideas, and bringing unwavering integrity to everything we do.

• Compassion: We foster an environment in which patients, visitors, and colleagues are treated with respect, dignity, and kindness in every encounter, every day.

• Innovation: We endeavor to develop new knowledge about disease and treatment, enhance the lives of patients through better care and treatments, creatively approach challenges, and inspire the next generation of physicians, scientists and health professions.

• Excellence: We strive for the highest standards of clinical excellence, educational distinction, research integrity, and administrative quality in all we do. We are rigorous in our commitment to ongoing improvement.

Accomplishing the mission of UT Southwestern demands a continuous process of quality assessment and improvement. The SACS accreditation preparation and the development of the new Quality Enhancement Plan (QEP) was, is and will continue to be a vital part of UT Southwestern’s ongoing process of quality assessment and improvement. Following the procedures used in the development of the successful 2009 QEP, the SACS Steering Committee canvassed key stakeholders for input and appointed a QEP Steering Committee (Table II-1). The stakeholders included the Southwestern Academy of Teachers (SWAT), the student body and



representatives of the three schools. SWAT encompasses a group of elite UT Southwestern Medical Center educators nominated by Department Chairs and Academy members, with membership based on sustained excellence in one or more areas relevant to teaching and learning. Table II-1: Quality Enhancement Plan Development Steering Committee

Individual Position Administrative Title Robert Rege, M.D., Chair Professor, Surgery Assoc. Dean for Undergraduate

Medical Education James Amatruda, M.D., Ph.D.

Professor, Pediatrics, Internal Medicine and Molecular Biology

Carolyn Bradley-Guidry, MPAS

Associate Professor, Physician Assistant Program

Sanjana Balachandra, MS1 Medical student Kim Hoggatt Krumwiede, Ph.D.

Professor, Health Professions Director of Interprofessional Practice and Education, Assoc. Dean for Academic Affairs, School of Health Professions

Mikey Kutschke, MS2 Medical student Lynne Kirk, M.D. Professor, Internal Medicine Helen Mayo Faculty Associate, Library Angela Mihalic, M.D. Professor, Pediatrics Dean of Medical Students and

Assoc. Dean Student Affairs Sarah Pennant, GSBS Student

Graduate school student

Crystal Silva, SSHP Student

Health Professions student

Daniel Scott, M.D. Professor, Surgery Asst. Dean Simulation and Student Integration

Jeff Van Dermark, M.D. Professor, Emergency Medicine James Wagner, M.D. Professor, Internal Medicine Assoc. Dean for LCME

Accreditation and Student Outcomes Jennifer Cuthbert, M.D. ex officio James Drake ex officio Asst. Vice President, Office of

Academic Planning and Assessment Ramona Dorough ex officio

At the initial meeting of the QEP Steering Committee, the emphasis was on the importance of institutional support and broad involvement of faculty and students in the selection of the QEP. The committee reviewed the priorities of 4 of the rolling Six-Year Strategic Plan committees (Medical Education, Health Professions, Ph.D. & Postdoctoral Training and Student & Trainee Affairs) to ensure that the QEP aligns with institutional planning. After the presentation of solicited input from SWAT and the student body, the committee members discussed continued interprofessional education from 2009 QEP, cultural competency, leadership and teamwork as possible themes in addition to the use of simulation in assessing learning outcomes from the QEP. The next step involved ensuring broad input from many different sources (Faculty Senate, Student Leadership Council, individual schools and programs). The Faculty Senate serves as the representative body of the faculty for conception, review, and recommendation of policies affecting UT Southwestern Medical Center. The Student Leadership Council brings together student leaders from each of the three



schools to address issues of interest or affecting all UT Southwestern Medical Center students. The Student Leadership Council also serves as a standing institutional committee in the Six-Year Planning process. The committee members explored ideas and options with the constituents that they represented. Topics emerging from the three schools included wellness, interprofessional hospital visits, communicating medical research and communication between each other and to a lay audience. Both cultural competence and leadership development again occurred as topics. The committee’s next task was to choose a focus that met the goals of involving all our constituents, identifying needs and improving learning outcomes. Criteria for selection of 2019 QEP Topic

o Measurable improvement in learning objectives and clinical outcomes o Achievable within five years o Impact the largest possible number of our learners o Scope to be achievable using available and dedicated resources o Include support for faculty and student development o Extend previous efforts at fostering interprofessional understanding at all levels o Generate generalizable knowledge to serve communities internal and external to the UTSW

departments, programs, schools, and health care facilities o Align with Association of American Colleges (AAMC), Interprofessional Education Collaborative

(IPEC) and UT Southwestern Six-Year Plan priorities


III. Identification of the Topic Page 8 of 73 pages

III. Identification of the Topic: The focus of the 2009 QEP (CONVERGENCE) was improving interprofessional understanding and communication of disease, roles and responsibilities, and ethical behavior. This program is now an integral part of our academic curricula at UT Southwestern. It includes nurses, physicians, pharmacists, psychologists, physical therapists, physician assistants, rehabilitation counselors, prosthetists, orthotists, radiation therapists, and dietitians from our institution, Texas Woman’s University, Texas Tech University Health Sciences Center, and UT Arlington. These activities have allowed us to deal with and develop solutions for many of the barriers facing institutions that wish to provide interprofessional education. Building on the success of CONVERGENCE quickly became one of the foundations for the 2019 QEP. Also, taking advantage of a brand new, state-of-the-art simulation center became another core requirement. The possibilities discussed by the committee members at the second meeting included:

1. Continuation of interprofessional education 2. Expansion of simulation 3. Written and spoken communication, written in the electronic health record, spoken during crisis

communication and on interprofessional rounds 4. Teamwork: Requires communication and cultural competence 5. Entrustable Professional Activities (EPAs) 9 and 11: Communication and teamwork. EPAs are 13

activities that all medical students should be able to perform upon entering residency, regardless of their future career specialty.

6. Team disclosure of error: Requires communication 7. Informed consent and treatment refusal: Require communication 8. Incorporation of TeamSTEPPS® (Team Strategy and tools to Enhance Performance and Patient

Safety), successfully used in the health system and suitable for adaptation The QEP Steering Committee considered the inter-relationships between proposals and applicability to all three schools. The capability to build on the construct from CONVERGENCE was one of the most influential factors in selecting a topic for the 2019 QEP. In particular, it was essential to realize the goal of capitalizing on the already established learning communities to accomplish the parallel learning and later converging these communities to allow practice in interprofessional teams. List of Proposals

o Extend IPEC –based training to team-based communication and care o Include interactive, experiential training utilizing the new simulation center o Emphasis on communication, both written in electronic health record and spoken o Incorporation of leadership development into the proposal (student request) o Include existing or innovative models for team training (Team STEPPS®, other) o Teaching critical safety principals and conflict communication to enhance communication

A consensus quickly formed that improved communication in the clinical arena, especially by teams, represented an area of opportunity that would not only be pertinent at UT Southwestern but at every site where our students would seek further training or practice. However, further discussion with stakeholders revealed a sense that the theme was still too broad. Based on this input, the focus was narrowed to a critical aspect of team communication, team handovers (shift change, inter-departmental transfers of care) given it’s one of the most ubiquitous team event in health care, is mandated by a series of regulatory agencies and is believed to be one of the most common sources of medical errors. Ad hoc groups of steering committee members worked in parallel on defining student learning outcomes and reviewing the literature thereby further refining the topic into an achievable goal. Also, faculty with particular expertise in TeamSTEPPS® (Oren Guttman, M.D., Asst. Professor, Anesthesiology and Pain


III. Identification of the Topic Page 9 of 73 pages

Management) and psychometric measurements in the areas of training and assessment (Shannon Scielzo, Ph.D., Asst. Professor, Internal Medicine) joined the Steering Committee. Emerging Themes

o Interprofessional team-based communication valued as a top priority o Students would benefit from more interactive learning in high-quality simulations in the clinical

learning environment The core values of UT Southwestern Medical Center include teamwork, an emphasis of the 2019 QEP. The Six-Year Strategic Plan priorities also align closely with the 2019 QEP (Table III-1). Thus, the 2019 QEP directly relates to institutional planning efforts. Furthermore, topic selection involved processes that generated information and specific ideas from a wide range of constituents and was a representative process that considered institutional needs and the viability of the plan. Table III-1: Six-Year Plan Priorities Aligning with 2019 QEP

Subcommittee Priorities Medical Education Develop a centralized university simulation-based education program:

Implementation and monitoring of medical school simulation curriculum, development, and implementation of centralized GME curriculum, design and implement faculty development, promote simulation discovery/scholarly activity, and develop community outreach. This will require long-term planning and development.

Medical Education Clinical learning environment: The creation of the optimal learning environment is ongoing and will require long-term changes to achieve.

School of Health Professions

Ensure the continued development of the Interprofessional Education (IPE) training program within the school, medical center, local universities, and community.

Clinical Transformation

Patient-centric health care delivery reform: Develop an overarching vision, governance model, and financial framework for the development of patient-centric delivery models at UT Southwestern, with a focus on the optimal delivery of multidisciplinary, team-based care across the continuum of care.


IV. Desired Student Learning Outcomes Page 10 of 73 pages

IV. Desired Student Learning Outcomes: Team FIRST is designed to provide students with a progressive series of interactive and simulation-based training experiences to become competent in the individual- and team-based knowledge — skills, and attitudes required to conduct, influence and assess handovers in the clinical learning environment. CONVERGENCE, our last QEP, has become a series of campus-wide learning community events hosted annually by the Academic Colleges (Southwestern Medical School)t he Interprofessional Development, Education & Active Learning Teams (IDEAL) from the School of Health Professions and other non-UT Southwestern Affiliated Nursing and Pharmacy programs. Thus far, these learning communities have focused on 2 (of the 4) IPEC core competencies listed below – Role and Responsibilities for Collaborative Practice and Values and Ethics for Interprofessional Practice. Core competencies for interprofessional collaborative practice defined by IPEC (Figure IV-1) include:

1. Roles / Responsibilities for Collaborative Practice 2. Values / Ethics for Interprofessional Practice 3. Interprofessional Teamwork and Team-based Practice 4. Interprofessional Communication Practices

Figure IV-1: From (Core competencies for interprofessional collaborative practice: 2016 Update, 2016)

Team FIRST expands the student’s exposure to IPEC core competencies by focusing on “Interprofessional Communication Practices needed to promote Interprofessional Teamwork and Team-Based Practices. The Interprofessional Education Collaborative (IPEC) defines several sub-competencies for each core competency. Aligning these constructs of competencies with each school’s educational learning objectives will be essential. For example, in the medical school, the IPEC competencies must be mapped to the Core Entrustable Professional Activities for Entering Residency


IV. Student Learning Outcomes Page 11 of 73 pages

(CEPAER), which after their definition in 2014 (Core Entrustable Professional Activities for Entering Residency, 2014), were used to create the QEP’s goals. Team FIRST goals are as follows: Learners participating in Team FIRST will gain the individual and team-based competencies required to execute a structured handover of patient care by learning how to:

1. Understand the criticality of team-based communication and care and use of tools that promote a

more structured handover process. 2. Demonstrate an ability to conduct a structured handover based on a team mental model and mutual

trust. 3. Identify performance strengths and weaknesses by utilizing communication tools and exhibiting

psychological safety. 4. Conduct structured handovers in an uninterrupted environment and use communication and

psychological to improve handovers.



Table IV-1 illustrates how the IPEC sub-competencies and CEPAER map to the QEP’s and UT Southwestern goals.

2016 IPEC

Sub-Competency:

Interprofessional Communication

2017 CEPAER EPA 8:

Give and Receive a Patient Handover to

Transition Care Responsibility

2020-24 QEP Goals

“Learners will… ”

2018-2024 UTSW Six Year Plan (6YP)

HRO Principle, TJC

Express one’s knowledge and opinions to team members with confidence, clarity, and respect, working to ensure a common understanding of information, treatment, care decisions. Gives timely, sensitive, instructive feedback to (from) the team. (CC3, CC5)

Provide succinct verbal communication conveying illness severity, situation awareness, action planning, and contingency planning (transmitter)

ICS2 PC8

Understand the criticality of team-based care which entails establishing and recognizing the roles and responsibilities of team members Conduct structured handovers

Clinical Transformation: “The highest priority of clinical transformation should be … with a focus on the optimal team-based continuum of care” (6YP: p. 8)

HRO Principle: Commitment to Resilience: the ability to anticipate trouble spot and improvise.

Use respectful language appropriate for a given difficult situation, crucial conversation, or conflict. (CC6)

Give or elicit feedback about handover communication and ensure closed-loop communication (transmitter & receiver)

PBLI5 ICS2 ICS3

Exhibit mutual trust to ensure that patient care plans are developed cooperatively and collaboratively Employ communication tools to ensure that information exchanged is structured and closed-loop Clarify issues and concerns pertaining to quality and safe patient care

Medical Education Priority #3: “Transitions in Training are key areas for establishing an educational continuum and lifelong learning.” (6YP: p. 36) Simulation-based handoff planned for Transition-to-Clerkship and Resident Essential programs

6YP Six-Year Plan CEPAER Core Entrustable Professional Activities for Entering Residency HRO High reliability organization IPEC Interprofessional Education Collaborative TJC The Joint Commission



Table IV-1 QEP Objectives (continued)

2016 IPEC Sub-Competency

Interprofessional Communication

2017 CEPAER EPA 8

Give and Receive a Patient Handover to

Transition Care Responsibility

2020-24 QEP Goals

“Learners will… ”

2018-2024 UTSW Six Year Plan (6YP)

HRO, TJC

Recognize how one’s uniqueness (experience level, expertise, culture, power, and hierarchy within the health team) contributes to effective communication, conflict resolution, and positive interprofessional working relationships. (CC7)

Provide a clinical learning environment (CLE) that ensures interprofessional communication by educating, supervising and providing feedback to learners from faculty and other team members

Demonstrate psychological safety Exhibit team mental models so that all team members have a common understanding related to teams, processes, and tasks Reflect on performance episodes regarding one’s own performance as well as the performance of others that participated in the performance

“Education on patient safety, health care quality, and care transitions need to be ongoing priorities for the curriculum at both the GME and UME level.” (6YP: p.19)

Med ED priority #4: “The creation of the optimal learning environment will require long-term changes to achieve” (6YP: p.36)

Choose effective communication tools and technique to facilitate discussions and interactions that enhance team function. (CC1)

Document and update an electronic handover tool and apply this to deliver a structured verbal handover (transmitter) PBLI7 ICS2 ICS3 P3

Conduct structured handovers Employ communication tools to ensure that information exchanged is structured and closed-loop

TJC Sentinel Event Alert #58 Rec. #5: “Use EMR to enhance handoffs” (9/12/2017) TJC Provision of Care standard PC.02.02.01: EP – 2 – Structured Handover (2010)

Listen actively, and encourage ideas and opinions of the other members. Communicate the importance of teamwork in patient-centered care (CC4/8)

Conduct handover using communication strategies known to minimize threats to the transition of care

Conduct structured handoffs Mitigate interruptions to foster a focused handover Clarify issues and concerns pertaining to quality and safe patient care

“The simulation center provides an excellent resource for evaluation and documentation of core EPAs before graduation.” (6YP: p.22)



Table IV-2: Matching Learning Outcomes and Activities to QEP Goals and Objectives Parameter Description Educational Activities CONVERGENCE

Forum facilitating understanding of roles and responsibilities of interprofessional team members and team-based behaviors in the context of a diverse healthcare team.

Goals Understand the roles and responsibilities of each team member and how to promote decision-making. Appreciate the criticality of team-based communication during handovers. Implement appropriate communication tools to promote effective handovers.

Learning Outcomes 1) Understand the criticality of team-based care 2) Conduct structured handoffs 3) Employ effective communication tools

KSAs (Knowledge, Skills and Attitudes)

i. Know the roles and responsibilities of team members and teams (1); ii. Understand the criticality of team-based communication (1,3); Appreciate the importance of a structured approach to handovers (2); iii. Demonstrate closed-loop communication (3)

Educational Activities TRANSITION TO CLERKSHIP Simulation activity and interactive group discussion emphasizing proper handoff technique and highlighting common pitfalls.

Goals Understand the importance of handovers and demonstrate its primary tasks and behaviors. Appreciate how to develop a team mental model leads to delays in diagnosis and treatment. Appreciate the importance of mutual trust and understanding of patient’s needs by all team members.

Learning Outcomes 1) Conduct structured handoffs 2) Exhibit team mental models 3) Exhibit mutual trust


i. Know the anatomy of a structured handover (1) ii. Demonstrate essential behaviors for handovers (1)

iii. Contribute to team mental model by voicing roles and responsibilities (2) iv. Rely on team members to foster the development of care plans (3)

Educational Activities HUMAN FACTORS FOR CLINICAL LEARNING ENVIRONMENT Simulation and small group activity focused on integrating students’ preclinical team training within the CUH clinical learning environment (CLE).

Goals Clarify issues and voice concerns to promote safe care practices and quality handovers. Appreciate how hierarchical constructs can lead to information loss during handovers. Implement appropriate communication tools to promote effective handovers. Learn how to reflect on performance to determine areas for remediation

Learning Outcomes 1) Clarify issues and concerns 2) Demonstrate psychological safety 3) Employ effective communication tools



Parameter Description KSAs (Knowledge, Skills and Attitudes)

i. Ask clarifying questions (1) ii. Demonstrate the ability to identify gaps in psychological safety (2)

iii. Express concern for critical issues (1) iv. Demonstrate the ability to read back (2) v. Demonstrate the use of communication tools (3)

vi. Exhibit an accurate understanding of performance (4) vii. Articulate plans to improve performance when necessary (4)

Educational Activities POST-GRADUATE ESSENTIALS Simulation-based experience reinforcing proper team behaviors and handoff techniques. Evaluation of students’ progress and retention of previous knowledge, skills and attitudes material.

Goals Students will appreciate the importance of critical behaviors and tools in creating a more structured handover process. Students will be able to identify interruptions and leverage strategies to mitigate interruptions. Students will be able to appreciate how hierarchical constructs can lead to information loss during handovers. Students will implement appropriate communication tools to promote effective handovers.

Learning Outcomes 1) Conduct structured handoffs 2) Mitigate interruptions 3) Demonstrate psychological safety 4) Employ effective communication tools 5) Clarify issues and concerns


i. Demonstrate essential behaviors for handovers. (1) ii. Voice concern when an outside interruption occurs (2)

iii. Verbalize statements to foster the end of the interruption (2) iv. Demonstrate the ability to ask clarifying questions (3) v. Demonstrate closed looped communication (4)

vi. Advocate for structured handover process (1,4)

(Core competencies for interprofessional collaborative practice: 2016 Update, 2016; Core Entrustable Professional Activities for Entering Residency. Curriculum Developers’ Guide, 2014; Framework for Action on Interprofessional Education & Collaborative Practice, 2010; McTighe, 2004) Goals

1. Learners will understand the criticality of structured handovers and the most effective use of team members, tools (example: SBAR tool) and technology (electronic medical record) to reliably communicate critical information succinctly and effectively.

2. Learners will conduct handovers in a structured manner that promotes the development of mutual trust and team mental models to anticipate the most critical needs of the patient and their families.

3. Learners will develop the skills to clarify critical issues and voice concerns to flatten the authority gradient to foster safer and effective handovers.

4. Learners will exhibit psychological safety and demonstrate their capability for performing team-based communication during handovers before graduation following a clinically-oriented refresher of the critical competencies.


V. Literature Review and Best Practice Page 16 of 73 pages

V. Literature Review and Best Practices: Healthcare is currently undergoing a fundamental paradigm shift from hierarchical (physician-centered) to team-based care. As such, it is an essential training and education of students adapt to meet this challenge. Failures in communication and teamwork are the primary causes of medical errors and have become a national patient safety goal. Inter-disciplinary team training saves lives (E. Salas, 2016). Accurate information about patient medical conditions and effective communication of that information among providers is imperative for safe patient care since current medical care is mostly interprofessional (IP) and team-based. Failures in communication among health care providers result in suboptimal care, contribute to adverse outcomes, and manifest as increased length of hospital stay for patients and unnecessary use of healthcare resources (Dingley, Daugherty, Derieg, & Persing, 2008; Malpractice risk in communication failures, 2015; Sentinel Event Alert #58, 2017). In 2017, The Joint Commission (TJC) issued a Sentinel Event Alert stating that inadequate communication during handover remains a national patient safety threat. Commitment by institutional leadership and team training were among the key recommendations ("Hospital National Safety Goals," 2018; Sentinel Event Alert #58, 2017). In 2014, the Association of American Medical Colleges (AAMC) published 13 Core Entrustable Professional Activities for Entering Residency (CEPAER) which included interprofessional teamwork (EPA #9) and handoff (EPA #8) skills (Core Entrustable Professional Activities for Entering Residency. Curriculum Developers’ Guide, 2014). In 2016, the Interprofessional Education Collaborative (IPEC) defined core competencies in communication (Core competencies for interprofessional collaborative practice: 2016 Update, 2016). The Joint Commission published a mandate for redesigning and implementing a more structured handover process (Handoff Communications: Toolkit for Implementing the National Patient Safety Goal., 2008). Thus, the focus of QEP 2019 is based on best practices. The foundation of the Simulation-Based Curriculum The training experiences will employ the science of training and learning. The science of training indicates that there are mainly five pillars (E. B. Salas, L.; Coultas, C.; Dietz, A.; Grossman, R.; Lazzara, E.; Oglesby, J., 2015):

1. Ensure the Need for Training 2. Create a Positive Learning Environment 3. Design and Implement Training for Maximum Accessibility, Learnability, and Usability 4. Evaluate Training Program 5. Create a System for Sustaining Training

Pillar 1 is focused on establishing a need as well as targeting the desired attitudes, behaviors, and cognition. Pillar 2 is centralized on preparing learners and the learning environment by framing the training positively, fostering a supportive environment, and strengthening learner’s efficacy, motivation, and engagement. Pillar 3 is targeted on the training design itself. Effective training leverages a partnership between domain and training experts to institute a multi-method instructional strategy (i.e., information, demonstration, practice, and feedback). Pillar 4 is concentrated on evaluation, and effective training evaluations are multi-level and iterative. Pillar 5 is honed towards the longevity of the training program as well as the sustainment of the training attitudes, behaviors, and cognitions by emphasizing practice opportunities and transfer. See the figure below for a pictorial representation of the pillars.



Before During After

Ensure Need for Training Create Positive Learning Climate Design and Implement Training for Maximum

Accessibility, Learnability, and Usability

Evaluate Training Program Create a System for Sustaining Training

Figure V-1: Science of Training Employing the science behind simulation-based team training, we will ensure that our curriculum has linkages between the clinical and team competencies, learning objectives, the requisite knowledge, skills, and attitudes (KSAs), events and corresponding responses, the scenario script, and the measurement tools (Rosen et al., 2008). Team and clinical competencies are the general specifications, and identifying the focal clinical and team competencies provides a practical scope to maximize learning. Learning objectives are the more granular specifications that will be taught within a given scenario. The KSAs are the particular displays that a team member must “think,” “do,” and “feel” to demonstrate mastery or expertise and meet the learning objectives. The events are mostly the content of the training, which provides opportunities for trainees to perform.

Figure V-2: Science of Simulation-Based Training



Meanwhile, the responses are observable, measurable behaviors that are elicited from the events embedded within the scenario, which indicates whether a trainee possesses the desired KSAs. The scenario script is the plan for how the events and responses will unfold throughout the scenario. Finally, the measurement tools indicate the proficiency of the trainee and are the basis for diagnosing performance and guiding specific, informative feedback. See the figure below for a visual depiction. Because measurement tools and feedback are so integral to knowledge acquisition and behavioral change, this training experiences will also apply best practices for performance measurement as well as feedback (Lyons et al., 2015). More details are provided in Appendix A. In addition to the measurement tools, the training experiences will incorporate feedback according to the science of debriefing. Meta-analytic evidence has demonstrated the benefits of feedback for performance improvement (Tannenbaum & Cerasoli, 2013). Consequently, the feedback provided within the training experiences will be couched within the four essential criteria of debriefs:

a) The learner is actively involved and engaged as opposed to a passive recipient of information when diagnosing performance and generating remediation plans

b) The content is focused on development as opposed to assessment c) Performance is discussed within the context of specific events and behaviors as opposed to an

overgeneralization of performance d) The feedback will employ multiple informational sources (e.g., instructor and video).

Active learning entails self-discovery by iteratively reflecting and planning and produces unique insights within learners. Utilizing a developmental intent encourages information exchange and perspective taking and can lead to insights that are more accurate since it is executed with impunity. Targeting specific events offers a prescriptive, diagnostic critique with greater depth and robustness. Finally, leveraging multiple sources increases the breadth of topics and events to be covered, strengthens diversity and comprehensiveness, and can improve credibility. With the understanding that feedback will adhere to the critical components of an effective debrief, the debriefing episodes will abide by the best practices established for team debriefs within the medical simulation (see Appendix A). Interventions included training using technology (such as high fidelity mannequins), simulated patients/family members, and debriefing. Most studies fell short of assessing behavioral change but evaluated student satisfaction with the learning, perceptions of self-efficacy and gains in knowledge and skills level. Although the primary conclusion was “The quality and rigor of the existing literature are inadequate to confidently determine factors that affect learning through simulation enhanced IPE,” the review summarized many of the challenges/barriers in providing IP education. Barriers include:

o Meeting the educational needs of all involved disciplines o Acquiring equipment, technical requirements and the ability to schedule students converging

from different curricula in different schools o The timing of the experiences, especially when they include learners from different disciplines

that have different lengths of training and different training paradigms o Recruiting and training faculty with expertise in the use of simulation as an educational tool to

teach IP skills. Suggested solutions include:

o Dedicating equipment and trained staff specifically for the scenarios



o Exploring everyday challenges relevant all disciplines/learners o Development of faculty skilled in the use of simulation education methodology o Include practicing providers from the targeted learner groups o Schedule learners and faculty from disparate training programs o Assignment of activities appropriate for the level of each learner group o Require a university-wide effort with support from leadership o Group of dedicated faculty from each professional group who “brainstorm” together to develop a

program that meets all learner needs (Palaganas, Brunette, & Winslow, 2016). This review also commented on the potential advantages of utilizing frameworks designed for IP training. One of these frameworks, TeamSTEPPS®, is a training system developed by the Agency for Healthcare Research and Quality ("TeamSTEPPS®," 2017) that provides evidence-based tools for improving communication and teamwork skills among health care professionals to optimize patient care. TeamSTEPPS® and the individual tools incorporated into it have demonstrated improvement in the knowledge and skills of health professionals and the outcomes of the care they provide. TeamSTEPPS® incorporates modules that introduce learners to the importance of teamwork, leadership, monitoring situations, mutual support of team members and effective communication. The training also provides learners with tools and strategies to be productive team members and to build effective teams (see Appendix B). Our institution has had some experience implementing TeamSTEPPS® for groups of students, residents, faculty and health care teams. We wish to expand this experience to all pertinent learners. We also have experience with interdisciplinary education from CONVERGENCE, our previous QEP. The CONVERGENCE Program began in 2009 and had been fully adopted into our academic curricula at UT Southwestern. The program includes nurses, physicians, pharmacists, psychologists, physical therapists, physician assistants, rehabilitation counselors, prosthetists, orthotists, radiation therapists, and dietitians from our institution, Texas Woman’s University, Texas Tech University Health Sciences Center, and UT Arlington. CONVERGENCE has allowed us to deal with and develop solutions for many of the barriers facing institutions that wish to provide IP education. We propose building on the structure already in place and using our past QEP as a platform for this proposed QEP. Expansion of our simulation center scheduled to open in August 2018 will also expand our ability to utilize simulation for all of our learners on campus. Best Practices Innovation Collaborative of The Institute of Medicine examined core principles and values required for effective team-based health care in a roundtable discussion and published the results in 2012 (Mitchell, 2012). They noted that although teams function as groups, the values and behaviors of individuals are critical in facilitating the effective functioning of the team. The specific values identified as important were honesty, discipline, humility, curiosity, and creativity. A capable team that includes individuals with these characteristics must then function under a set of principles that ensure the team functions together effectively. Team members need to develop a set of shared goals, to clearly define roles for each team member, develop mutual trust for their colleagues to communicate information while allowing all members of the team to contribute, and decide upon and to use measurable processes or outcomes to determine the successes and failures of the group. Again, team members must communicate using a construct that efficiently shares information across the team. Use of critical safety language is one method to ensure effective communication. One specific area of communication among health professionals that has been demonstrated to have significant risk for patient safety is care transitions (also referred to as handoffs, handovers or sign-out) (Mitchell, 2012). The Joint Commission has also identified handoffs as a high risk for communication errors and recommend a standardized process (Breuer, Taicher, Turner, Cheifetz, & Rehder, 2015; Handoff Communications: Toolkit for Implementing the National Patient Safety Goal., 2008) (Sentinel Event Alert #58, 2017). Handoff errors have been shown to result in adverse events, delays in diagnosis and treatment, and unnecessary tests and procedures (Patterson & Wears, 2010). Handoffs have been defined as “transfer



of information and responsibility of care for a patient from one health care provider (or team) to another” (Lane-Fall, Brooks, Wilkins, Davis, & Riesenberg, 2014). Segall and colleagues (Segall et al., 2012) reviewed the literature on improving postoperative patient handoffs and made several recommendations, including 1) use a standardized process; 2) complete all urgent patient care tasks prior to the handoff; 3) allow only patient-specific discussion during the handoff; 4) require all relevant team members to be present; and 5) provide training in teams on handoff communication. Others have noted handoffs are improved if done in a designated private space with no distractions and done face-to-face, using a standardized tool. Starmer and colleagues at Boston Children’s Hospital implemented training for handoffs to reduce adverse events in hospitalized children (Starmer et al., 2013; Starmer et al., 2014). They utilized multi-modal, multi-dimensional training using a standard sign-out mnemonic, team sign-out and a designated quiet location for sign-out. They demonstrated a reduction of medical errors, preventable adverse events, and reduced omission of information in handoffs after the intervention. Even though up to 80% of severe medical errors are attributed to failures in communication during such care transitions ("Sentinel Event Data: Root Causes by Event Type 2004 - June 2013," 2013), there is limited evidence how best to teach students individual and team-based competencies critical to communication during handovers. Furthermore, systems wide diffusion of handover education best practices will likely require an implementation science-based approach to impact patient and organizational outcomes (Greilich, Phelps, & Daniel, 2018). The skills needed to develop highly functional teams are critical to achieving high reliability in healthcare (Chassin & Loeb, 2013; Wilson, Burke, Priest, & Salas, 2005). This proposal represents an institutional commitment to providing students with the skills needed to advance team based communication and care. In addition, it’s a meaningful response to the AAMC’s entrustable professional activity for graduating allopathic medical students (Core Entrustable Professional Activities for Entering Residency. Curriculum Developers’ Guide, 2014) for handovers and the ACGME’s required training and supervision of handovers during residency and fellowship.


VI. Actions to be Implemented Page 21 of 73 pages

VI. Actions to be Implemented: Introduction After the selection of a topic, the next task was ensuring that the most experienced and successful faculty members constituted an Implementation Steering Committee. Dr. Philip Greilich, a practicing cardiovascular anesthesiologist, involved in quality, safety and health services research, was the unanimous choice to lead the group. Dr. Greilich’s research focuses on understanding the influence of patient, provider and organizational ergonomics on outcomes when implementing and diffusing best practices. Table VI-1: Quality Enhancement Plan Implementation Steering Committee

Individual Position Role Philip Greilich, M.D., Chair Professor, Anesthesiology and

Pain Management QEP Director

Kim Hoggatt-Krumwiede, Ph.D.

Professor, Health Professions CONVERGENCE, Office of Interprofessional Education

Joseph Keebler, Ph.D. Assoc. Professor, Human Factors and Behavioral Neurobiology

Clinical Learning Environment

Elizabeth Lazzara, Ph.D. Asst. Professor, Human Factors and Behavioral Neurobiology

Distinction and Scholarly activity projects

Brad Marple, M.D. Professor, Otolaryngology / Head and Neck Surgery

Resident scholarly activity projects, Assoc. Dean Graduate Medical Education

Angela Mihalic, M.D. Professor, Pediatrics Transitions to Clerkship course director

Robert Rege, M.D. Professor, Surgery Development Committee chair, Assoc. Dean Undergraduate Medical Education

Eduardo Salas, Ph.D. Professor, Psychological Sciences

Distinction and Scholarly activity projects

Dorothy Sendelbach, M.D. Professor, Pediatrics Transitions to Clinical Training course director, Asst. Dean Undergraduate Medical Education

James Wagner, M.D. Professor, Internal Medicine Faculty Development lead David Weigle, Ph.D. Asst. Professor, Family and

Community Medicine Resident scholarly activity projects, Asst. Dean Graduate Medical Education

Eric Brighton 1st year Prosthetics - Orthotics SHP student Madison Bahe 1st year Physician Assistant

Studies SHP Student

Roberto Gonzalez MS1 Class President SMS Student Sonakshi Manjunath MS3 AMWA President Jordan Hughes MS3 IHI liaison Ramona Dorough Instructor Health Care Education James Drake ex officio Asst. Vice President, Office of

Academic Planning and Assessment



Individuals from the QEP Development Steering Committee and related Six-Year Plan committees comprise the remainder of UT Southwestern’s members. Because the Six-Year Plan defines our institutional priorities and goals and undergoes continual review and updating, there will be constant alignment between the QEP and institutional planning efforts, External consultants providing substantial input are members of the QEP Implementation Steering Committee also. QEP Implementation Team The Team FIRST implementation team was formed from members of the QEP Steering Committee and augmented by appointing the Team FIRST Director, a Project Manager, student representatives, subject matter experts in human factors, team training and organizational psychology, and support from the Office of Quality, Safety, and Outcomes Education for student projects.

Figure VI-1: QEP Implementation Team Overview The conceptual framework for the 2019 Quality Enhancement Plan (QEP), Team FIRST, is illustrated in Figure VI-2 (below). Its three primary components are the academic curriculum, faculty development, and the clinical learning environment.

Team FIRST Director

Academic Curriculum

Convergence

Transition to Clerkship

Human Factors for CLE*

Post-Graduate Essentials

Assessment

Psychometrics & Analytics

Academic & HS Affairs Analytics

Faculty

Faculty Recruitment

Faculty Training

Faculty Scholar Development

Clinical Learning

Environment

Signature Units

Hospitals

Clerkship

Directors

Residency Directors

Student Engagement

Student Leadership

Council

Student Focus Groups

Student QI & Scholarly Activity

Administrative Assistant

Project Manager

Accreditation Specialist



Figure VI-2: QEP Conceptual Framework

The academic curriculum is aligned as a progressive series of interactive and simulation-based training experiences. Whereas CONVERGENCE has already been established, the other programs are in development or are currently limited to medical students. Faculty development is a critical component of Team FIRST. A cadre of faculty will need to be recruited, prepared, and developed to teach and assess learners in the simulation center and the clinical learning environment. The piloting, implementation, and optimization for the 3-fold increase in the educational curriculum will require careful consideration and investment in both existing and emerging programs. The “faculty scholar” is the linchpin for the successful implementation of this QEP. The role is central to 1) Directing the development of the innovative curriculum; 2) Mentoring medical students pursuing scholarly activity and Distinctions in Medical Education or Quality Improvement; 3) Serving as handover champions within their respective clinical units and departments, and 4) Producing generalizable knowledge suitable for publication and potential extramural funding. Translation of the Team FIRST curriculum into the clinical learning environment is perhaps the most innovative and ambitious aspiration of the 2019 QEP. Although changes in culture and organizational outcomes are not a primary measure of the success of Team FIRST, a set of carefully selected metrics with a causal relationship to handovers will be monitored and reported to institutional leadership. The development of “signature units” undergoing handover redesign and implementation is being orchestrated by Office of the Vice President for Health System’s Affairs and Chief Medical and Quality Officer, creating the potential for synergy between Academic and Health System Affairs within our institution. This commitment to high-impact simulation-based training will both distinguish our QEP proposal nationally and benefit the patients we serve locally.



Designing the Training Experience for Handovers Healthcare has increased drastically in complexity over the past few decades, with modern medicine consisting of a complicated set of tasks, procedures, equipment, tools, and hospital environments working towards the goal of positive patient outcomes (Holden et al., 2013). Diverse sets of provider teams are often at the center of patient care, yet these teams are often unaware of their membership and poorly trained in working together interdependently. To improve teamwork in this setting, it is paramount for providers to receive team training. Meta-analytic evidence suggests that team training can be an effective strategy for reducing patient harm, including up to a 15% reduction in patient morbidity after team training has been introduced (Hughes, et al., 2016). This evidence suggests that team training, especially early in one’s medical career, will facilitate mastery of knowledge, skills and attitudes (KSAs) relevant to improved patient safety. The clinical transformation taking place at UT Southwestern requires students to build strong competencies related to effective team-based communication. These skills are essential for care coordination, anticipating potential harm and working effectively in complex healthcare environments. Teamwork is one of UT Southwestern’s core values and relies on individual and team-based competencies to translate this into action. Data collected both locally and nationally, reveals a significant gap in student knowledge, skills, and attitudes required for team-based communication (see Section X. Assessment for data). The learning outcomes for Team FIRST is to ensure students understand the importance of team-based communication during handovers. The curriculum is designed to develop individual and team-based competencies to apply and influence the clinical learning environment. Although the student’s reaction, learning and behaviors will be the primary measures of success for the curriculum, the transformation of the clinical learning environment and improvement in organizational outcomes will also be monitored, analyzed and reported. Novice learners will be socialized to a culture of safety and trained in the language and the structure to use communication tools to ensure safe, effective communication. Once socialized and trained, these beginners will be immersed in role-playing and simulations events that prepare them to apply, influence, and assess handovers in the clinical learning environment. This will initially be done within each learning community and as well as later as through involvement in interprofessional simulated-based training experience. As students approach competency, their experiences will be reinforced by participating in actual clinical teams during their clinical rotations, at first as observers and then later as actual clinicians. As they approach graduation, assessments of their performance in clinical simulations will be made to document that they have reached expected levels of competency before graduation. Students who have not reached expected levels of competency will have opportunities to return to simulations or to have additional clinical experiences so they may remediate. The science of teamwork and training is rapidly emerging and becoming integrated into medicine, yet the field has already produced an astounding evidence base over the past decade identifying core competencies surrounding for team-based communication during handovers. To ensure the design of a curriculum that addresses the “key issues” (or barriers) at our institution, representatives of the QEP Steering Committee engaged and retained experts in organizational psychology and human factors to guide the design and implementation of Team FIRST. Dr. Eduardo Salas, Chair of Psychological Sciences at Rice University (see Appendix C for background) serves as the senior consultant and is a world expert on teamwork and communication. Drs. Joseph Keebler and Elizabeth Lazzara work as faculty members in the Department of Human Factors and Behavioral Neurobiology at from Embry Riddle Aeronautical University (see Appendix C for background) and will serve as experts in teamwork and training and serve as architects of the educational experiences in conjunction with experts in medical education at UT Southwestern. Representatives of the QEP Implementation Steering committee (PG, RR, KH, SS, JD) have interacted with Dr. Salas on multiple occasions in 2018 (including two site visits 5/9/18 and 11/13/18) and Drs. Keebler



and Lazzara have been working with the Director of Team FIRST for over three years on handover redesign and implementation within the health system. From these discussions, a model tailored for students at UT Southwestern emerged (see Figure VI-3 immediately below).

Figure VI-3: QEP Model for Critical Competencies and Surrounding Organizational Conditions The core individual competencies were identified as: 1) understanding the criticality of team-based communication; 2) conducting of a structured handover using supportive tools and technologies; 3) ability to asking clarifying question to guide contingency planning; and 4) reflecting on performance episodes to detect and assess gaps in handover best practices and importance of avoiding interruptions. The core team competencies were identified as: 1) psychological safety; 2) mutual trust; 3) closed- looped communication; 4) structured communication; and 5) team mental models. Dr. Salas also emphasized the critical importance of the organizational “conditions” surrounding these behaviors within the microenvironment and meso-environment (hospital or healthcare system). The ability of the students to translate the impact of their team training to the clinical learning environment and organizational outcomes depends on these conditions. On the unit level, this is governed by the unit managers and medical director and at the organizational level by its most senior executives. Our advisory team also recommended that the QEP Implementation Steering Committee include the following feature in the development of Team FIRST:

• The curriculum must be “back-engineered” starting with the learning outcomes and then determine the core competencies needed to achieve the outcome.

• The design of the curriculum (simulation) follows with a trigger designed to elicit the competencies embedded within the exercise (Salas 2002, Salas 2015). He felt most of the critical behaviors were those related to building high-reliability teams (Wilson et al., 2005).



• Early learning must occur in an environment of psychological safety in which the learner is allowed to fail and learn from their mistakes, hence the use of small interactive sessions and simulations. Formative assessment is essential early; summative assessments will play a role later.

• Trainees must be held to standards, and the program requires rigor, even rigidity, to ensure complete effective communication occurs. Structured tools, such as checklists, to certify that the learning has been completed should be required. The use of learner passports or journals to document their experiences was recommended in addition to incentives (e.g., gift cards) to enhance learner compliance.

• The program should include “mystery” shoppers who attend team meetings, evaluate information exchange, and send trained observers to evaluate courses, simulations, and individual performance during training sessions to provide feedback and assessment without interfering in the process.

Finally, Dr. Salas believes team-based communication during handovers is an emerging topic critical to any medical center committed to clinical transformation. He believes that this QEP could grow into a more extensive program capable of becoming a center of excellence for the institution. This might include research and training programs that confer advanced degrees in medical education and patient safety in addition to further promoting a culture of safety at UT Southwestern. Leveraging Established Learning Communities:

The School of Health Professions developed a program in which students from various disciplines were assigned to small interdisciplinary teams, termed Interprofessional Development, Education & Active Learning teams (IDEAL). IDEAL provides learning communities within the School of Health Professions for its students and with other students across the medical center. The School of Health Professions offers a variety of asynchronous health professions programs of varying lengths (most are approximately two years). The first year health profession students will be assigned to one of the IDEAL teams. In addition to the weekly IDEAL meetings, there will be monthly “School of Health Professions Grand Rounds” with required attendance by enrolled students and faculty during the fall and spring semesters. This venue will serve as the IDEAL Learning Community Seminar Series and provide mechanisms for the delivery of educational content that prepare the student for the interprofessional simulation-based training experiences in Team FIRST. In 2007, Academic Colleges were established at UT Southwestern Medical School to create an informal environment where mentors and MS1 and MS2 students could share the experience of being a physician. A College at UT Southwestern is a learning community that brings together gifted clinical teaching faculty as mentors for small groups of students. Each of the six Academic Colleges has a master, 6 or 7 mentors, and 40 first-year medical students. Each mentor is assigned five or six students. The Academic Colleges will serve as building blocks for developing and sustaining additional learning communities in the medical center. Like IDEAL, the resources of the College system will serve a foundational role in preparing students for Team FIRST training and providing the faculty and educational space required to support these activities. Academic Curriculum CONVERGENCE: This first interprofessional encounter at the beginning of the health professions and medical students’ curriculum already occurs and is in conjunction with other affiliated programs in nursing and pharmacy students. A 2-hour event introduces the student to the roles and responsibilities of the interprofessional team members and describes some basic teamwork skills. The curriculum for CONVERGENCE is evolving continuously and will increasingly emphasize team-based communication. The faculty for CONVERGENCE comes from the UT Southwestern Medical School and School of Health



Professions and affiliated nursing and pharmacy programs. In the future, additional UT Southwestern faculty will be drawn from the Simulation Center for the QEP. These additional instructors are already involved with teaching medical students team-based behaviors during six simulation lab encounters occurring throughout their 18-month pre-clerkship experience. This pre-existing content will be developed to complement CONVERGENCE while simultaneously integrating the relevant systems-based didactic content that they are covering in their lectures. Faculty recruitment and allotment of time are mostly in place for CONVERGENCE and these associated activities, although some adjustment in the composition may occur as the emphasis shifts to team-based communication and handovers. TRANSITIONS TO CLERKSHIP: The second encounter will occur as students are transitioning from their pre-clerkship education to the wards. For medical students, this occurs approximately 18 months into their curriculum, and for the health professions and other affiliated students, this occurs at various times as they enter the clerkship phase of their curriculum. The Transition to Clerkships currently takes place over one week and is limited to medical students. This QEP curriculum expands the scope of the handover training within this program so that interdisciplinary team behaviors can be emphasized. By doing so, we will have the capability to teach inter-departmental handovers in addition to those performed by students within a given specialty or discipline during shift change. As with the CONVERGENCE program, the expanded curriculum will require the recruitment and training of additional faculty from various medical and allied health specialties. HUMAN FACTORS FOR CLINICAL LEARNING ENVIRONMENT: The third interprofessional encounter will occur after students are several months into their core clerkship rotations. The objective of this encounter will be to prepare students to apply, influence, and assess the presence of behaviors that are critical to effective team-based communication during handovers. This exercise intends to aid the students in reconciling their pre-clerkship training in handovers with the clinical learning environment. Similar to the first two encounters, this curriculum will be simulation-based and occur over two days. Faculty for this encounter needs to be recruited and trained to teach a human factors-based approach to communication and include methods to handle suboptimal communication in teams with a steep authority gradient. Faculty will be recruited from the Academic Colleges and other learning environments such as the SWAT, IDEAL, the Simulation Center, and departmental Clerkship Directors. Given the novelty of this training experience, it will require an iterative piloting phase driven by our partners with subject matter expertise in human factors and ergonomic and team science. POST-GRADUATE ESSENTIALS: The fourth and final interprofessional encounter will occur as students are transitioning into the post-graduate phase of their training. This encounter is intended to be an experience to review, practice, and be tested on skills of team-based communication and handover before graduation. The Medical School is currently developing a multidisciplinary, simulation-based Residency Essentials course. Reinforcing and evaluating the team handover techniques that the students have learned over the past few years will be a significant part of this encounter. Post-Graduate Essentials in handovers (for medical, health professions, nursing and pharmacy students) will be implemented in a manner analogous to that used for handover training in “Transitions to Clerkship.” Although the focus is currently medical students, it is our goal to expand this course to include students in health professions and other non-UT Southwestern programs. As with the Transitions to Clerkship course, we have a few faculty allocated at this time. It is likely that we will need to recruit faculty from multiple medical and allied health specialties to teach this course. The faculty used to teach handovers in the Post-Graduate Essentials curriculum would be used to train other medical school faculty as well as those from the Health Professions and other non-UT Southwestern programs to support the expansion of this activity into an interprofessional educational experience.



Learning Objectives For Team FIRST to achieve its goals, learners will need to be exposed to the individual level and team level knowledge, skills, and attitudes (KSAs). The primary individual learning objectives for this effort will be comprised of the KSAs surrounding handoff events. These will include the following:

• ability to execute structured handovers utilizing supportive tools and technology • ability to present a verbal handover that is prioritized, relevant, & succinct • ability to understand and apply the importance of avoiding interruptions or distractions during

handover • ability to efficiently manage time surrounding handoff events • ability to highlight illness severity accurately • ability to complete action plans and appropriate contingency plans • ability to understand the structured handoff process (i.e., SBAR) • ability to demonstrate a willingness to solicit regular feedback and listen actively • ability to ask clarifying questions and use closed-loop communication • ability to highlight patient preference • ability to identify issues in regards to communication during handoffs, instilling of best-practice

values for handoffs, and understanding of adverse outcomes in regards to poorly conducted handoff events

The objectives for the progressive series of interactive and simulation-based training experiences are summarized below:

Training Experience 1: CONVERGENCE

CONVERGENCE is a training event that occurs shortly after matriculation within each of the undergraduate training programs. Its goal is to socialize a group of interprofessional student and help team members better understand one another respective role and responsibilities in team-based communication. The individual and team-based objectives are as follows for this exercise: Individual Objectives

1. Learners will understand the criticality of team-based care 2. Learners will conduct structured handover

Team Objectives

1. Employ effective communication tools a. Structured Communication – The team will demonstrate the application of SBAR

structure during b. Closed Loop Communication – The team members will demonstrate closed loop-

communication. This involves acknowledgment of receipt of messages during communication dialogue, usually characterized by a message being sent, acknowledgment of receipt and a follow-up from sender to ensure the message was interpreted correctly.

Potential Assessment Tools

1. Declarative knowledge metrics – to assess comprehension of the importance of team-based care 2. Behavioral Observations – to determine proficiency in structured handovers as well as the

implementation of communication tools



Training Experience 2: Transitions to Clerkship

Transition to clerkship occurs just before entering the clerkship phase of training. Its goals provide the learner an understanding of the importance of handovers and demonstrate its primary tasks and behaviors. This training experience has two parts, the order of which will vary. One part will include a 15-20 minute presentation about how communication (or lack thereof) contributes to breaches in patient safety; an experiential activity (either role playing in small groups and/or short videos demonstrating good and bad handoffs); and group discussion about barriers to good handoffs and how to professionally challenge, mitigate, and be empowered to give a thorough handoff. The other part will be a high-fidelity handoff simulation activity that is done in small groups. Individual Objectives

1) Learners will conduct structured handoffs 2) Ask clarifying questions

Team Objectives

1. Exhibit team mental models 2. Exhibit mutual trust


1. Behavioral Observations – to determine proficiency in structured handovers 2. Self-report – to garner insights regarding the attitudes towards mutual trust and team mental

models

Training Experience 3: Human Factors for the Clinical Learning Environment

Human Factors for the Clinical Learning Environment occurs within six months of entry into the clerkship phase of their training. Its goal is to teach the student how to apply, influence and assess the presence of critical team-based behaviors during handovers. The students’ role in handovers during their core clerkship rotation can be quite variable, and this training experience is intended to accelerate and increase the learner’s influence of team-based communication during handovers over time. Given that students are almost always present during handover on many units, they will be taught to assess the evolving state of key teamwork behaviors (e.g., psychological safety) on the clinical units, especially the “signature units.” Individual Objectives

1. Learners will clarify issues and concerns 2. Learners will reflect on performance episodes

Team Objectives

1. Demonstrate psychological safety – Team members will describe and demonstrate behaviors that ensure the psychological safety of the handover environment.

2. Employ effective communication tools a. Structured Communication – The team will demonstrate the application of SBAR

structure during b. Closed Loop Communication – The team members will demonstrate closed loop-

communication. This involves acknowledgment of receipt of messages during communication dialogue, usually characterized by a message being sent, acknowledgment of receipt and a follow-up from sender to ensure the message was interpreted correctly.





Potential Assessment Tools 1. Behavioral Observations – to determine the ability to clarify issues and voice concerns as well as

implement communication tools 2. Self-report – to ascertain the level of psychological safety 3. Performance logs – to document the reflections regarding performance episodes as well as the

plans to remediate performance as needed Training Experience 4: Post-Graduate Essentials

Post-Graduate Essentials is a simulation-based, capstone experience that allows the learner to review and reinforce previous individual knowledge and attitudes and practice team-based behaviors and skills. The goal of this experience asses the learner competency in team-based communication during handovers. The only new skill is the incorporation of the patient and their family as a member of the handover team. A summative evaluation process will be used during the debriefing to aid the assimilation and this material as they prepare for their respective post-graduate roles.

Individual Objectives

1. Learners will conduct structured handoffs 2. Learners will mitigate interruptions 3. Learners will clarify issues and concerns

Team Objectives

1. Demonstrate psychological safety – Team members will describe and demonstrate behaviors that ensure the psychological safety of the handover environment.

2. Employ effective communication tools a. Structured Communication – Team members will use SBAR to communicate during

handover events.

b. Closed Loop Communication – Team members will use behaviors that demonstrate closed-loop communication.


1. Behavioral Observations – to determine the proficiency in conducting structured handovers, to establish the ability to clarify issues and voice concerns, to record the identification of issues and raised concerns, and to assess the ability to implement communication tools

2. Self-report – to ascertain the level of psychological safety 3. Performance logs – to document the reflections regarding performance episodes as well as the

plans to remediate performance as needed



Team FIRST Faculty Piloting, implementing and optimizing Team FIRST plan will require the recruiting, training, and development of faculty capable of training students and translating this curriculum to clinical units and departments. Like the curriculum, this process will be “phased in” throughout three years utilizing the faculty from the medical school, health professions and other programs (nursing, pharmacy) affiliated with UT Southwestern. Our previous QEP, Convergence, has provided us with valuable operational insights that will be utilized for expanded curriculum focusing on team-based communication. Recruitment: Recruitment will occur in a multi-step process, which involves faculty from the medical school, school of health professions, and other non-UT Southwestern programs participating in the QEP. In FY20, we will begin identifying, screening, and interviewing potential QEP faculty for participation in the transition to clerkship experience, the first new interprofessional experience. Instructors or facilitators currently involved in CONVERGENCE would ideally remain in place. The QEP Faculty Development Lead for Recruitment will oversee the execution of the recruitment strategy. This individual will have a leadership role in the Medical School’s Academic Colleges and undergraduate medical education and/or experience with interprofessional program development. To the successful execution of the QEP curriculum, s/he will guide faculty recruitment based on the needs of the program. The first group to be identified will be a small group of faculty scholars with a high level of investment in curriculum development and academic productivity in the fields of education, quality improvement, and/or patient safety. This tier of faculty will be required to meet specific criteria to qualify for the additional support provided to faculty scholars. These individuals must demonstrate a commitment to advancing undergraduate, graduate, and interprofessional education in addition to relevant program development and iteration. Ideally, these individuals have already conveyed their interest in simulation-based training. Once they have completed our QEP training curriculum, they will be capable of training the group of interprofessional faculty in team-based communication. Finally, this tier of faculty will be responsible for generating generalizable knowledge and seeking both intramural and extramural funding to support their academic interest in education and patient safety. After solidifying the core (QEP) faculty scholars, the next step will be to recruit a slightly larger, interdisciplinary group of faculty trainers with a keen academic interest in education, patient safety, and simulation. They will receive highly involved training in simulation, teaching, and assessment of team-based communication, and training of interprofessional faculty and they will be instrumental in our plan to train the rest of the QEP faculty instructors who are ultimately recruited to teach the curriculum to our students. The final group to be recruited will be the largest and considered entry level. These facilitators or instructors will be trained by the two groups described previously and will be responsible for teaching and assessing team skills. Their primary role will be to teach the students in each of the four QEP curriculum experiences. A database of potential QEP faculty has already been constructed. It includes faculty from the Medical School’s Academic Colleges, Clerkship Directors, Transitions courses; Health Professions School; Simulation Center; SWAT; and other affiliated programs. Since the faculty of Convergence has already been established, the priority will be to recruit and train an interprofessional group of QEP faculty for the Transitions to Clerkship handover training experience. Priority will be given to faculty with experience in Convergence and those who have already invested time and effort in undergraduate medical education programs within the simulation center and for the transition in medicine programs.



Training: With the help of the faculty scholars, we will provide didactic and interactive team science training for all QEP faculty who are recruited. It is anticipated that some faculty will elect to build the portfolio required to become a faculty scholar. They will be supported to attend programs and seminars at other institutions or national meetings. All faculty will receive basic simulation center training, including TeamSTEPPS education since a large portion of the QEP curriculum will be simulation-based. Once they have completed the curriculum, they will be an institutional certificate to teach and assess learners in the QEP educational program. Depending upon which of the four components of the QEP they are assigned to teach, they will receive further instruction that is specific to those activities. By necessity, the faculty development program will continue to train faculty members to replace and to expand the core of QEP faculty as needed. However, a more significant number of faculty members will be required to teach the curriculum, primarily to teach and assess learners at clinical sites. As with the core QEP faculty, this group also will require expertise in teaching communication skills in the clinical arena, including assessment of team skills in situ. A modified faculty development program will be developed for instructors whose contributions are limited to the clinical learning environment. Just as we will design and implement an evaluation methodology to assess the progress of students as they go through this process, we will design an evaluation quality tool to assess the effectiveness of training that will be provided to all faculty who are recruited to assist us with this project. These evaluations will yield data that can be analyzed and published, and the faculty scholars who are recruited to help design and implement the various steps will have the opportunity to be part of the publication process. During the year before QEP begins, we will pilot our faculty development program by training a small group of faculty (the 5 to 10 faculty trainers) in QEP concepts. Our goal is for the faculty trainers to develop expertise in this field and to become faculty leaders who will subsequently train and mentor additional faculty teachers. Their experience will be used to hone faculty development curriculum for future QEP faculty. It is anticipated that the initial cadre of faculty will be more deeply prepared in didactics and the use of simulation technology to accomplish our goals in the initial phase of learner education. Faculty Development: We anticipate that a large portion of the faculty recruited will be individuals on the “Clinician Educator” track. The institution of the QEP will provide many opportunities for the generation of generalizable academic knowledge, which creates a valuable opportunity for faculty interested in team science education to expand their academic portfolios. This scholarly activity will translate to a higher potential for promotion for these individuals. All faculty who are recruited and trained will serve to expand the cadre of Simulation faculty and, more importantly, advance UT Southwestern’s status as a national leader in education. However, as their degree of involvement will vary, so too will their institutional support. The interest level and existing body of work of a given faculty will determine if they will fall into the faculty scholar, faculty trainer, or faculty instructor category. A highest level of institutional support will be for a limited number of faculty scholars whose portfolio’s suggests the likelihood of a good return-on-investment is high. To this end, the QEP provides time-limited protected non-clinical time to be supported by the QEP budget, matched in kind with protected time by the respective Department Chairman. Funding for non-clinical time will be renewable annually and based on an a priori expectation of program improvement, scholarly activity, and lectures to clinical departments. To qualify to become a faculty scholar, these individuals must have produced a body of work in education, quality improvement, or program development that demonstrates a high degree of motivation to become masters in team-based communication. They will perform scholarly activity in advancing the field of handover education in healthcare and as such will have minimum required deliverables for student mentoring, presentations and publications, and generation of intramural and extramural support for team



science education. In addition to the benefit to the individuals’ academic portfolios, these faculty scholars will also potentially be valuable resources for development and advancement in the Simulation Center, Office of Quality, Safety, and Outcomes Education, and other advanced OME education priorities. Support for the faculty trainers will be on both the institutional and departmental levels, though to a lesser degree than with the faculty scholars. We envision these individuals as coming from many diverse, interdisciplinary departments throughout the UTSW medical educational, allied health, and affiliated programs. As they develop expertise and scholarly interest in team science education, they will become eligible for becoming faculty scholars. Their ability to influence and train faculty in team-based communication during handovers will be an essential consideration for becoming a faculty scholar. They will have the opportunity to participate in the academic activities led by the faculty scholars or to pursue academic work of their own about the respective educational content that they have helped to develop and implement. Translation to Clinical Units and Departments: The QEP faculty development program will offer benefits to the institution not only in the areas of undergraduate education and academic production but also in the propagation of the QEP curriculum into the clinical arena. Each faculty, regardless of their level of involvement with the program, will affect team-based communication and patient safety in their respective clinical department by becoming a departmental “champion.” In addition to overseeing student participation and impact of QEP education on handovers during the students’ core clerkships, these faculty may recruit and train other faculty in their department in communication skills and handover assessment. Through lectures, discussions, and bedside modeling, they can influence their peers, graduate, and undergraduate trainees on the importance of effective communication strategies, thus furthering patient safety in all corners of the UT Southwestern system. Probably, the most challenging aspect of this proposal is the development of faculty to teach Team FIRST, especially during the clinical phase. Teaching and assessing Team FIRST will be time-consuming and clinical faculty already have significant demands on their time. On the other hand, the importance of team-based care has already been recognized by our faculty and the need to ensure that all of our graduates attain specific skills before graduation is becoming more compelling as team-based care becomes the preferred practice paradigm. Moreover, the need to improve direct observation of learners and to provide feedback to them by accrediting bodies is a fait accompli. Thus, development of faculty observation, clinical assessment, and feedback skills is already an imperative, and the goals of the QEP mesh very nicely with the faculty skills that are essential for the academic professors of the future. Although culture change on rotations is a challenge, the culture in our clinical learning environments is already changing. Although team-based care has already been accepted by our caregivers, the communication skills needed to build highly functional teams are still emerging. The challenge is to include students in this evolution in a meaningful manner. The articulated need for us to teach our learners team communication through experiential training programs and translate these competencies into the clinical learning environment calls for us to find the best way to incorporate students into teams in a manner that facilitates this process.


VII. Timeline Page 35 of 73 pages

VII. Timeline: Piloting, implementation, and optimization of the 2019 QEP, Team FIRST will be rolled out over five years. Institutional capacity for the plan can be seen in the successful evolution of Convergence, the implementation of Transfer to Clerkships and Post-Graduate Essentials for medical students and development of signature clinical units at Clement University Hospital (CUH). Figure VII-1 illustrates the timeline for Team FIRST.

Figure VII-1: QEP Timeline The timeline for implementing various activities associated with Team FIRST is shown below. There are new positions established, and many key personnel will be recruited from our faculty. Tables VII-1 to VII-5: QEP Yearly Timeline

Team FIRST Year 0 Pilot 2019

Year 0 Tasks (2019) Responsibility Needs assessment for faculty recruitment Faculty Recruitment and Training Leads CONVERGENCE Update CONVERGENCE Program Lead Design CONVERGENCE measurement system & tools

CONVERGENCE Program and Assessment Team Leads

Onboarding: Student focus group: Convergence

CONVERGENCE Program Lead and Medical Student Lead

Onboarding: Student QI Teams: Convergence

CONVERGENCE Faculty Scholars and Project Manager

Define Specifications for QEP Measurement System

Assessment Lead & Team FIRST Director

Optimize CONVERGENCE Measurement System

CONVERGENCE Program and Assessment Team Leads



Team FIRST Year 1 – 2020

Year 1 Tasks (2020) Responsibility Recruit Team FIRST leadership team Team FIRST Director, Faculty Development Leads Assessment for pre-clerkship faculty development

Faculty Training Lead and Team FIRST Director

Convergence Implementation Convergence Program Lead & Student/Faculty QI Teams Convergence analysis Assessment Lead & Student/Faculty QI Teams Transition to Clerkships (T2C) Design & Pilot

T2C Program Lead & Student/Faculty QI Teams

Design T2C Measurement System & Tools Assessment Lead & Student/Faculty QI Teams Onboarding: Student focus group: T2C T2C Program lead and Medical Student Lead Onboarding Student QI Teams: T2C T2C Faculty Scholars and Project Manager


Year 2 Tasks (2021) Responsibility Needs assessment for clerkship faculty development

Faculty Recruitment/Training Leads and Team FIRST Director

Convergence Optimization Convergence Program Lead & Stud/Faculty Teams T2C Implementation T2C Program Lead & Student/Faculty QI Teams T2C analysis Assessment Lead & Student/Faculty QI Teams Human factors (HF) for CLE) design & pilot HF for CLE Program Lead & Stud/Faculty QI

Teams Design HF for CLE measurement system & tools Assessment Lead & Student/Faculty QI Teams Onboarding: Student focus group: HF for CLE HF for CLE Program Lead and MS Lead Onboarding: Student QI Teams: Human Factors for CLE

HF for CLE Faculty Scholars and Project Manager


Year 3 Tasks (2022) Responsibility Needs assessment for post-clerkship faculty development

Faculty Recruitment/Training Leads and Team FIRST Director

Convergence standardization Convergence Program Lead and Student/Faculty QI Teams T2C Optimization T2C Program Lead & Student/Faculty QI Teams Human Factors for CLE implementation HF for CLE Program Lead & Student/Faculty QI Teams Human Factors for CLE analysis Assessment Lead & Student/Faculty QI Teams Post-Graduate Essentials (PGE) design & pilot PGE Program Lead and Student/Faculty QI Teams Design PGE measurement system & tools Assessment Lead & Student/Faculty QI Teams Onboarding: Student focus group: PGE PGE Program Lead and Medical Student Lead Onboarding: Student QI Teams: PGE PGE Faculty Scholars and Project Manager




Year 4 Tasks (2023) Responsibility Needs assessment for faculty development Team FIRST Director, Faculty Recruitment and

Training Leads T2C Standardization T2C Program Lead & Student/Faculty QI Teams Human Factors for CLE optimization HF for CLE Program Lead & Student/Faculty QI Teams PGE Implementation PGE Program Lead and Student/Faculty QI Teams PGE Analysis Assessment Lead & Student/Faculty QI Teams Onboarding: Student focus group: Special Projects

Special Projects Lead and Medical Student Lead

Onboarding: Student QI Teams: Special Projects

Special Projects Faculty Scholars and Project Manager

Annual QEP Report Program and Assessment Leads, Team FIRST Director


Year 5 Tasks (2024) Responsibility Needs assessment for faculty development Team FIRST Director, Faculty Recruitment and

Training Leads Human Factors for CLE standardization HF for CLE Program Lead & Student/Faculty QI Teams PGE Optimization PGE Program Lead and Student/Faculty QI Teams Onboarding: Student focus group: Special Projects

Special Projects Lead and Medical Student Lead

Onboarding: Student QI Teams: Special Projects

Special Projects Faculty Scholars and Project Manager

Annual QEP Report Program and Assessment Leads, Team FIRST Director


VIII. Organizational Structure Page 38 of 73 pages

VIII. Organizational Structure:

Figure VIII-1: UT Southwestern QEP Organizational Structure


IX. Resources Page 39 of 73 pages

IX. Resources: Approved Budget

2020 2021 2022 2023 2024

Faculty Support $ 446,925 $ 503,490 $ 576,944 $ 608,485 $ 606,407

Administrative Support $ 130,347 $ 133,392 $ 143,760 $ 154,629 $ 159,268

Faculty/Staff Benefits $ 141,338 $ 154,787 $ 174,368 $ 184,894 $ 185,968

Faculty Development $ 50,000 $ 50,000 $ 50,000 $ 50,000 $ 50,000 Simulation & Learning

M&O $ 65,100 $ 39,500 $ 48,900 $ 52,900 $ 54,900

Technical Support $ 7,000 $ 10,000 $ 13,000 $ 16,000 $ 16,000

Travel / M&O $ 19,000 $ 22,500 $ 27,500 $ 26,000 $ 26,000

Total (Per FY) $ 859,710 $ 913,669 $ 1,034,472 $ 1,092,908 $ 1,098,543

QEP 5-Year Total $4,999,302 BUDGET JUSTIFICATION: Director of QEP The QEP Director is accountable for the successful development and execution of the QEP. This effort is funded with 0.25 FTE of support. Faculty Development Lead and Scholars A Faculty Development Lead is responsible for the planning, recruiting, training and monitoring of 60-80 QEP faculty. This effort is funded with 0.25 FTE of support. Up to 10 faculty scholars are selected annually to train new QEP faculty, revise and create new educational content that is suitable for publication by medical students and another faculty collaborator. This effort is funded with up to 1.0 FTE of support divided over 5-10 faculty scholars. Matching efforts will be required/requested by/from Departmental Chairs. These individuals will be selected from the Academic Colleges, School of Health Professions, Simulation Center, Clerkship Directors and other related venues based on an outstanding record teaching and mentoring and publishing scholarly work. Team Scientist Contractors Team Scientists are responsible for designing, implementing and publishing the results the QEP educational experience. A contract for 0.75 FTE of effort will be used as a “bridge-to-hire” given the unavailability of this expertise on campus. Their subject matter expertise in team-based communication and organizational psychology is drawn from other high-reliability industries. Working in conjunction with local experts in medical education, this team will use an iterative process by applying a Kirkpatrick model of learning. QEP Assessment Lead The QEP Assessment Lead is responsible for the selection, analysis and ongoing monitoring of the metrics used to assess the impact of the QEP. This effort is funded with up to 0.20 FTE of support. This individual analyzes the psychometric value of a given metric and its relationship to the curriculum and organizational outcomes.


IX. Resources Page 40 of 73 pages

Graduate Fellow The Graduate Fellow is responsible for advancing the scholarly activity of the students, faculty scholars and team scientists. The position will be funded up to 1.0 FTE of effort. Project Manager The QEP Director is accountable for the successful development and execution of the QEP. The project manager uses disciplined project management practices, works directly with the QEP Director and is responsible for ensuring that the initiation, implementation, monitoring, project team facilitation, and outcome reporting is fully aligned and executed within scope, on time, and within budget. This effort is funded with 0.40 FTE of support. Senior Administrative Assistant II The Senior Administrative Assistant works under the supervision of the QEP Director and is accountable for relieving the supervisor and another faculty of a variety of administrative duties. Examples of these include managing and coordinating meetings, appointments, conferences, and workshops. Responsibilities include managing schedules, composing letters, memorandums, and another nonroutine, moderately complex correspondence, which does not require the attention of a supervisor. This effort is initially funded with 0.50 FTE of support. Communication Lead The Communication/Marketing Lead is responsible for widespread awareness of the QEP and all its programs and activities within the academic and health system communities. This effort is funded with up to 0.20 FTE of support. Full institutional engagement relies on effective marketing of the “value-add” of team-based communication and care. Innovation in asynchronous communication and dissemination of progress is required to address extreme time constraints affecting the majority of QEP participants. Education Coordinators Education Coordinators are responsible for the curriculum and activities for four interprofessional educational experiences provided to >1,500 undergraduate students annually. This effort is funded with up to 0.80 FTE of support divided over multiple coordinators. Data Analytics Data analytics will be responsible for curating and analyzing institutional data related to QEP. This effort is funded with 0.20 FTE of support. Departmental QEP Champions The ability to translate high-impact undergraduate (and graduate) medical education curriculum (and training) to the clinical environment requires a visible commitment by respected clinician-educators and rising education leaders within hospital-based clinical Departments. Departmental QEP Champions will be selected from QEP faculty who demonstrate exceptional commitment to influencing their respective Departments by providing lectures, mentorship and overseeing the assessment of ward-based handoffs. Champions from hospital-based clinical Department like Anesthesiology, Emergency Medicine, Internal Medicine, Obstetrics and Gynecology, Surgery and Radiology will be the priority. Student Expert Observers and Facilitators Paying students an hourly wage to perform essential duties as trained observers and facilitators is both cost effective and value-added means for executing the QEP. Each student FTE would be defined as 40 weeks; 15 hours/ week @ $15.00/hr = $9,000.00


X. Assessment Plan Page 41 of 73 pages

X. Assessment Plan: Team FIRST will be assessed using a set of metrics designed to detect the program’s ability to reach the target audience and measure their reaction, learning, and behaviors in both a simulated and clinical learning environment. An implementation science-based approach will be used to assess penetration, completeness, acceptability, and feasibility (Proctor 2011). The timeline, shown in Figure X-1, outlines the intended piloting, implementing and optimizing each of the four educational experiences (Convergence, Transition to Clerkship, Human Factors for the CLE, Post-Graduate Essentials). The Team FIRST Director, Project Manager, and Coordinators will be responsible for the administration and oversight of the implementation process. Implementation of Team FIRST will be assessed using the tools illustrated in Appendix D. Team FIRST seeks to provide students with individual and team-based competencies essential for team-based communication during handovers. The goals outlined in Table IV-2 are tied to specific learning outcomes. Progress towards these goals will be measured using a set of metrics capable of detecting differences in the knowledge, skills, and attitudes gained by each educational experience. The timeline for developing, piloting and deploying Team FIRST assessment tools are shown in Figure X-2 (below). The initial version of the assessment tools to be used to assess the impact of Team FIRST are summarized in Appendix D. This Appendix also include a list of additional validated instrument that will guide further development of tools designed to assess all the individual and team competency targeted in the QEP.

Figure X-1: QEP Assessment Plan Timeline Measurement systems should adhere to six criteria: 1) describe and 2) diagnose performance; 3) address processes and 4) outcomes; 5) offer remediation plans, and 6) incorporate multiple levels of measurement. Recognizing the importance and comprehensiveness of evaluation, the training experiences will incorporate the most widely accept training evaluation framework (Kirkpatrick, 2006) as seen in Figure X-2 below. Kirkpatrick and Kirkpatrick’s training evaluation framework includes four levels (Kirkpatrick, 2006). The first level, reactions, determines if trainees enjoyed the training. Reactions to the protocol and training will be measured using Likert-type attitudinal questions. The second level, learning, establishes whether the trainees acquired the targeted knowledge, skills, and attitudes. Learning will be assessed with declarative knowledge questionnaires. Additionally, we will also measure learning in the simulation with observational metrics. These tools will use dichotomous ratings with a priori events to ameliorate the cognitive workload of the observers. The third level, behavior, identifies the extent that trainees exhibited desired performance on-the-job. Within this level, the first performance outcome is the actual performance. Consequently, performance will be evaluated with observational metrics, and any written documentation will also be collected and analyzed. The final level, results, provides insights into how well the training improved provider, patient, and organizational outcomes. For this QEP, outcomes will be limited to providers. Although changes in patient and organizational outcomes are out of the scope, several metrics will be tracked, and their improvement will be considered “aspirational”.



Figure X-2: Kirkpatrick’s Four Levels of Training Evaluation The Assessment Team Lead will be, Shannon Scielzo, Ph.D., an expert in industrial and organizational psychology and psychometric assessment. Dr. Scielzo, who works within the Office of Graduate Medical Education, will be assisted by Joseph Keebler, Ph.D., an expert in Human Factors and biostatistics who has been working with our institution on handovers in the clinical learning environment for the past three years. Assessment instruments linked to the learning outcomes of Team FIRST are summarized in TABLE X-1. A multi-modal, multi-dimensional approach will be used to assess marker variables (outcomes). These metrics will range from dichotomous testing (present/absence) for implementation, categorical (Likert scale) testing for reaction, declarative knowledge questionnaires for learning (knowledge, skills, attitudes), continuous (scales) for behaviors (on-the-job) and situational judgment tests (SJT) for mental models and confidence. Measurement tools will be used to assess knowledge and attitudes before and immediately following each of the four training experiences (Goddard III, 2006; Schwarz, 1999; Shavelson, 1989). Skills testing will be added with the 2nd (Transition to Clerkship) and subsequent training experiences. Design and validation of these instruments will occur during the pilot phases of each of these programs. Using the panel of assessment tools curated in Appendix D, we propose to develop and validate marker variables to more effectively assess our training efforts. As has been previously inferred (Keebler 2016, Davis 2017), the quality of currently available metrics are questionable at best. Appropriate psychometric development and validation are imperative not only for the efforts of this project, but to also standardize inferences across studies and to bring hand-off science to the next level. We will be collecting several marker assessments to map to our nomological net (Cronbach & Meehl, 1955; Messick, 1995) – i.e., other tools that have been published assessing hand-offs that demonstrate at minimum some degree of face validity (and normative information). The validated and in-house tools included in Appendix D assess all the core individual and team-based competencies deemed critical-to-quality in a series of focus group discussions guided by Dr. Eduardo Salas (Figure VI-1). Moreover, we will establish convergent and discriminant validity. For convergent validity, we will collect other



assessments that address constructs that are related to hand-off success (e.g., supportive context, the utility of support tools, etc.). For discriminant validity, we will ensure that constructs that should not affect our inferences actually do not (e.g., gender and race should not impact ratings of behaviors). Regarding capturing self-reported mental models and confidence, we will employ a variety of approaches to overcome some of the limitations noted in other studies. For example, to better assess hand-off knowledge, we will develop and employ a Situational Judgement Test (SJT). The development of the SJT will require careful review of ‘critical incidents’ related to handoffs (i.e., reviewing all patient safety events over an extensive period of time to identify specific incidents that lead to negative outcomes, and also further identify examples of exemplary processes/instances within our institution from our subject matter experts). The critical incidents will serve as starting points for item development. Items will present scenarios, and then there will be several viable behaviors that a participant can undertake (all with their weightings – with manipulation of various components across items – no item necessarily the ‘best possible solution,’ based on subject matter review and piloting efforts). These assessments allow for a much more accurate understanding of individuals’ likely future behaviors (and current mental heuristics) than other types of self-report assessments. In addition to the SJTs, we will employ quite a few other home-grown assessments (coupled with other appropriate markers and validation instruments) to ensure that we are adequately capturing the true underlying levels of skills in our trainees. We will merge subjective perceptions with more indirect objective approaches – and gain not only an understanding of perceived confidence – but also an understanding of whether individuals lack a self and contextual insight. Table X-1: Matching Assessment Instruments to Learning Outcomes of Team FIRST Goals Team FIRST Goals

Learning Outcomes Assessment Instruments

Goal 1 Students will understand the roles and responsibilities of each team member and how to promote interprofessional decision-making. Students will appreciate the importance of critical behaviors and tools in creating a more structured handover process. Students will implement appropriate communication tools to promote effective handovers.

CONVERGENCE SELF-REPORT Reactions – In-house (K1) Team Perceptions Questionnaire – Keebler et al. (K2) Knowledge and Attitudes Probe (K2) BEHAVIORAL ASSESSMENT – ECHO ICU (K3 Proxy)



Team FIRST Goals

Learning Outcomes Assessment Instruments

Goal 2 Students will be able to conduct a structured handover employing basic tasks and behaviors. Students will appreciate how to develop a team mental model leads to delays in diagnosis and treatment. Students will demonstrate mutual trust by having collaborative interactions to understand patient needs and develop care plans.

TRANSITION TO CLERKSHIP SELF-REPORT Reactions – In-house (K1) Interpersonal Trust – McAllister (K2) Mutual Trust – Wildman et al. (K2) Transactive memory systems – Lewis (2003) (K2) Knowledge and Attitude Probe (K2) BEHAVIORAL ASSESSMENT – ECHO ICU (K3 Proxy) DEBRIEFING

Goal 3 Students will clarify issues and voice concerns to promote safe care practices and quality handovers. Students will be able to appreciate how hierarchical constructs can lead to information loss during handovers. Students will implement appropriate communication tools to promote effective handovers Students will learn how to reflect on performance to determine areas for remediation

HUMAN FACTORS FOR CLE SELF-REPORT Reactions – In-house (K1) Psychological Safety – Edmonson (K2) Knowledge and Attitude Probe (K2) SITUATIONAL JUDGMENT TESTS – In-house (K3 Proxy) BEHAVIORAL ASSESSMENT – ECHO ICU (K3 Proxy) DEBRIEFING

Goal 4 Students will appreciate the importance of critical behaviors and tools in creating a more structured handover process. Students will be able to identify interruptions and leverage strategies to mitigate interruptions Students will be able to appreciate how hierarchical constructs can lead to information loss during handovers. Students will implement appropriate communication tools to promote effective handovers. Students will clarify issues and voice concerns to promote safe care practices and quality handovers.

POST-GRADUATE ESSENTIALS SELF-REPORT Reactions – In-house (K1) Psychological Safety – Edmonson (K2) Knowledge and Attitude Probe (K2) BEHAVIORAL ASSESSMENT – ECHO ICU (K3 Proxy)

Goal 5 (aspirational)

Students’ influence on team-based communication during handovers will improve the culture of safety on CUH signature units.

CLINICAL LEARNING ENVIRONMENT Number of monthly event reports (submitted in RL Solutions) on a CUH signature unit.

Goal 6 (aspirational)

Students’ influence on team-based communication during handovers reduce adverse events on CUH signature units.

CLINICAL LEARNING ENVIRONMENT Vizient composite of risk-adjusted complications on CUH signature unit.



Students have been and will continue to be an essential part of improving team-based communication at UT Southwestern. A series of over 20 medical students pursuing their scholarly activity or distinction in quality improvement or medical education has been actively driving the advancement of making care transfer more structure and reliable. This work has involved our undergraduate, graduate and continuing medical education programs at our institution and has resulted in national recognition. Results from a recent survey of members from our Student Leadership Council (SCL) are depicted in Figure X-3 (below).

Figure X-3: Results of Survey of Student Leadership Council This group represents all of our interprofessional learning communities on campus and has been instrumental in forming an interprofessional focus group that will be added to our cadre of students who will be driving this work as part of their requirements (M.D. with Distinction in Medical Education or Quality Improvement) scholarly activities. We intend to extend similar opportunities to students of the Health Professions and other non-UT Southwestern programs (nursing and pharmacy). Several survey instruments are currently being used by our institution to longitudinally assess educational programs for medical and health profesions students and in some instances compare them to their peers nationally. More specifically, these efforts demonstrate our capacity to collect and curate data on the knowledge, skills, and attitudes of student related to team-based communication. Three of these instruments have been used to collect pilot data for Team FIRST. The first knowledge and attitude probe comes from CONVERGENCE, a product of our last QEP. Five questions from the survey administered in September of 2018 in 750 interprofessional students demonstrated the following:

• 94% believed team-based communication was a significant source of medical errors • 45% had not heard of the importance of a structured handover • 79% had never used a handover cognitive aid or tool • 70% preferred SIM or Case study to learn handovers (vs. lecture/On-Line) • 40% did not know what check back (closed-loop communication) meant



The second is a needs and assessment survey arising from an interactive workshop on handover being piloted during the transitions to clerkship training. This longitudinal data representing 194 medical students demonstrated the following:

• >50% of MS believe they need handover training before clerkship and residency • Exposure to any handover training during clerkships ranged from 1% -59% (median 8%) • Only 7% of students felt very confident to perform written or verbal handovers following core

rotation • 15-month retention of handover knowledge from the workshop remained high

The final instrument is an example of longitudinal work that allows comparison of UT Southwestern graduates with those from other medical schools. This survey instrument probes recent graduate (interns – 1st-year post graduation) on their exposure to simulation-based training related to team-based communication during handovers. Throughout the past three years (2016-2018), the following was comparison were determined from 628 post-graduate trainees (UT Southwestern vs. non-UT Southwestern trainees):

• Confident in handoff skills (93% vs. 91%) • 2 or more handoffs performed using simulation (37% vs. 50%; p < 0.0073) • 2 or more observed (99 vs. 98%) • 2 or more performed in a clinical setting with supervision (84% vs. 87%) • 2 or more performed without supervision (48% vs. 61%; p < 0.009) • Medical school required a minimum passing standard for handoffs (1% vs. 10%; p < 0.0001)

We are fortunate to have a large number (~60 medical students/year) who remain at our institution allowing more granular longitudinal data measurements for these learners after graduation using an educational data warehouse linking both undergraduate and graduate medical education that is currently being implemented by the University. The assessment plan provides feedback for each of the four programs within the academic curriculum, for faculty development to drive improvements during the pilot, implementation and optimization phases for each of these programs. Data assessing the presence of critical team-based behavior in the clinical learning environment (e.g., psychological safety) will be shared with those responsible for handover redesign and implementation within the Health System Affairs. The Team FIRST Director is accountable for the success of the QEP and as a Health System Quality Officer will serve as the lead for diffusing handover best practices at Clements University Hospital under the direction of the Vice President and Chief Medical and Quality for Health System Affairs. The relationship between changes in students’ competencies in team-based communication during handovers, the behaviors within the clinical learning environment and organizational outcomes will be presented to the Executive Vice Presidents for Academic Affairs and Health System Affairs periodically for guidance and any programmatic adjustments that may be required.


XI. Appendices Page 47 of 73 pages

XI. Appendices: Appendix A – Debriefing Best Practices (Lyons et al., 2015) Table: Best Practices for Team Debriefs in Medical Simulations

Best Practice Considerations Considerations for Debrief Preparation

Design measurement and debrief tools around learning objectives and targeted knowledge, skills, and attitudes

• Are the knowledge, skills, and attitudes captured on the debriefing tools?

• Are the evaluation tools linked to simulation events?

Consider facilitate skills when selecting debriefers

• Were domain expertise and interpersonal skills considered when selected debriefers?

• Are the debriefers able to enhance team engagement?

Prepare debriefers (especially for difficult conversations)

• Have debriefers been trained on what and how to debrief?

• Are debriefers prepped to lead difficult conversations?

Consider multimedia to enhance debriefing • Are technological resources available to capture and review performance?

Considerations for Debriefers

Establish a positive learning environment • Were the expectations for debriefing explicitly stated?

Facilitate discussion and encourage participation

• Are debriefers trained on strategies on how to elicit participation?

• Did the debriefer consider the debrief configuration?

Protect debriefing time while prioritizing critical discussions

• Have debriefers identified the most critical behaviors?

• Is the discussion organized around learning objectives?

Considerations for Debrief Content

Discuss teamwork processes, emotions, and different opinions

• Are different perspectives incorporated positively? • Are debriefers trained to handle learner’s

emotions? Address individual and team performance • Is there an opportunity to discuss the team and

individual performance? Emphasize processes, not outcomes • Is the debriefing targeting processes over

outcomes? • Have learners discussed implications of poor

behaviors and performance? Develop solutions • Have remediation plans been developed?

• Have specific goals been established based on the debriefing discussions?



Appendix B – Content for Use in Designing the Educational Experiences TACTICS: • Illustration, Education, Socialization (K-1 Reaction)

• PowerPoint Presentations • Blended e-learning • Problem/Case-Based Learning

• Application, Training (K-2 Learning) • Team-Based Learning • Workshops with table exercises • Team Drills with Role Playing • Just in Time Drills

• Orchestrated Immersion and Experiential Learning (K-3 Behavioral) • Scenarios with scripted Standardized Patients • High Fidelity Simulation

TOPIC OUTLINE: • Critical Safety Communication

• Check-backs & Closed Loop Communication • Briefs • Structured Huddles • CUS • Challenge Rule (to stop imminent danger)

• Conflict Communication • DESC • Contrasting • STATE (to deal with Conflict Resolution) • “Yes and” (medical improve)

• Adversarial Review and Ideation • Brain Writing • Trizz Consulting Technique • Wise Crowd Consulting Technique

• Transitions of Care Communication • SBAR • i-PASS

• Debriefing • Debriefing with Good Judgement • Inquiry with Advocacy • 5-Whys • Focused Group Analysis • Critical Incident Debriefing

• Feedback • Giving Feedback: 5-Start Feedback (Start, More,

Change, Less, Stop) • Taking Feedback: Reframing Storms (5P Technique)



Definitions and References of Communication Topics The foundational definition used for communication is the accurate and precise exchange of information between two or more parties. Feedback • Giving Feedback: 5-Start Feedback

o Description: a technique derived from the SKS (stop, keep, start) format, where a person gives feedback to a member of the team regarding five domains: Start doing, do more of, change doing, do less of, stop doing. Reference: https://hbr.org/2011/08/three-questions-for-effective-feedback

• Taking Feedback: Reframing Storms (5P Technique) o Description: “Reframing” is a cognitive behavioral

technique used to manage emotions and focuses on modulating perceptions. It consists of recognizing the current frame and emotional association then selecting a different, more effective frame/emotion. References: Pichoff AM, Lin DM, Stiegler M. Emotional Intelligence: Critical for Patient Safety and Professional Success. May 1, 2015 Volume 79, Number 5. ASA Newsletter. Prehn A. Create reframing mindsets through Framestorms. Neuro Leadership Journal. 2012; 4:1-11.

Critical Safety Communication • Check-backs

o Description: A check-back is a strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was heard by the sender. Reference: see below for CLC

• Closed Loop Communication o Description: After a check-back has been completed, the original

sender of the information confirms the receiver has heard the correct information (accuracy) and all of the intended information (precision). References: El-Shafy IA, Delgado J, Akerman M, Bullaro F, Christopherson NAM, Prince JM. Closed-loop communication improves task completion in pediatric trauma resuscitation. J Surg Educ. 2017; 1-7. Schuenemeyer J, Hong Y, Plankey M, et al. Foreign body entrapment during thoracic surgery—time for closed-loop communication. Euro J Cardio-Thorac. 2017; 51(5): 852–855.



• Briefs o Description: A short session before the start of team function

to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies. Reference: https://www.ahrq.gov/teamstepps/instructor/essentials/ pocketguide.html

• Huddles o Description: Huddles are team events for problem-solving and

updating the plan. Anyone can call for a huddle to deal with new issues, added complexities, unusual circumstances, or any need to adapt the earlier plan. Reference: https://www.ahrq.gov/teamstepps/instructor/essentials/ pocketguide.html

• CUS o Description: CUS is a communication protocol involving a series of escalating statements, both in

tone and assertiveness, to stop a potentially dangerous situation. (I am Concerned, Uncomfortable, Stop!) Reference: CUS Tool - Improving Communication and Teamwork in the Surgical Environment Module. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/cus-tool.html

• 2-Challenge Rule (to stop imminent danger) o Description: Out of the army aviation technical manual states the two-challenge rule as “ one crew

member ( is allowed ) to automatically assume the duties of another crew member who fails to respond to two consecutive challenges, to prevent the aircraft from moving into unsafe conditions. Reference: https://www.apsf.org/newsletters/pdf/winter2013.pdf

Conflict Communication • Contrasting

o Description: When intentions are misunderstood between two parties, contrasting is merely a pair of statements that address first the misunderstanding (i.e., The last thing I would want you to understand is X….), followed by the correct intention (I am merely trying to convey Y) Reference: https://www.vitalsmarts.com/crucialskills/glossary/#q6

• STATE (to deal with Conflict Resolution) o Description: This is a skill to raise sensitive topics with others. The acronym stands for “Share your

Facts, Tell your story, Ask for other’s stories, and in doing this Talk with tentative language and Encourage the other side to share their perspective with testing statements.” Reference: https://www.vitalsmarts.com/crucialskills/glossary/#q6

• “Yes and” (medical improve) o Description: "Yes, and..." thinking is a rule-of-thumb in improvisational comedy that suggests that a

participant should accept what another participant has stated ("yes") and then expand on that line of thinking ("and"). It is also used in business and other organizations as a principle that improves the



effectiveness of the brainstorming process, fosters effective communication, and encourages the free sharing of ideas References: "What I Learned From the First Rule of Improv - Yes, And". Plantingourpennies.com. Retrieved 2014-02-05. Kulhan, Bob (2013-04-10). "Why "Yes, and…" Might Be the Most Valuable Phrase in Business". Big Think. Retrieved 2016-11-1

Adversarial Review and Ideation • BrainWriting

o Description: Brainstorming is often the method of choice for ideation, but it is fraught with problems that range from participants’ fear of evaluation to the serial nature of the process — only one idea at a time. Brainwriting is an alternative to face-to-face brainstorming, and it often yields more ideas in less time than traditional group brainstorming. In this technique, participants write down answers to questions on cards at once, de-identified. Cards are shuffled and redistributed to the group to allow for a reaction to others thoughts, without fear of conformity or groupthink. Reference: https://www.smashingmagazine.com/2013/12/using-brainwriting-for-rapid-idea-generation/

• Trizz Consulting Technique o Description: this is an ideation technique utilized to answer the difficult question of “what must we

stop doing” in a resource-constrained environment. References: The Surprising Power of Liberating Structures: Simple Rules to Unleash A Culture of Innovation By Henri Lipmanowicz, Keith McCandless. 2013, Liberating Structure Press.

• Wise Crowd Consulting Technique o Description: This is an ideation technique that offers director mentorship from a group to aid in

solving a problem. The technique is useful in that it avoids group thinks, anchoring, and other biases. References: as immediately above

Transitions of Care Communication • SBAR

o Description: This is a communication protocol developed by the US Navy nuclear submarine industry, to exchange critical information with prioritization and timeless. SBAR stands for Situation, Background, Assessment, and Recommendation (SBAR). Reference: Curry-Narayan M. Using SBAR communications in efforts to prevent patient rehospitalizations. Home Healthc Nurse. 2013; 31(31): 504-517.

• i-PASS o Description: this is a communication protocol developed to enhance information exchange during

resident handoffs of patients. I-PASS stands for Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by the receiver Reference: Starmer AJ et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012 Feb;129(2):201-4.

Debriefing



• Debriefing with Good Judgement o Description: A debriefing technique

based on the principles of reflective practice that aims to guide a person towards understanding the frames of reference, or mental models, that motivate their actions while delivering judgment about those actions in a psychologically safe way. This is accomplished with an inquiry and advocacy technique. References: Jenny W. Rudolph, Ph.D., et al. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare • Volume 1, Number 1, Spring 2006

• Inquiry with Advocacy o Description: This is a conversational technique that allows one to manage the apparent tension

between sharing critical, evaluative judgments while maintaining a trusting relationship with others. It is designed to allow for one person to share opinion and judgment with another in order to understand the others mental model or frame of reference. Advocacy is a type of speech that includes an objective observation about and subjective judgment another’s actions. Inquiry is a genuinely curious question that attempts to illuminate the other’s frame of reference or mental model about the action described by the person's advocacy. References: Jenny W. Rudolph, Ph.D., et al. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare • Volume 1, Number 1, Spring 2006

• 5-Whys o Description: This is an iterative ideation technique used to explore the

cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?" Each answer forms the basis of the next question. Reference: Semler, Ricardo (2004). The Seven-Day Weekend. Penguin. ISBN 9781101216200. Ask why. Ask it all the time, ask it any day, and always ask it three times in a row.

• Focused Group Analysis o Description: This is an ideation technique to collect qualitative data, involving a small number of

people in an informal group discussion (or discussions) that represent a larger cohort,‘focused’ around a particular topic or set of issues”. Reference: Wilkinson, S. (2004). Focus group research. In D. Silverman (ed.), Qualitative research: Theory, method, and practice (pp. 177–199). Thousand Oaks, CA: Sage

• Critical Incident Debriefing o Description: A psycho-educational small group process that focuses on structured group story-telling

combined with practical information to normalize group member reactions to a critical incident and facilitate their recovery. Reference: http://www.info-trauma.org/flash/media-f/mitchellCriticalIncidentStressDebriefing.pdf



Appendix C – Consultants and Team Science Collaborators Eduardo Salas, Ph.D. Allyn R. & Gladys M. Cline Professor and Chair Department of Psychological Sciences Rice University Rice University Houston, TX 77019 Mobile (407) 970-1375 Office: (713) 349-3917 Dr. Salas manages an interdisciplinary staff and the team science portfolio supporting NASA, the Department of Defense, the oil and gas sector and healthcare. Previously, he was a Trustee Chair and Pegasus Professor of Psychology at the University of Central Florida where he also held an appointment as Program Director for the Human Systems Integration Research Department at the Institute for Simulation and Training (IST). Dr. Salas over the last 30 plus years has generated over $54M in funding and managed numerous multi-disciplinary research and applied projects focused on understanding the competencies needed for effective team functioning; the mechanisms and conditions need to boost and sustain team effectiveness and how to design and develop interventions to boost team performance. Dr. Salas has co-authored over 450 journal articles & book chapters and has co-edited 33 books and authored one book on team training. His expertise includes assisting organizations, including oil and gas, aviation, law enforcement, and healthcare industries, in how to foster teamwork, design and implement team training strategies, facilitate training effectiveness, manage decision making under stress, and develop performance measurement tools. Dr. Salas is a Past President of the Society for Industrial/Organizational Psychology, recipient of the Meritorious Civil Service Award from the Department of the Navy, 2012 Society for Human Resource Management Losey Lifetime Achievement Award, the 2012 Joseph E. McGrath Award for Lifetime Achievement from the INGroup, the 2016 Distinguished Scientific Contributions – awarded by the Society of Industrial and Organizational Psychology and 2016 Lifetime Achievement Award for Contributions to Psychology from the American Psychological Association. Education 1984 OLD DOMINION UNIVERSITY Norfolk, Virginia Received Doctorate Degree in Industrial/Organizational Psychology. Major Area: Personnel and Training Minor Area: Engineering and Systems Psychology 1980 UNIVERSITY OF CENTRAL FLORIDA Orlando, Florida Received Master of Science Degree in Industrial Psychology.



Limited Selection of References: Salas, E., Zajac, S., & Marlow, S.L. (2018). Transforming health care one team at a time: Ten observations and the trail ahead. Group & Organization Management, 1-25. Salas, E., Reyes, D.L., & McDaniel, S.H. (2018). The science of teamwork: Progress, reflections, and the road ahead. American Psychologist, 73 (4), 593-600. McDaniel, S.H., & Salas, E. (2018). The science of teamwork: Introduction to the special issue. American Psychologist, 73 (4), 305-307. Marlow, S.L., Lacerenza, C.N., Paoletti, J., Burke, C.S., & Salas, E. (2018). Does team communication represent a one-size-fits-all approach? A meta-analysis of team communication and performance. Organizational Behavior and Human Decision Processes. 144, 145-170. Sottilare, R.A., Burke, S.C., Salas, E., et al. (2018). Designing adaptive instruction for teams: A metaanalysis. International Journal of Artificial Intelligence in Education, 28 (2), 225-264. Salazar, M., Feitosa, J., & Salas, E., (2017). Diversity and team creativity: Exploring underlying mechanisms. Group Dynamics: Theory, Research and Practice. 21 (4), 187-206. Lacerenza, C.N., Reyes, D.L., Marlow, S.L., Joseph, D.L., & Salas, E. (2017). Leadership training design, delivery and implementation: A meta-analysis. Journal of Applied Psychology. 12, 1686- 1718. Fiscella, K., Mauksch, L., Bodenheimer, T., & Salas, E. (2017). Improving care teams’ functioning: Recommendations from team science. The Joint Commission Journal on Quality and Patient Safety. 43 (7), 361-368. Hughes, A.M., Gregory, M.E., Joseph, D.L., Sonesh, S.C., Marlow, S.L., Lacerenza, C.N., Benishek, L. E., King, H.B. & Salas, E. (2016). Saving lives: A meta-analysis of team training in healthcare. J App Psychology. 101(9), 266-304. Lyons, R., Lazzara, E. H., Benishek, L. E., Zajac, S., Gregory, M., Sonesh, S. C., & Salas, E. (2015). Enhancing the effectiveness of team debriefings in medical simulation: More best practices. Joint Commission Journal on Quality and Patient Safety, 41(3), 115-125. Salas, E., Shuffler, M.L., Thayer, A.L., Bedwell, W.L., & Lazzara, E.H. (2014). Understanding and improving teamwork in organizations: A scientifically based practical guide. Human Resource Management. 1-24. Keebler, J.R., Dietz, A.S., Lazzara, E.H., Benishek, L.E., Almeida, S.A., Toor, P.A., King, H.B. & Salas, E. (2014). Validation of a teamwork perceptions measure to increase patient safety. BMJ Quality & Safety, 23. 718-726. Lazzara, E.H., Benishek, L.E., Dietz, A., Adriansen, D.J., & Salas, E. (2014). The eight success factors of simulation. The Joint Commission Journal on Quality and Patient Safety, 40, 21-29.



Joseph Roland Keebler, Ph.D. Embry-Riddle Aeronautical University Associate Professor (Tenured) of Human Factors Department of Human Factors and Behavioral Neurobiology 610 S. Clyde Morris Blvd Daytona Beach, FL 32173 Email: [email protected] Personal Website: www.josephkeebler.com Dr. Keebler has over 12 years of experience conducting experimental and applied research in human factors, with a specific focus on training and teamwork in the military, medical, and consumer domains. He is a tenured associated professor of human factors and systems at Embry Riddle Aeronautical University. Dr. Keebler has partnered with multiple agencies and institutions in his career, with most projects aimed at the implementation of human factors in complex, high-risk systems, to increase safety and human performance. This work includes command and control of teleoperated unmanned vehicles, communication, and teamwork in medical systems, and the development of simulation and gamification of training for advanced skills including playing the guitar and identifying combat vehicles. Joe’s work includes over 50 publications and over 60 presentations at national and international conferences. Dr. Keebler involved in conducting medical human factors work when he began his post-doctoral work. This work includes three major projects – the first being an awarded grant where I served as Co-PI examining the effectiveness of augmented reality training systems for learning anatomy. The second was a collaboration with DoD/AHRQ’s TeamSTEPPS program, where I served as a statistical analyst and lead author on a publication validating their survey of team perceptions (TPQ), which was later published in the British Medical Journal of Quality and Safety. The third was an investigation at Jackson Memorial Hospital in collaboration with the University of Miami examining the effects of telemedical robots in a trauma intensive care unit (TICU). In 2016, he published the most comprehensive systematic review and meta-analysis on handovers in healthcare. Education: Post–Doctoral Research Scientist 2011 – 2012 Institute for Simulation & Training Location: Department of Human Systems Integration, IST, Orlando, FL Topic Areas: Military and Medical Team Systems, Science, & Training Supervisor: Eduardo Salas Ph.D., Applied/Experimental Human Factors Psychology 2011 University of Central Florida Dissertation – Effects of 3D stereoscopy, visual working memory, and perceptions of simulation experience on the memorization of confusable objects Supervisor: Florian Jentsch M.A., Applied/Experimental Human Factors Psychology 2010 University of Central Florida B.S. Psychology 2005 University of South Florida



Limited Selection of References: Guttman, O., Lazzara, E.H., Keebler, J.R., Webster, K., Gisick, L, & Baker, A. (accepted for publication). Dissecting communication barriers in healthcare: A path to enhancing communication resilience, reliability, and patient safety. Keebler, J.R., Lazzara, E.H., Blickensderfer, E., & Looke, T. (2018). Applying human factors to process improvement in the perioperative setting. Anesthesiology Clinics, 36(1), 17-29. Gisick, L., Webster, K., Keebler, J.R., Lazzara, E.H., Fouquet, S., Fletcher, K., Lew, V., & Chan, YRC (2018). Measuring shared mental models in healthcare. Journal of Patient Safety and Risk Management. Lynch, I., Roberts II, P.E., Keebler, J.R., Guttman, O., Greilich, P.E. (2017). Error Reporting and Detection in the Intensive Care Unit: Progress, Barriers, and Future Direction. Current Anesthesiology Reports. Wahr, J. A., Abernathy, J., Lazzara, E. H., Keebler, J. R., Clinton, M., Wall, M., Lynch, I., Stratman, R., Cooper, L. (2017). Medication safety in the operating room: Literature and expert-based recommendations. British Journal of Anesthesia. Keebler, J. R., Lazzara, E. H., Patzer, B. S., S Smith, D. C., Plummer, J. P., Fouquet, S., Kafka, M., Palmer, E. P., Chan, Y. R., & Riss, R. (2016). Do handoff protocols work? A meta-analysis of the effects of handoff protocols on information passed, provider, patient, and organizational outcomes. Human Factors: The Journal of the Human Factors and Ergonomics Society, 58(8), 1187-1205. Lazzara, E. H., Palmer, E. M., Keebler, J. R., Smith, D. C., Patzer, B., Chan, Y. R., Riss, R. R., Fouquet, S. D., & Kafka, M. (2016). Developing an empirically-based handoff protocol for pediatric hospitalists. Hospital Pediatrics, 6(12), 722-729. Keebler, J.R., Dietz, A.S., Lazzara, E.H., Benishek, L., Toor, P., Almeida, S., King, H., & Salas, E. (2014). Validation of a team perceptions measure to increase patient safety. British Medical Journal: Quality and Safety. doi:10.1136/bmjqs-2013-001942



Elizabeth Hunter Lazzara. Ph.D. Embry-Riddle Aeronautical University Assistant Professor of Human Factors Department of Human Factors and Behavioral Neurobiology 610 S. Clyde Morris Blvd Daytona Beach, FL 32173 [email protected] Office: 386.226.4922 Dr. Lazzara is a Human Factors Psychologist and patient safety researcher in the areas of medical teams. Within this arena, she has assisted in advancing the field from a theoretical perspective as well as an empirical perspective. From a theoretical lens, she offers recommendations on how to better interact and perform in a team within the medical setting. In particular, Dr. Lazzara has provided guidance for medical interprofessional (i.e., teamwork) education, medical translational teams, and surgical teams. From an empirical lens, she has assisted in validating a metric developed by the Agency for Health Research and Quality and the Department of Defense designed to assess medical teamwork perceptions. This work is novel in that it corresponds to an empirically-supported theoretical team framework. Dr. Lazzara is an expert in team training and its effective in enhancing team performance. Similar to medical teams, she has forwarded the theory of team training by translating the science of team training to practitioners to offer guidance on developing, implementing, and evaluating team training within the healthcare context. She has forwarded the field of team training by assisting in a project that developed, implemented, and evaluated TeamSTEPPS, the team training developed by the Agency for Health Research and Quality and the Department of Defense. This study found that team training improved teamwork on multiple criteria: reactions, learning, behaviors, and results. Perhaps the most noteworthy aspect of this project is that it employed a multi-level evaluation framework. Dr. Lazzara has made major contributions include a comprehensive qualitative review that determined the state of the science as it pertains to simulation-based team training. Further, her work has focused on dissecting the challenges inherent in simulation-based team training to develop solutions on how to address these challenges accordingly. Education: Ph.D. Applied Experimental Human Factors Psychology 2013 University of Central Florida Committee Chair: Eduardo Salas, Ph.D. M.A. Applied Experimental Human Factors Psychology 2010 University of Central Florida B.A. Psychology 2005 University of South Florida



Limited Selection of References: Salas E., Benishek, L, Coultas, C., Dietz, A., Grossman, R., Lazzara, E., & Oglesby, J. (2015). Team training essentials: A research-based guide. New York: Taylor & Francis. Driskell, T., Lazzara, E. H., & Salas, E. (2012). Does team training work? Where is the evidence? In E. Salas & K. Frush (Eds.), Improving patient safety through teamwork and team training (pp. 201-217). New York: Oxford University Press. Weaver, S. J., Rosen, M. A., Diaz Granados, D., Lazzara, E. H., Lyons, R., Salas, E., et al. (2010). Does teamwork improve performance in the operation room?: A multi-level evaluation. The Joint Commission Journal on Quality and Patient Safety, 36, 133-142. Salas, E., Almeida, S. A., Salisbury, M., King, H., Lazzara, E. H., Lyons, R., et al. (2009).What are the critical success factors for team training in health care? The Joint Commission Journal on Quality and Patient Safety, 35(8), 398-405 Benishek, L. E., Lazzara, E. H., Sonesh, S. C., Leaphart, C., & Salas, E. (2015, April). Recommendations for dealing with the challenges inherent to simulation-based team training. Poster to be presented at the 2015 International Symposium on Human Factors and Ergonomics in Health Care, Baltimore, MD. Rosen, M. A., Weaver, S. J., Lazzara, E. H., Salas, E., Wu, T., Silvestri, S., et al. (2010). Tools for evaluating team performance in simulation-based training. Journal of Emergencies, Trauma, and Shock, 3(4), 353-359. Weaver, S. J., Lyons, R., Lazzara, E. H., Rosen, M. A., Diaz Granados, D., Grim, J., et al. (2010). Simulation-based team training (SBTT) at the sharp end: A qualitative study of SBTT design, implementation, and evaluation in healthcare. Journal of Emergencies, Trauma, and Shock, 3(4), 369-377. Rosen, M. A., Salas, E., Wu, T. S., Silvestri, S., Lazzara, E. H., Lyons, R., & Weaver, S.J. (2008). Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine residents. Academic Emergency Medicine, 15(11), 1190-1998. Simulation-Based Training Simulation-based team training is undoubtedly intimately related to simulation-based training



Appendix D - Assessment Instruments Assessment of QEP Implementation

Team FIRST Tracker

Adapted from (Schall et al., 2008) and (Damschroder et al., 2009)



Implementation Acceptability and Feasibility

SA=Strongly Agree / A=Agree / N=Neutral / D=Disagree / SD=Strongly Disagree Acceptability Survey for Learners SA A N D SD

1 The information in the prework helped me to understand the nature & importance of handoffs

2 The quality of the prework material maintained my interest and attention

3 I felt that I understood what I would learn in the Handoff section in the Transition to Clerkship Course

4 I felt that the Handoff section in the Transition to Clerkship Course maintained my interest and attention

5 I think the time allotted for the Handoff section in the Transition to Clerkship Course was just right

6 I think the exercises in the Handoff section in the Transition to Clerkship Course were effective in teaching me the importance of reliable communication

Feasibility Survey for Facilitators/Trainers Yes No Unk

B1 Training: Does staff require specific training to deliver the curriculum? B3 Time: Is the training time-consuming to provide? B6 Material: Does the training require additional material resources?

E1 Population: Is the training applicable given the curriculum of the population of interest?

E3 Flexibility: Is the training flexible?

E6 Goals: Do the learning objectives of the training address the objectives of the AAMC EPAs and ACGME CLER pathways

E7 Pilot: Can the training be piloted?

Unk Unknown Adapted from (van der Krieke et al., 2015)



Reactions to Training (K1)

Scale

1 = Strongly Disagree / 2 / 3 / 4 / 5 / 6 / 7 = Strongly Agree Items

1. The training was well organized. 2. The training content was appropriate. 3. As a result of the training, I feel confident that I am prepared. 4. I believe that this training will help my organization improve patient safety. 5. I am confident that I can use the knowledge that I learned on the job. 6. As a result of the training, I feel more confident about my ability to work effectively in a team. 7. I am likely to apply the tools in this training to a variety of situations on the job. 8. I would recommend this training to others.



Team Perceptions Questionnaire (TPQ) (K1)

SA A N D SD Team Structure

1. The skills of staff overlap sufficiently so that work can be shared when necessary.

2. Staff are held accountable for their actions. 3. Staff within my unit share information that enables timely decision making by the direct patient care team.

4. My unit makes efficient use of resources (e.g., staff supplies, equipment, information).

5. Staff understand their roles and responsibilities.

6. My unit has clearly articulated goals. 7. My unit operates at a high level of efficiency.

Leadership 8. My supervisor/manager considers staff input when making decisions about patient care.

9. My supervisor/manager provides opportunities to discuss the unit’s performance after an event.

10. My supervisor/manager takes time to meet with staff to develop a plan for patient care.

11. My supervisor/manager ensures that adequate resources (e.g., staff, supplies, equipment, information) are available.

12. My supervisor/manager resolves conflicts successfully.

13. My supervisor/manager models appropriate team behavior.

14. My supervisor/manager ensures that staff are aware of any situations or changes that may affect patient care.

Situation Monitoring 15. Staff effectively anticipate each other’s needs.

16. Staff monitor each other’s performance. 17. Staff exchange relevant information as it becomes available.

18. Staff continuously scan the environment for important information.

19. Staff share information regarding potential complications (e.g., patient changes, bed availability).

20. Staff meets to reevaluate patient care goals when aspects of the situation have changed.



SA A N D SD 21. Staff correct each other’s mistakes to ensure that procedures are followed properly.

Mutual Support 22. Staff assist fellow staff during high workload.

23. Staff request assistance from fellow staff when they feel overwhelmed.

24. Staff caution each other about potentially dangerous situations.

25. Feedback between staff is delivered in a way that promotes positive interactions and future change.

26. Staff advocate for patients even when their opinion conflicts with that of a senior member of the unit.

27. When staff have a concern about patient safety, they challenge others until they are sure the concern has been heard.

28. Staff resolve their conflicts, even when the conflicts have become personal.

Communication 29. Information regarding patient care is explained to patients and their families in lay terms.

30. Staff relay relevant information in a timely manner.

31. When communicating with patients, staff allow enough time for questions.

32. Staff use common terminology when communicating with each other.

33. Staff verbally verify information that they receive from one another.

34. Staff follow a Standardized method of sharing information when handing off patients.

35. Staff seek information from all available sources.

SA Strongly Agree / A Agree / N Neutral / D Disagree / SD Strongly Disagree

(Keebler et al., 2014)



CONVERGENCE Knowledge and Attitude Probe 2015-2016 (K1) Indicate the extent of your agreement or disagreement with each of the following statements. All items are scored as: Strongly agree (5), Agree (4), Neutral (3), Disagree (2), Strongly Disagree (1) 1. Professional Identity Scale “this profession” refers to that for which you are training.

a. I feel like I am a member of this profession b. I feel I have strong ties with members of this profession c. I am often ashamed to admit that I am studying for this profession. d. I find myself making excuses for belonging to this profession e. I try to hide that I am studying to be part of this profession f. I am pleased to belong to this profession g. I can identify positively with members of this profession h. Being a member of this profession is important to me i. I feel I share characteristics with other members of the profession

2. Teamwork and collaboration

a. Learning with other students will help me become a more effective member of an interprofessional team

b. Shared learning with other health care students will increase my ability to understand clinical problems

c. Communication skills are enhanced in an academic environment with other health care students d. For small group learning to be effective, students need to trust and respect each other e. It is essential for all health care students to learn teamwork skills f. Interprofessional learning will help me to better understand my own professional limitations g. Relationships across professions should be included in educational programs

3. Interprofessional identity

a. I don’t want to waste my time learning with other health care students b. Problem-solving skills are best learned with students from my own program c. Interprofessional learning with other health care students will help me to communicate better with

patients and other professionals d. I would welcome the opportunity to work on projects with other health care students in other

disciplines e. Shared learning will help to clarify the nature of patient problems

4. Roles and responsibilities

a. I’m not sure what my role will be in an interprofessional team b. In an interprofessional team, each member has expertise others do not c. Each member of an interprofessional team is responsible for contributing his or her expertise

Attitude Section* (MS, HP, Nursing) *Customized from the Professional Identity Scale (Adams, Hean, Sturgis, & Clark, 2006) and (Reid, Bruce, Allstaff, & McLernon, 2006)



Behavioral Assessment (K2) Handoff Clinical Evaluation (Tool) Exercise (CEX): Inpatient shift-to-shift change

(Horwitz et al., 2013)



Team Psychological Safety (K3)

Scale:

1= Never / 2 / 3 / 4 / 5= Always α = .81

1. If you make a mistake on this team, it is often held against you. 2. Members of this team are able to bring up problems and tough issues. 3. People on this team sometimes reject others for being different. 4. It is safe to take a risk on this team. 5. It is difficult to ask other members of this team for help. 6. No one on this team would deliberately act in a way that undermines my efforts. 7. Working with members of this team, my unique skills and talents are valued and utilized.

(Edmondson, 1999) Validated Test to be Used to Optimize Assessment Tools during Development

Interpersonal Trust (McAllister, 1995)

Preference for Teamwork (Campion, Medsker, & Higgs, 1993)

Propensity to Trust (Couch, Adams, & Jones, 1996)

Team Effectiveness (Gibson, Zellmer-Bruhn, & Schwab, 2003)

Teamwork Quality (Hoegl & Gemuenden, 2001)

Team Role Experience and Orientation (Mathieu, Tannenbaum, Kukenberger, Donsbach, & Alliger, 2015)

Transactive Memory (Lewis, 2003)

Trust/Distrust (Wildman, Fiore, & E., 2009)



Appendix E – Reaffirmation of Accreditation 2019 COMMITTEES Steering Committee

Individual Position Administrative Title

Andrew Zinn, M.D., Ph.D., Chair

Professor of Internal Medicine Dean, Southwestern Graduate School of Biomedical Sciences

Arnim Dontes, M.B.A. Executive Vice President for Business Affairs

Charles Ginsburg, M.D. Professor of Pediatrics Vice Provost and Senior Associate Dean for Education

Angela Mihalic, M.D. Professor of Pediatrics Dean of Medical Students & Assoc. Dean Student Affairs

Daniel K. Podolsky, M.D. Professor of Internal Medicine President

Robert Rege, M.D. Professor of Surgery Assoc. Dean for Undergraduate Medical Education

Dwain Thiele, M.D. Professor of Internal Medicine Interim Executive Vice President for Academic Affairs and Provost, Dean Southwestern Medical School, Vice Provost, and Senior Assoc. Dean for Faculty Affairs

Jon Williamson, Ph.D. Professor of Health Care Sciences Dean, Southwestern School of Health Professions

James Drake ex officio Asst. Vice President, Office of Academic Planning and Assessment

Ramona Dorough ex officio Subcommittees:

• Administration (p 69) • Educational Program (p 69) • Faculty (p 70) • Institutional Effectiveness (p 70) • Student Affairs and Services (p 71)



SACS Administration Subcommittee

Individual Administrative Title

Arnim Dontes, M.B.A., Chair Executive Vice President for Business Affairs

Juan Guerra Jr., M.B.A. Vice President for Facilities Management

Suresh Gunasekaran, M.B.A. Vice President for Health System Operations

Robin Jacoby, Ph.D. Vice President and Chief of Staff

Dinah Middleton

Michael Serber, M.B.A. Vice President for Financial Affairs

Cameron Slocum, M.B.A. Vice President and Chief Operating Officer for Academic Affairs

Ivan Thompson Vice President for Human Resources

Andrew Zinn, M.D., Ph.D., ex officio Dean, Southwestern Graduate School of Biomedical Sciences

James Drake, ex officio Asst. Vice President, Office of Academic Planning and Assessment

Ramona Dorough, ex officio SACS Educational Programs Subcommittee


Charles Ginsburg, M.D., Chair

Professor of Pediatrics Vice Provost and Senior Associate Dean for Education

Jennifer Cuthbert, M.D. Professor of Internal Medicine

Robert Rege, M.D. Professor of Surgery Assoc. Dean for Undergraduate Medical Education

Dorothy Sendelbach, M.D. Professor of Pediatrics Asst. Dean for Undergraduate Medical Education

Jon Williamson, Ph.D. Professor of Health Care Sciences Dean, Southwestern School of Health Professions

Andrew Zinn, M.D., Ph.D. Professor of Internal Medicine Dean, Southwestern Graduate School of Biomedical Sciences


Ramona Dorough ex officio



SACS Faculty Subcommittee

Individual Position Administrative Title Dwain Thiele, M.D., Chair Professor of Internal Medicine Interim Executive Vice

President for Academic Affairs and Provost, Dean Southwestern Medical School, Vice Provost and Senior Assoc. Dean for Faculty Affairs

Beth Brickner, M.D. Professor of Internal Medicine Kim Hoggatt-Krumwiede, Ph.D.

Professor of Health Care Sciences Associate Dean for Academic Affairs, School of Health Professions

Sandra Schmid, M.D. Professor and Chair of Cell Biology Lance Terada, M.D. Professor of Internal Medicine and

Surgery

Ruth Womack Andrew Zinn, M.D., Ph.D. ex officio Dean, Southwestern Graduate

School of Biomedical Sciences James Drake ex officio Asst. Vice President, Office of


Ramona Dorough ex officio SACS Institutional Effectiveness Subcommittee

Individual Position Administrative Title Dwain Thiele, M.D. Professor of Internal Medicine Interim Executive Vice

President for Academic Affairs and Provost, Dean Southwestern Medical School, Vice Provost and Senior Assoc. Dean for Faculty Affairs

Melody Bell Suzanne Farmer, Ph.D. Asst. Professor of Psychiatry Asst. Vice President for

Organizational Development and Training

Chris Faulkner, Ph.D. Asst. Professor of Health Care Sciences

Wade Radicioni Andrew Zinn, M.D., Ph.D. ex officio Dean, Southwestern Graduate

School of Biomedical Sciences James Drake ex officio Asst. Vice President, Office of





SACS Student Affairs and Services Subcommittee


Angela Mihalic, M.D., Chair Professor of Pediatrics Dean of Medical Students & Assoc. Dean Student Affairs

Blake Barker, M.D. Assoc. Professor of Internal Medicine

Assoc. Dean of Students

Kelly Gonzalez Asst. Vice President for Library Services

Kim Hoggatt-Krumwiede, Ph.D.

Professor of Health Care Sciences Associate Dean for Academic Affairs, School of Health Professions

Wade Radicioni

Nancy Street, Ph.D. Asst. Professor of Microbiology Assoc. Dean, Southwestern Graduate School of Biomedical Sciences

Preston Wiles, M.D. Professor of Psychiatry

Shannon Williams

Andrew Zinn, M.D., Ph.D. ex officio Dean, Southwestern Graduate School of Biomedical Sciences




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Quality Enhancement Plan Full Report - UT Southwestern · for interprofessional simulation-based team training for handovers. Faculty within our Academic Colleges, Health Professions