LEADING INNOVATION IN

PATIENT SAFETY

Gregory Botz, MD, FCCM Professor, Department of Critical Care Division of Anesthesiology and Critical Care The University of Texas, MD Anderson Cancer Center, Houston, TX

Translational Safety Through Immersive Learning: Practice What you Preach

Patient Safety Innovation:

Translational Safety through Immersive Learning: Practice what you preach!

Gregory H. Botz, MD, FCCM UT System Distinguished Teaching Professor Professor of Anesthesiology and Critical Care Associate Medical Director of Intensive Care Medical Director, Simulation Center UT M.D. Anderson Cancer Center UT System Chancellor’s Health Fellow for Quality of Care and Patient Safety

DISCLOSURE I have no financial relationships with commercial support to disclose.

Hospitals are Dangerous!

November 30, 1999: Medical Injuries in the U.S. account for:

44,000 - 98,000 deaths per year

More people die from medical errors than from

breast cancer or AIDS or motor vehicle accidents

Direct health care costs:

$9 - 15 billion per year

Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.

Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.

Key Findings: • Errors occur because of system failures

• Preventing errors means designing safer

systems of care

• Organizations, not individual physicians and nurses control those systems of care

Key Findings: “Between the health care we have and the care

we could have lies not just a gap, but a chasm.” “Trying harder will not work! “Changing systems of care will”

Committee on Quality of Health Care in America. Crossing the Quality Chasm. Institute of Medicine, 2001.

…[T]he true number of premature deaths associated with preventable harm to patients was estimated at more than

400,000 per year.

Serious harm seems to be 10- to 20-fold more common than lethal harm

James JT: A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety 2013; 9:122-8

How Hazardous is Healthcare?

1

10

100

1000

10000

100000

1 10 100 1000 10,000 100,000 1,000,000 10,000,000

DANGEROUS (>1/1000)

REGULATED ULTRA-SAFE (<1/100K)

Healthcare

Driving

Scheduled Airlines

Chartered Flights

Chemical Manufacturing

Mountain Climbing

Bungee Jumping

European Railroads

Nuclear Power

Number of encounters for each fatality Source: 2002 Institute of Healthcare Improvement

Modern Medicine!

So, What’s the Problem?

The science and technolog y of our current healthcare system is the best the world has ever seen; (and continues to improve rapidly) while the performance of American Healthcare delivery leaves much to be desired.

It’s a Failure of Execution!

Adapted From Brent James: Managing Clinical Processes: Doing Well by Doing Good

Advanced Training Program in Healthcare Delivery Improvement. IHC

Chassin, MR, Galvin, RW, and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA 1998; 280(11):1000-1005. Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.

Performance Gaps

There is often a GAP between how we think we BEHAVE and PERFORM and how we actually BEHAVE and PERFORM.

Within that GAP, there is a potential for: Efficiency Waste, Patient Safety Lapses, and Harm

Recent Approaches

Best Practices!

Translational Patient Safety

Translate

What You Know

into

What You Do!

Translational Research

Immersive Learning

Modern Aviation Simulator

Medical Simulation

Medical Simulation

“Simulation is a technique, not a technolog y” Gaba, 1992, 1993, 1994, 1995…

Realistic Environment Realistic Circumstances Realistic Stressors – “Stress Inoculation” Safe and Supportive Reproducible

Medical Simulation

Education Training Assessment

Medical Simulation

Education Training Assessment

“Teaching” “Knowledge-building” “Adult Learning”

“Doing” “Deliberate Practice” “Mastery Learning”

“Measuring” “Performance” “Evaluation”

Medical School Education

Surgical Skills Training

Radiation Therapy

Education vs. Training

→ “Education does not mean teaching people to know what they do not know. It means teaching them to behave as they do not behave.” (Glavin)

→ Training is learning an expected behavior

→ Evaluation is measuring the performance of that behavior

Deliberate Practice is a strategy to periodically practice in order to gain mastery of, and maintenance of the behavior.

Deliberate Practice

Expert Performance is not necessarily innate

Expert-level performance is primarily the result of expert-level practice

“10,000 Hours” threshold to expert performance (Gladwell, Outliers. 2008)

Deliberate Practice in Industry

Aviation Nuclear Power Maritime Services Rail Services Law Enforcement Emergency Medical Services Fire Services

Manufacturing Litigation Computer Science Food Services Hospitality Performing Arts Sports

Examples from Other Domains

Examples of Deliberate Practice in Healthcare

Life Support Training

http://laparoscopytraining.net/main/

https://cuschieri.dundee.ac.uk/courses/general-surgery/core-skills-laparoscopic-surgery-course

Procedural Training

Anesthesia Crisis Resource Management Development of the ACRM Concept

• Anticipation and Planning • Communication Leadership and

Assertiveness • Use of all available resources • Anesthesia resident utilizing a cognitive aid

during ACRM training • Distribution of Workload & mobilization of

help • Re-evaluation of situations • Use of all available information and cross

checking of redundant data

Breaking Bad News

Medical Error Disclosure

Deliberate Practice in Healthcare

Emergency Medicine • Trauma Team Skills • Medical Emergencies • Highly Infectious Diseases • High Risk Transports

Intensive Care • Urgent Admissions • Medical Emergencies • Unplanned Extubation • Equipment Failure

Operating Room • Emergent Surgery • Medical Emergency • Massive Bleeding • Equipment Failure

Procedure Areas • Medical Emergencies • Oversedation • Procedural Complications • Equipment Failure

“Systems-Probing”

In-Situ Simulation Periodic Performance Measurement Assessment of:

• System Performance • Provider Performance • Training Effectiveness

Deliberate Practice: Booster Shot Mock Codes for Medical Emergencies Fire Drills for Life Safety

Practice What You Preach!