# Presentation: 704167

## A Curriculum for Health Professions  Leaders to Promote Patient Safety: Moving a Toolkit Online

- Pamela H. Mitchell & Lynne Robins, Project Directors
- AHRQ 2005 Annual Patient Safety & Health Information Technology Conference – Health Care Education Tools IIJune 7, 2005, Washington DC

## Faculty Leadership in Interprofessional Education to Promote Patient Safety (FLIEPPS)

- Cooperative agreement from the Division of Medicine and Dentistry and the Division of Nursing, Bureau of Health Professions (BHPr), Health Resources Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number 5 D50 HP 10006.
- Building on the work of the Center for Health Sciences Interprofessional Education & Research, University of Washington

- Creating a curriculum for training health profession faculty, pp.299-312,* in Advances in Patient Safety: From Research to Implementation*. Volume 4, AHRQ Publication No. 050021-4). February 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/advances/

**Notes:**
The FLIEPPS (Faculty Leadership in Interprofessional Education to Promote Patient Safety) project is a cooperative agreement from the Division of Medicine and Dentistry and the Division of Nursing, Bureau of Health Professions (BHPr), Health Resources Services Administration (HRSA), Department of Health and Human Services (DHHS), building on the infrastructure of the Center for Health Sciences Interprofessional Education & Research.  
The goal of the grant was to create an integrated curriculum for the collaborative education of physicians, nurses, and health professionals emphasizing the promotion of patient safety 

## What is the FLIEPPS project?
Lessons learned in construction & implementation
Moving the curriculum online

- Lessons learned in construction & implementation
- Moving the curriculum online

- What is FLIEPPS?
- Curriculum for the collaborative education of physicians,  nurses, health professionals emphasizing interprofessional approaches to promote patient safety.
- Train the trainer approach
- Toolkit

- Faculty Leadership in Interprofessional Education to Promote Patient Safety (FLIEPPS)

**Notes:**
In this presentation we will address 3 areas: what FLIEPPS is, Practical lessons learned in constructing and implementing a curriculum that blends interprofessional leadership and patient safety, and practical lessons learned in moving a ‘live’ curriculum online.  

FLIEPPS is a curriculum for the collaborative education of physicians, nurses and other health professionals emphasizing patient safety. The curriculum is essentially a toolkit for educators, and is delivered via a ‘train the trainer’ approach.

FLIEPPS is also an interprofessional team of educators working collaboratively to develop, pilot test, evaluate, and disseminate an integrated patient safety curriculum based on patient-centered interprofessional collaboration for patient safety. FLIEPPS provides tools for assessing and improving teaching practices that influence patient care using the current best practices in interprofessional education and patient safety. Using a “train the trainer” approach, FLIEPPS is developing leaders who can influence educational change in the service of patient safety at their schools, colleges or health care institutions.

## FLIEPPS curriculum is a toolkit

- FLIEPPS Handbook
- 5 Modules, linking to workshop
- 2 day Interactive Workshop  (in person; online)
- Train the trainer
- Action plan
- CE credit
- Website
- Cases, presentation materials, reference links

**Notes:**
Our curricular approach in the proposed project was to integrate a culture of safety approach with a culture of interprofessional collaboration.  The curriculum is an integrated package, or ‘toolkit’ consisting of 1) a modular handbook linked to 2) experiential and reflective exercises that can be used with learners in a variety of settings.  
Although the vision for health professionals education was published after the FLIEPPS project began, it clearly articulates the environmental forces that brought interprofessional education together with national and international safety concerns that all health professionals should be educated to deliver patient-centered care, as member of an interdisciplinary team,emphasizing evidence-based practice, using quality improvement techniques and using informatics. (Health Professions Education: A Bridge to Quality – IOM 2003, National Academies Press)
The growing call for interprofessional education intersected with work done by the Institute of Medicine Committee on Quality that outlined compelling national needs for leadership in developing interprofessional programs in the area of patient safety.32, 33 The confluence of need and will to improve the situation led the Bureau of Health Professions to issue a request for applications to create a nationally disseminated curriculum in interdisciplinary leadership to promote patient safety.  The Center for Health Sciences Interprofessional Education at the University of Washington received a 3-year cooperative agreement from the Health Resources and Services Administration (HRSA) Division of Medicine and Dentistry and Division of Nursing to develop and disseminate a curriculum to achieve these aims.

## Curricular Toolkit

*Key Issues in Patient Safety & Interprofessional Collaboration***Eric Larson and DeDe Boerger**

**Patient Safety Basics**

**Academic Leadership**

**Culture of Practice**

**Changing Response to Error**

**Teaching-Learning**

**Goal Setting Exercise**

- ObjectivesContent outlineReference linksGlossaryInteractive exercisesWorkshop links

**Notes:**
 Content was organized within these five major topics, using a handbook of modules. Each module contains objectives, detailed content outlines, terminology, suggested readings and interactive educational activities:  Users of the handbook will find content that enables discussion of the basic principles and tenets of patient safety, the scope of the problem of errors in health care, the systems approach to patient safety, definitions of common patient safety terminology, facilitators of and barriers to promoting a culture of patient safety, attributes of successful academic leaders, and strategies for incorporating interprofessional learning and patient safety into their home curriculum.  Further, the users of the materials will find content useful in identifying aspects of organizational culture that are critical to patient safety, evaluating the organizational culture about patient safety in their own environment, defining and using tools of continuous quality improvement in promoting patient safety, and using tools and strategies such as root cause analysis, crew resource management in teaching and learning about patient safety.   Other specific tools include approaches to error reporting and disclosure of errors, including patients and families in the culture of safety and strategies to use active learning exercises such as case study, role-playing and reflective practice in the areas of interprofessional collaboration and patient safety.

## Curricula Workshop Objectives - Integration

*After attending this course, participants will be better able to:*
- Assess the culture of clinical practice that affects their students.
- Identify opportunities for improving the culture of clinical practice.
- Write an action plan for implementing and evaluating an interprofessional educational experience around patient safety at their own institutions.
- Educate students and other educators about the principles and tenets of patient safety.
- Take a leadership role in patient safety and interprofessional educational activities at own institution.

**Notes:**
The experiential and reflective learning exercises developed are organized in workshop format and build on the content modules to achieve these objectives

The workshop carried 16.5 contact hours (continuing nursing & pharmacy education) 13.5 Category I credits for CME)

Handbook coupled with workshop with these objectives

## Issues pertinent to creating a curriculum

- Application of patient safety research
- Application of collaborative team research
- What are the critical issues?
- What general knowledge?
- What site-specific knowledge
- What are the core competencies?
- What educational strategies
- How to address educational needs in different delivery systems?

- Interprofessional Steering Committee
- Interprofessional Advisory Committee
- Development of content
- Development of process
- Iterative formative evaluation

**Notes:**
quickly verified that there was no existing curriculum that could be packaged and used to meet the goals of this project.  Therefore, our first task was to survey and catalogue existing materials in the areas deemed core to the two curricula by our executive and advisory groups.  We surveyed existing materials from the Institute of Medicine (IOM) quality series, National Patient Safety Foundation, Institute for Safe Medication Practices, VA safety education system, and the Institute for Healthcare Improvement, among others. 
Examples of existing  patient safety initiatives that involve team-based practices founded on conceptual/behavioral models adopted from high-risk industries with exemplary safety records. These include processes such as root cause analysis (RCA), Failure Mode and Effect Analysis (FMEA), plan, do, study and act cycles (PDSA) for quality improvement, the use of aviation-style checklists, and the incorporation of human factors science and high-reliability organization theory. 
Also gathered material that recognized that successful implementation of patient safety practices frequently depends upon changing the organizational response to error from one in which an individual is singled out for blame and training to one in which system level breakdowns are investigated. This represents a significant culture shift, 

## Iterative formative evaluation

- Full curriculum – Seattle (March, Sept 2003)
- Preconferences – how to use the curriculum
- Association of Academic Health Centers, Washington DC, June 2004
- AHRQ 3rd Patient Safety Conference, Arlington VA, September 2004
- Online curriculum – beta tests 1&2, 2004, 2005

- About the curriculum
- Poster: 5th International Conference on the Scientific Basis of Health Services, Sept. 2003
- Panel: American Association of Colleges of Medicine- Nov. 2003
- Keynote: Ontario Patient Safety Research Cluster, Feb.2004
- Podium: All Together Better Health Interprofessional Congress, Vancouver BC,  May 2004
- Product cafe: AHRQ 3d Patient Safety Conference, Sept. 2004
- Panel: AHRQ 4th Patient Safety & HIT conference, June 2005
- HRSA, BHPr All grantee meeting, June 2005
- Paper – Advances in Patient Safety, Vol.4, May 2005

## Achieving curricular objectives

- Did we achieve curricular objectives?
- Workshop evaluations: average of 5.5 on 6 point scale
- Most favorable ratings:
- Error disclosure
- Creating blame free environment
- Developing effective interprofessional teams

- 59% applied workshop content
- 73% left with project
- 73% taught at least one patient safety seminar or workshop
- 16 respondents taught 948 health care providers (~60/trainee)
- 41% used FLIEPPS web resources after workshop

**Notes:**
Overall workshop evaluations – both full and mini
7 Month follow-up from workshop objectives
Projects and application example: integrating medical errors into existing courses, initiating patient-family centered rounds; implementing toolkit around patient safety issue; quality and safety fair, standardizing pre-operative practices, bar-coding

## Formative evaluation for online format

- Overall home page – clearly identify patient safety, interprofessional education
- Online curriculum
- Simplify home page
- Clarify purpose- process
- Flexibility for multiple approaches, goals and learning styles – ‘parking capacity’
- Add to toolkit – downloadable tools to use (e.g. slides)
- Preserve interactive features

**Notes:**
Further the advisory group recommended several useful revisions of the online format, based on workshop evaluations and the beta testing.   

## Dissemination – Webhttp://interprofessional.washington.edu/fliepps/

## Slide 12

##    		Susan Grant, RN, MSN Changing the Culture – A New Way of Thinking

**From**:
- Who’s to blame
- Punishment
- MDs don’t participate
- Cooperative practice
- Add more checks
- Errors are rare

**To**:
- Why & how did it happen; root cause
- Encouragement, support, celebration
- Multidisciplinary work
- Collaborative practice
- Simplify & standardize
- Errors are everywhere

**Notes:**
Example from Susan Grant – Dana Farber case, change in culture – application of modules 1 &3
Case description, slides
Discussion of applicability to own site

## Slide 14

## Continue Evaluation: Dissemination and impact

- Number & professional mix of faculty participants
- Participant characteristics
- Interprofessional educational activities trainees subsequently engage in
- Action plan with 6 month follow-up

- Frequency of patient safety as content focus of these activities
- 6 month follow-up
- Influence of program graduates on interprofessional & pt safety improvement initiatives

**Notes:**
Evaluation of the workshop toolkit progresses from counting the number and professional mix of participants to evaluating the interprofessional educational activities in which they subsequently engage, the frequency of patient safety as content focus of those activities, and the impact of program participants in interprofessional and patient safety improvement initiatives. 

## Participants –2002-2005 

**Notes:**
Over 200 have participated in some phase: Full workshops, mini-workshops and beta tests for online
White – in-person workshops; Blue mini-preconferences and web beta test 
Professions of all participants who filled out profiles (184) from first developmental workshops through national workshop April 2005
They come from 20 states, representing 14 health professions, as well as a variety of patient safety specific groups
 The largest single group is from the nursing profession, reflecting the extent to which nursing is charged with quality improvement education in hospitals. The remainder have been physicians (N= 40), pharmacists (N = 11), physician assistants, public health practitioners, physical therapists, social workers, health educators, information specialists, dentists, risk managers, public health professionals, safety specialists, and laboratory science specialists 

## FLIEPPS Workshop Participants     

- FLIEPPS Workshop Participants

- HRSA Regions

- Over 200 participants, average outreach to 60 more

**Notes:**
Using the number each regional participant taught annually – roughly 200 in full, min or web beta tests – average influence of participants is 60 people, therefore huge reach already
For the WWAMI region used 10-100 per participant

Mini workshop had organizatioal reach – Northern Ontario medical assn not shown

Participants estimated they educate from 2 to 1000 health professionals yearly in patient safety and collaborative issues.  Multiplying this range by the number of participants in the train-the-trainer workshops, we conclude they have the potential to influence from 274 to more than 10,000 individuals nationally 

Mini workshop at AHC added following: additonal UT Houston; Additional Creighton U; Organizations – college of pharmcy, coleges of nursing, graduate medical education at AMA with nationwide influence

## Perceived Influence of Participants

| Category | General Workshops (mean, range) | Mini-Workshops (mean, range) |
| --- | --- | --- |
| Organizational Influence | 42%, 2-100% | 54%, 10-100% |
| Patient safety knowledge | 51%, 5-100% | 53%, 18-100% |
| Patient safety activity | 51%, 2-100% | 59%, 18-100% |
| Interprofessional collaboration | 39%, 2-100% | 53%, 25-100% |

**Notes:**
Perceived influence Sept 2003 workshop
Participants have strong potential to influence patient safety within their own organizations through their educational activities.  On average, participants perceived that they influence about 42% of their organization’s overall function and about 38% of interprofessional collaboration.  On the average, they spend about 50% of their time in activities related to patient safety and harm reduction.  However, they also rated their own knowledge as about half of that found in the domain of patient safety. Presumably this was a major motivator to attend the workshops and use the curriculum. 
Followup – N =22 7 Month follow-up N = 22 

47.2% pre	  40.8% post

53.3% pre   47.1% post

49.4% pre   30.4% post

39.4% pre   33.2% post 

General workshop participants
Organizational influence (42%, range 2-100%)
Patient safety knowledge (51%, range 5-100%)
Patient safety activity (51%, range 2-100%)
Interprofessional collaboration (39%, range 2-100%)
Mini-workshop participants
54%, range 10-100%, 
53%,range 15-90%
59%,range18-100%
53%, range 25-100%

## Effects on Patient Care – Institutional Influence

- Some projects of ‘trainees’ intend patient care effects
- Test bar-coded patient wristbands
- “Good catch” system
- Standardizing pre-operative practices
- Patient-family centered rounds
- Implementing toolkit around patient safety issue
- Some indirect through student, faculty, staff education
- Modules to integrate medical errors into existing courses
- Quality and safety fair

**Notes:**
The curriculum materials and workshops have been evaluated quite favorably, receiving overall ratings at the most recent workshop of 5.4 on a scale of ranging from 1 (very poor) to 6 (excellent).  The ratings of the workshop, individual speakers and suggestions for improvement have been used in each iteration to improve the overall curriculum. The final evaluation is determined by the extent to which participants implement their action plans and achieve some change in patient safety through interprofessional collaboration within their own institutions.  We are still in the process of collecting that information for our earliest participants. Some of these early participants have endeavored to infuse patient safety into every course in a health professions curriculum, and are making steady progress toward that goal.  Others have developed a stand-alone course in medication safety, and are now seeking to expand that to other health professions schools in their university.  Still others have developed patient safety fairs that include both health professionals and consumers

- Provide health science students with leadership training aimed at enhancing community health
- Enhance interprofessional understanding and collaboration across the health sciences
- Facilitate student commitment to ending health disparities

**Notes:**
Students involved in leadership team for fliepps were drawn from those developing interprofessional course and practicuum for those in transition from homelessness.  While this activity was not what they formally developed in their participation, it is an example of the truly magnificent work that came directly from the interprofessional education and leadership skills we all learned. They are choosing to get at some of the true root causes of issues in patient safety.