# Presentation: 478493

## Thomas H. Gallagher, MD
University of Washington

- Thomas H. Gallagher, MD
- University of Washington

## Curricular deficiencies

- Curriculum focused mostly on history-taking
- Ignores MD communication with other healthcare providers
- Communication training insufficiently intense
- Failure to recognize communication as skill
- “Bedside manner”--can’t be taught (or measured)
- Communication discounted as “soft,” “touchy-feely”
- Little opportunity to practice, get feedback
- Learners struggle to apply general skills to specific situations
- Culture of medicine values technical proficiency over interpersonal skills

## Patient satisfaction

- Ethics, professionalism
- Complaints, malpractice claims
- Health outcomes
- Safety culture, transparency; disclosure and reporting of adverse events and errors

## Allows learner to practice complex communication skills, receive feedback in safe environment

- Allows learners to confront communication dilemmas that are important but uncommon
- Types of simulations
- (role plays, interactive computer cases, rehearsal)
- Standardized patients

## Standardized patients are individuals trained to:

- Present consistent scenario
- Be reliable observers of behavior
- Offer feedback
- Extensively validated as assessment tool
- Now used in high-stakes certifying exams
- Increasingly used as research methodology

## Recognize communication as a skill

- Can be learned, practiced, improved, discussed with colleagues
- Worthy of learner’s attention
- Need cases that take learners out of their comfort zone without overwhelming them
- Ability to practice, receive feedback on key skills

## Creating high-fidelity cases

- Identifying key observable skills
- Communication incredibly complex task
- Easy for learners to express socially desirable behaviors

## Team communication about error

- Error disclosure to patient

**Notes:**
We received AHRQ funding to assess whether simulation could be used effectively to improve health care workers’ knowledge, skills and attitudes related to team communication and error disclosure.  This project builds on work that Tom, Doug, Peggy and I had done previously in designing team-based OSCEs to certify graduating students’ core interprofessional skills, including team communication and teamwork.  The project aims to assess whether simulation improves healthcare workers’ knowledge attitudes and skills in team communication and team error disclosure.

## Growing experimentation with disclosure approaches

- New standards
- State laws re disclosure, apology
- Increased emphasis on transparency in healthcare generally

**Notes:**
Disclosure is increasingly an area of interest and experimentation. In the United States, the National Quality Forum (NQF), recently added standards for disclosure of unanticipated outcomes to its list of safe practices. Several institutions report that the implementation of aggressive disclosure policies has reduced their exposure to malpractice litigation. A few states have mandated the disclosure of certain events to patients, and many states have adopted laws that protect apologies for unanticipated outcomes from being used in litigation as evidence of fault on the part of the provider. Although the push for transparency originated outside the medical profession, there appears to be increasing receptivity to the concept within the profession.  

## Many harmful errors not disclosed to patients

- When disclosure does take place, it often falls short of meeting patient/family expectations

**Notes:**
Until recently, virtually no guidance was available to health care professionals regarding how or when to disclose errors; professional societies merely identified disclosure as an ethical obligation.  In 2001, JCAHO, issued the first nationwide disclosure standard. The standard requires that patients be informed about all outcomes of care, including “unanticipated outcomes.” It was a modest start. The standard did not specify the content of disclosure, nor did it mandate that patients be told when unanticipated outcomes were due to error. Still, the Joint Commission’s move was groundbreaking; it heralded a shift from mere endorsement of the importance of disclosure to a requirement with teeth because it was linked to the accreditation status of hospitals.
However, without explicit guidelines and opportunities to practice and get feedback, it’s no wonder that when clinicians do disclose, their efforts often fall short of meeting patient and family expectations.

## Slide 11

## Slide 12

**Notes:**
Our project really has 2 prongs – the one being to train physicians and nurses in disclosure, the other to really promote interprofessional teamwork and disclosure.  Traditionally, disclosure is conceptualized as a doctor-patient conversation.  But, the question arises, if teams make errors, why send in individuals to disclose?  Nurses have expressed an interest in being present in disclosures to ensure that blame is not laid at their feet for errors as they are often on the front lines. Additionally, many involved in errors express an interest in having an opportunity to apologize  to patients as a means of putting their feelings of guilt behind them. But how will patients/families react when a team walks in to speak to them about an error that occurred? Will they feel ganged up upon?  When is team disclosure helpful or harmful?  And how do existing hierarchies between physicians and nurses complicate team error disclosure?  These are all issues that need to be addressed if team error disclosure is ever to become routine practice.

## What do team members owe one another?

- Absolute loyalty?
- Falling on sword?
- What are roles of different team members in the disclosure process?

**Notes:**
Other considerations in performing team disclosure include: What do team members owe to one another? Are certain team members better suited to play particular roles in a disclosure?
In some of our early simulations, we’ve seen a nurse or a physician scramble to take full responsibility for an error – falling on sword – despite clear evidence of shared responsibility.
In others, we’ve watched teams agree to go in as a team to speak to a patient, but, without planning who will actually perform in what role – the team gets lost.  Often times, they recover by letting one individual – usually the physician – speak for the whole team.

## Practicing physicians & nurses

- 40  nurse-physician teams (1⁄2 surgeons and OR nurses; 1⁄2 medical physicians and nurses)
- 40 control group teams
- Actors
- 1 *standardized team member *per team
- Plays role of hospital administrator
- Helps team progress through simulation, think out loud
- 1 *standardized patient *per case, 2 cases per simulation
- 12 Risk Manager “Coaches”

**Notes:**
THERE ARE MANY MOVING PARTS TO THIS GRANT!!!  We will be running 40 nurse-physician teams through our simulations. Half of the teams are composed of surgeons and OR nurses and the other half consists of medical physicians and nurses.  In each simulation, we have one “plant” –a trained actor playing the role of a facilitator. Every simulation includes a nurse, a physician, 1 standardized team member, an d1 standardized patient.  We developed 2 surgical cases: retained sponge, lost specimen
2 medicine cases: insulin overdose, Lovenox overdose. Because our focus is also on assessing the effectiveness of simulation, we will also run a control arm of 40 teams.
Finally, at the same time that we are attempting to teach physicians and nurses how to disclose, we are also training risk managers in the skills of coaching.  Our hope is that long after funding for this project ends, the coaches will remain in place to support and guide clinicians who find themselves having to perform error disclosure.

**Notes:**
The training itself consists of 2 simulations and 2 brief coaching sessions.  The team discusses case 1, discloses it to the patient, and then gets feedback from the coach on how they did and encouragement to try specific skills in the subsequent scenario.
Teams have the option of not disclosing as a team and some select this option because they say it’s not routine practice.  The coach will encourage a try at team error disclosure.The team then  goes on to complete case 2 focusing on a different medical error.  Again, they go through the phases of disclosure -- discussing the error, planning their disclosure, and disclosing the error to the patient, and then receives final feedback from the disclosure coach.
Everyone is debriefed at the end of the experience.

## 1.  Team discussion and planning for disclosure

-  Team discusses what happened, responsibility for the error, and plan what they will disclose to the patient
- 2. Team Error Disclosure
- The team discloses the error to a standardized patient

**Notes:**
So to reiterate, within the scenarios teams go through a 2-part sequence.  At first they discuss what happened, come to consensus about the events that occurred, then plan how to disclose those events to the patient.  During these discussions the standardized team member acts as a facilitator, drawing out team thinking and making sure they are moving toward an action plan.  In the second part of the sequence, the standardized patient is brought in and the team performs their error disclosure with that SP.

## Acknowledge error occurred

- Offer facts regarding error
- Solicit and respect team members’ views of what happened
- Negotiate differences respectfully
- Avoid blaming; respond appropriately to blaming behavior
- Respond empathetically to team members’ emotions

**Notes:**
These interactions are complex and there are numerous skills we’ll be looking at on videotape.  But in the moment, we are encouraging coaches to focus on key behaviors.  (More later)

## Plan roles for disclosure discussion

- Advocate for full disclosure
- Identify core content of full disclosure
- Explicit statement that error occurred
- What happened, implications for patient health
- Why it happened
- How will recurrences be prevented
- Explicit apology
**Anticipate patient questions and emotions and plan team responses**
**Negotiate differences respectfully**

**Notes:**
Planning stages, looking for agreement that full disclosure should occur and that an apology should be offered.  But also to plan who will say what and to anticipate the patient’s anger and to plan for responses, rather than to just go in and wing it.

## Team member introductions

- Empathetic disclosure of core content
- Ask patient what they know about error
- Explicitly state that error occurred
- Implications for patient health
- Solicit patient questions, respond truthfully
- Make explicit apology
- Explain how recurrences will be prevented
- Avoid blaming team members; resist patient’s attempts to fix blame
- Empathetic communication with patient
- Plan for future meetings

**Notes:**
In actually carrying out the disclosure, we are looking for early apology and forthright explanation of what occurred.  Information patients want disclosed
Explicit statement that error occurred	
What happened, implications for their health
Why it happened
How will recurrences be prevented
Importance of an apology	

## Slide 20

**Notes:**
Recognizing that many of our participants have had only limited experience with disclosure and almost no experience with team disclosure, we developed coaching priorities to ensure that key behaviors would be advocated and fostered.  These are rooted in the literature about what patients want, as well as the literature on effective team communication.  Between cases, coaches are asked to select 2 behaviors on which to focus their feedback – one related to team communication, the other related to disclosure.  

## Web assessment

- Case-based: 2 cases, 2 different team approaches
- Knowledge, skills, attitudes assessed tied to coaching priorities and simulations
- Participants complete web-based assessment pre and post training
- Controls take web assessment (pre and post) but without the training
- Other data sources
- Videos of simulations
- Debriefing interviews with participants

**Notes:**

As I mentioned earlier, we will be assessing the effectiveness of simulation as a training method by comparing how control group participants compare with simulation group participants on a web-based assessment. There are 2 different medical scenarios and 2 very different team approaches to each.

## Patient admitted to ICU with recurrent seizures

- Given loading dose of Dilantin (300 TID), then switched to 300 QD
- Physician writing transfer orders to floor mistakenly writes for larger loading dose
- Error not noticed by nursing, pharmacy
- Patient falls, hits head; Dilantin level 29.  Head CT normal
- Patient thinks another seizure caused her fall

**Notes:**
Set up case for videos in next slides.

## Slide 23

**Notes:**
Blaming behavior

## Slide 24

**Notes:**
Support in making a bad decision not to fully disclose

## Slide 25

## Slide 26

**Notes:**
Participants watch video of cases and answer a series of open and closed ended questions.  For example, on this screen, they will be asked to make a judgment about how effective the team was in explicitly stating that an error occurred, explaining how it occurred, truthfully communicating with the patient and presenting a plan to prevent future errors. 

## Slide 27

**Notes:**
For this open-ended question, they’ll view a video snippet and identify the team behaviors that were effective and should be reinforced.

## Simulation design

- Maximizing learning potential of simulation
- Skilled coach essential
- Maximizing case fidelity
- Nature of events
- Choice of case
- Actor training
- Interprofessional interaction
- Role of standardized team member in simulation
- Especially important in engaging “Silent team member”
**Simulation implementation**
- Managing logistics of recruitment, scheduling a major undertaking
- Coordinate schedules of two clinically active subjects, 3 actors, risk manager coach, at least two team members for each session

## Immersive simulation around communication possible outside simulation center

- Even senior clinicians found experience educational
- Providing expert coaching, feedback is key
- Logical challenges can be substantial
- Multiple opportunities for communication simulations on other interprofessional topics

## Thomas Gallagher (PI) – Medicine

- Lynne Robins-Medical Education
- Sarah Shannon – Nursing
- Peggy Odegard – Pharmacy
- Sara Kim – Medical Education
- Doug Brock – Medical Education
- Carolyn Prouty – Project Manager
- Odawni Palmer – Support Staff
- Andrew Wright-Surgery

**Notes:**
First, I want to acknowledge the other members of the interprofessional team that I work with.  They include Tom Gallagher from Medicine, Sarah Shannon from nursing, Peggy Odegard from Pharmacy, Sara Kim and Doug Brock from Medical Education, and our Project Manager and Support Staff, Carolyn Prouty and Odawni Palmer.