In my last post, I gave an overview of the curriculum and structure for the Patient Safety elective we designed and offered at the University of Illinois College of Medicine. Each patient safety domain studied was covered through comprehensive and collective literature reviews addressing research questions with the guided focus I provided. The students then discussed their response online, furthering the groups critical thinking around each topic. I added additional “devil’s advocate” and real world comments to the discussions in order to push the critical thinking in each area.
An example of how a few of the patient safety topics (or domains) were studied in greater depth follows. Please share your curriculum content, or comment on how we can improve our course going forward.
WEEK 1, MODULE 2: ADVERSE EVENT DEFINITION (Day 3-4)
The goal of this module was to (a) introduce the students to the adult, online learning methodology used in the elective, and (b) take what at first appears to be a simple task – defining “adverse event” – and show the students that the task is not as easy as it first appears. Because of a lack of harmonization of message from many of the leading safety and quality organizations through the years, we have had many different definitions offered up. As many say “if you can’t define it, you can’t measure it”.
Healthcare frequently uses the term “adverse event” to describe different patient safety incidents or occurrences. Pharmaceutical companies use the term “adverse event” differently. Through a search of the literature and interactive discussion, students are expected to:
- Discuss different ways in which the term “adverse event” has been used.
- Come to a consensus definition of “adverse event.”
WEEK 2, MODULE 3: HISTORY OF PATIENT SAFETY MOVEMENT (Days 1-2)
The goal of this module is to understand the history of the patient safety movement and the role the Institute of Medicine (IOM) has played in its evolution. Upon successful completion of this module, students will have:
- Learned about and discussed the IOM report “To Error is Human: Building a Safer Health System,” and the impact of the report on the patient safety movement.
- Discussed and gained a greater appreciation of the follow-up IOM reports, their conclusions and recommendations for safer healthcare.
- Identified key political, societal and regulatory drivers helping push the patient safety movement forward.
Through a search of the literature and interactive discussion, each group of students will:
- Identify which studies the IOM used for their annual, preventable death rate conclusions?
- Discuss the validity of the IOM’s conclusions, and be able to defend the answer given.
- Discuss if/how leadership in politics, business and society effectively began implementing change after the first IOM report. Pick one of these three sectors – discuss and defend your position using specific examples based on a review of the literature.
WEEK 2, MODULE 4: LEARNING FROM OTHER HIGH-RISK INDUSTRIES (Day 3-4)
Upon successful completion of this module, students should be able to:
- Articulate what other industries can teach us about creating conditions for delivering safe patient care.
- Describe the appropriate use of qualitative (i.e. focus groups, interviews, observations) and quantitative methods (i.e. risk and hazards analysis, FMEA, RCA, PRA) when assessing complex and hazardous operations.
- List key elements of creating effective reporting systems in healthcare.
- Identify key principles of High Reliability Organizations (HRO), and the risk management and hazard reduction tools that underlie the creation of a safety culture.
- What are the key risk management concepts non-medical industries use to manage their high-risk operations?
- What is a safety culture and how can it help enable creating reliable and patient centered care?
- What can we learn from HRO research that can help inform patient safety practices in healthcare?
Our Patient Safety four-week elective course became increasingly popular as time passed. We found that students chose the course not only because of the online, adult-learning format making it easy to access the course and materials remotely, but also because:
- A strong interest in patient safety had been nurtured over their first three years of experience in a medical school with a growing safety culture.
- Apprehension of impending July 1st milestone, when students would then be responsible for patients and the related fear of hurting someone.
- Ability to do residency interviews and still learn from a distance without taking vacation time to interview. Many students have to do 20-30 interviews today at different programs. They feel it increases their chance for getting into one.
Following is an example of the course expectations and curriculum studied. I will discuss the research questions for each patient safety domain in greater depth in future posts. Please share your thoughts, comments and curriculum ideas!
- Each course day (Monday – Friday) during the four weeks required about 5-8 hours of research, reading and interactive sharing and discussions with fellow students on each patient safety domain of focus.
- The patient safety elective used an on-line, adult-learning format. As such, comments, insights, shared learnings and follow-up discussions with fellow students on each patient safety topic was expected, and an important component to the learning process.
- Effective teamwork is an important safety quality in any high-risk field, especially healthcare. Each week, students were required to share their research and discovery with others while coming to a consensus on the research questions posed for each patient safety domain. Students posted their responses to the questions so others were able to read and comment on them. Through this sharing of knowledge and interactive discussions, we take our learning to a higher level.
- Being an online course, students had the ability to participate in the educational activities from anywhere access to a computer with high-speed online capabilities was available. Students were free to complete coursework at a time convenient to them, as long as they completed and shared their assignments with fellow students by the posted deadlines, and had commented on other student’s conclusions.
- Literature review was a vital part of this four-week elective. Students were expected to navigate different literature sites, conduct searches on the research questions posed, and cite journals that were reviewed to support findings using correct citation rules
The four-week course was divided into three components:
- Days 1-2: Patient safety topic #1
- Days 3-4: Patient safety topic #2
- Day 5: Weekly individual reflection
Students were asked to address 1-3 specific research questions around each patient safety topic, and to share 2-3 relevant articles from a literature search that addressed the questions posed. Responses to each question (no less than 400 words) were then posted on the course blackboard site so others could then read and respond to their peers’ conclusions as appropriate. Answers to the questions were required to demonstrate critical thinking and scholarly investigation, and to be taken from peer-reviewed literature and referenced appropriately. The interactive, adult-learning format allowed for discourse via the blackboard around the posted answers. The course provided a forum for each student to gain substantial knowledge in patient safety, as well as prepare students for the responsibilities of residency.
Following are the Patient Safety Domains studied during the four weeks:
- Week 1: Introductions (Days 1-2), Adverse Event definition (Days 3-4), Reflection (Day 5)
- Week 2: History of Patient Safety Movement (Days 1-2), Learning From Other High-Risk Industries (Days 3-4), Reflection (Day 5)
- Week 3: Medical Malpractice; Current Legal Climate (Days 1-2), Open and Honest Communication in Healthcare (Days 3-4), Reflection (Day 5)
- Week 4: Medication Errors (Days 1-2), Healthcare Informatics (Days 3-4), Reflection (Day 5)
Individual student reflection were assigned for Day 5 of each week, and designed for students to reflect on the week’s discovery and learning. Reflections were due on Saturday, and students were instructed to post comments and reactions to one another’s posts. The reflections addressed the following questions:
- How would you apply what you have learned this week to your professional life?
- What are the concepts that made you think differently than before and why?
- What’s your greatest “take away” learning from this week? Why?
- What unanswered questions remain?
- Any additional comments and thoughts?
The final component of the four-year patient safety medical school curriculum we put in place at UIMC was the patient safety fourth-year elective. This was the capstone of the program so to speak, and was my favorite course to teach. When we first created this elective five years ago, it was offered as a two-week classroom experience, and continued to build upon the first three years of patient safety education integrated into the medical curriculum. As with most classroom experiences, this educational experience had some limitations. The number of students had to be capped at 12-14 due to the small group interactive nature of the case-based activities. Faculty had to be on campus, though we did experiment with Skype and other types of distance learning applications. And the number of times the elective could be offered each year had to be limited due to time restraints on faculty and classrooms.
Because of continued student interest, we decided to move the patient safety elective to an online format using Blackboard as the web-based educational portal. We used the opportunity to extend the course to four weeks, allowing for greater depth of learning in the eight chosen safety domains that had been previously covered in the 10 days of classroom work. Using this online approach also allowed us to change our educational approach, and we were able to apply the same adult learning, student-centered model utilized in our Masters in Patient Safety Leadership program. This approach had been very successful with our Masters students and, as many who have used this educational format already appreciate, takes the student learning to a higher level. Students do the research and discovery, come to conclusions based on the research questions given to them, and engage in interactive discussions by sharing what they have learned.
Faculty are no longer simply teachers…but facilitators who push the learning to higher levels by posing additional questions, playing “devil’s advocate” or, many times, just reaffirming the learning objectives so the students take the important messages with them before moving on to the next patient safety domain. In future posts, I will share the elective outline, safety domains, learning objectives from a domain or two, and the research questions given to the students along with some of the experiences, reflections and take-aways of running a patient safety elective for young learners.
Overhauling the pervasive academic medical curriculum at any institution is an audacious task, yet a tremendous need to revamp undergraduate and graduate medical education so tomorrow’s caregivers can meet the needs of future patients is all too real. Longitudinal patient safety and quality curricula are just two glaring omissions from today’s offerings. Team-based care, understanding and appreciating the roles of other health science professionals in the care-team, effective communication skills, high reliability and risk reduction methodologies, information technology, outcomes-based care, transparency, population health and wellness are all areas where current medical education and experiences are being short-changed or left out altogether–and this void continues to affect the delivery of care, as well as the overall well-being of healthcare itself.
Older health science schools hold on to traditional curricula in place for many years…curricula deeply embedded in their school’s history. “It worked twenty years ago so it must be working today,” is what many academic deans hear from their curricular committees when change is proposed. “We cannot add anything new to the curriculum – the schedule is already jammed-packed,” is another change-halting response. Tenured professors do not like to give up long-standing lecture spots for forward thinking but less understood educational needs. As a result, educational progress is shut down.
However, with 18 new medical schools in various stages of accreditation, fresh starts are emerging across the US. The question remains, however, how will their curricula address the areas of opportunity mentioned above? These schools have the benefit of starting anew, and creating programs that meet the needs of the 21st century caregiver. And if the Florida International University (FIU) Herbert Wertheim College of Medicine is any indication, perhaps there is hope. There is a creativity at FIU, and other new academic programs, not commonly seen in medical colleges of old. For example, FIU’s Medicine & Society curriculum takes a new and different approach to medical education by claiming to:
…prepare physicians to not only treat the disease, but also to assess and address the non-medical causes that affect health outcomes. Students will learn to approach the treatment of disease from a “cell to society” perspective, incorporating both molecular and societal factors. The curriculum integrates ethics, public health principles, the social determinants of health, cultural competency, interdisciplinary experiences, and household community visits.
…prepare physicians to identify the personal skills and systems-level processes that support continuous quality improvement and patient safety, and use standard precautions in the healthcare setting.
…send medical students along with their counterparts in social work, nursing and public health, into the community from the onset of their academic programs (through a program called NeighborhoodHELP).
Concepts such as community health and interdisciplinary teams are being taught in real-time at FIU, as soon as students step onto campus — a glaring difference to the experiences at the medical schools where many of this year’s Telluride student scholars attend. A number of Telluride senior level students voiced not knowing whom their nursing counterparts were, how those colleagues were trained and what their role was in patient care. As physicians and educators, we swore to “recognize the limits of (our) knowledge and pursue lifelong learning to better care for the sick and to prevent illness”. We owe it to our patients and our students to find the courage to recognize our personal educational biases and limits, and continue redesigning curriculum that fits the changing needs of society and healthcare.