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Paul Barach, M.D. MPH Department of Anesthesiology

Associate Dean for Safety and Quality Improvement

University of Miami Medical SchoolMedical Director for SafetyJackson Memorial Hospital

pbarach@med.miami.edu

Reflective Learning, Mindful Practice

and Patient Safety

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Case # 1: Evaluating and Preventing Wrong Sided Procedures

40-70 cases/ year in Florida reported

JCAHO 300 cases ALL of US 1997-2003

6000 cases NPDB 1990-2003

UM has largest anonymous database

of wrong sided procedures in world

Seiden, S, Barach P. Annals of Surgery accepted.

www.Wrong-side.orgMiami Herald, 1.27.04

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What Went Wrong?

• The personnel – The attending surgeon

– The resident

– The 3rd year medical student

– The nurse

– The anesthesiologist

• The system– The team in the OR

– Students and residents are often in the best position to recognize and prevent errors

– Punitive systems mitigate against disclosure

– Disempowerment mitigates against action

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Institute of Medicine, November 1999Institute of Medicine, November 1999

• Medical errors are a serious problem• The cause is bad systems• We need to redesign our systems • We must change the way we train

our future clinicians• We need to make safety a national

priority• Develop a safety curriculum• Simulation and team training are key

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Six Dimensions of Care QualitySix Dimensions of Care Quality

• Safe: Avoids Injuries to Patients• Timely: Minimizes Waits and Delays for All• Effective: Based on Scientific Evidence• Efficient: Avoids Waste of Equipment, Supplies • Equitable: Not Discriminatory • Patient Centered: Responsive to Patient’s Needs

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Event Rates in US Hospitals

-7

-6

-5

-4

-3

-2

-1

0Dangerous

SystemsRegulatedSystems

Ultra SafeSystems

Ideal System

Lo

g(1

0) E

rro

r R

ate Bungee Jumping,

Extreme Mountain Climbing, Motor Cycle Racing

Auto driving, Chemical Industry,

Charter Flights

Scheduled Airlines, Nuclear Power, European Railroads, Aircraft CarriersHospitals

???

Amalberti, R. Safety Science, 2001

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Florida Annual Accidental Deaths, 2003 Florida Annual Accidental Deaths, 2003

0

500

10001500

2000

2500

3000

35004000

4500

5000

Medical Auto Workplace Air

Deaths

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How many ways can it be said?

• IOM Chasm Report Aims• Chasm Report Rules• AAMC Report• IHI’s framework• Recent Reports on AHCs

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Recent Reports Calling for Reform in Medical Education

• Commonwealth Fund Task Force on AHCs: Training Tomorrow’s Doctors, 2002

• IOM - Health Professions Education. A Bridge to Quality, 2003

• IOM - AHCs: Leading Change in the 21st Century, 2003

• Blue Ridge Academic Group: Reforming Medical education, 2003

Some things to remember as we get into education…

Aristotle

• The first aim of education is the development of virtue in the citizen

• Virtue is both intellectual and moral, reason and habit

• Seeks truth and goodness

• Harmony

• Citizenship

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The Research on learning..

• 60’s– Learning principles (Gagne, 1962)

• 70’s Dormant: little empirical work– Theoretical, dull irrelevant and faddist (Campbell, 1971)

• 80’s– Goldstein, Wexley (1984) Method based– Cognitive psychology and expertise– Tannenbaum (1992)– Dreyfuss--expertise

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Theoretical Advancements

• Organizational frameworks (Tanenbaum, 1993)

• Climate to transfer (Thayer, 1995)

• Training motivation (Colquit et al, 2000)

• Pre training context (Quiones, 1995)

• Individual/situational characterizes (Mathieu, 1997)

• Participation and development (Noe, 1992)

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Post Training Conditions

• Training evaluation– Expanded (Kraiger, 1993)

• Transfer of Training (Thayer)– Transfer “climate” matters– Opportunity to perform

• Training as part of an organizational system (Tanenbaum)

The advances in biomedical science and education require that academic

medical institutions either get serious about education or get out of

education.

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Organizing Principles for Learning

• General competencies

• Continuum (rules and contexts)

• Measurements

• Improvement models

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ACGME Competencies

Patient CareMedical Knowledge

CommunicationProfessionalism

Practice-based Learning and Improvement

SystemsWicked Hard

Mindfulness

Paying attention, on purpose, to one’s own mental and physical processes during everyday tasks to act with clarity and

insight.

… leads the mind back from theories, attitudes and abstractions to the experience

itself

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Mindfulness

• the study of subjective experience from the inside out

• a state of mind that permits insight• can apply to emotions, thinking, ethics, technique,

actions• refers to actions in the moment, not just

philosofizing or “monday morning quarterbacking”

After Langer

Practice-based Learningand

Systems-Based Care

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Case # 2: Cefazolin and Vecuronium

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Swiss Cheese Model of Accident Causation

Modified from Reason, 1991 © 1991, James Reason

Triggers

DEFENSES

Accident

Regulatory Narrowness

Incomplete Procedures

Mixed Messages

Production Pressures

Responsibility Shifting

Inadequate Training

Attention Distractions

Deferred Maintenance

Clumsy Technology LATENT

FAILURES

Goal Conflictsand Double Binds

The World

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Issues in Competence

• Individual issues– poor info gathering*– poor judgment– inattentiveness– lack of presence– lack of compassion– fatigue– ignoring the obvious

• Systems issues– undue deference to

authority– protection of colleagues– poor communication

between staff (or inadequate means to do so)

– no mechanism for f/b– diffusion of responsibility– Poor human factors design

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Stages of Development: The Dreyfus Model

• Novice

• Advanced beginner

• Competent

• Proficient

• Expert

• Master» Dreyfus and Dreyfus, 1992» (modified by Batalden and Leach et al,

Health Affairs, 2002)

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Is there an underlying construct that describes good medical practice?

• Skills

• Knowledge

• Attitudes

• Caring

• Self-awareness

• Patient-centeredness

• Knowing one’s limits

• Setting boundaries

• Tolerance of Ambiguity

• Biopsychosocial approach

• Compassion

Professional Competence and Mindfulness

Defining Professional Competence

The habitual and judicious use of communication, knowledge, technical

skills, evidence-based decision-making, emotions, attitudes and reflection to improve the health of the individual

patient and the community.

After Hundert

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From Competence to Capability (Frazer BMJ 2001;323:799-803)

• Competence = what individuals know or are able to do in terms of knowledge, skills, attitude

• Capability = extent to which individuals can adapt to change, generate new knowledge, and continue to improve their performance

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Complexity and Uncertainty (S Frazer. BMJ 2001;323:799-803)

Cultivating Mindfulness

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Levels of Mindfulness

• Level 0: denial, externalization

• Level 1: imitation

• Level 2: critical curiosity (cognitive)

• Level 3: critical curiosity (socio-emotional)

• Level 4: insight

• Level 5: generalization, incorporation, presence

Epstein, 2003

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Reflective Questions• “How might your prior clinical experience affect your decision-

making in this case?” • “What are you assuming about this patient that might not be

true?” • “What did you observe?”• “What surprised you about this patient?” “How did you

respond?”• “What interfered with your ability to observe?”• “What latent errors might be present in this situation?” • “If there were relevant data that you ignored, what might they

be?”

Both medicine and education are cooperative arts rather than

productive arts.

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The “Matryoshka” Model

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Educational MicrosystemsMatryoshka Model

Individual learning

One-on-one teaching

Resident and preceptor interacting in patient care

Program level

Microsystem

Institutional level

National level

Highlights the institution as a meso-level entity.It contains lower levelsystems and functions within a larger macro-system.

This has implications for efforts to measure and Increase institutional competence.

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An Example of the “Within-Institution” Level: The Clinical Microsystem

•A microsystem in health care delivery can be defined as a small team of people who work together on a regular basis to provide care to a discrete group of patients. It has linked processes, shared information, and produces clinical outcomes.

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Surgical Microsystems

• Initial emergency response effort.

• Transport.

• Second care team and next care planning.

• Operating room.

• Post-operative.

• Communication and documentation.

• F/U care.• Clinic care.• Information assembly.• Bad outcome management.• Scheduling, coverage.• Pt/surgeon bonding.• Doctor-manager.• Cost.

With Laser Greenfield, M.D.

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Characteristics of High-Performing Microsystems

•Constancy of purpose•Alignment of roles and training•Interdependence of team•Integration of information•Measurement•Investment in improvement•Supportiveness of the larger system•Connection to community

Mohr J, Barach P, 2003

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Attitudes of medical students toward adverse medical events

• Attitude survey of med students at the University of Chicago/University of Miami

• Assess attitudes towards patient safety practices and organizational support

• Exposure to medical errors and adverse events appears to negatively affect student attitudes towards patient safety.

• Physicians-in-training face large institutional barriers vs. fostering culture of safety

• Barriers include work overload, limited support from seniors and chiefs; and a culture of blame.

http://umdas.med.miami.edu/links/MedicalStudentSurvey/

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What are the important team competency requirements?

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Medical Team Training (MTT)

• Which knowledge, skill, and attitude competencies are important for medical team effectiveness?

• Does this vary by medical specialty?• What is the role of accreditation and regulatory bodies in

assessing team competencies?

Baker D, Salas E, Barach P, 2004

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Team Competencies

• Team competencies are the knowledge, skills, and attitudes required to be an effective team member.

• Understanding team competency requirements is necessary for:– Designing and conducting training

– Assessing team performance

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Team Competencies

• Knowledge Competencies – The principles and concepts that underlie a team’s effective

performance

• Skill Competencies– The learned capacity (psychomotor and cognitive) to interact

with other team members

• Attitude Competencies– Internal states that influence team members to act in a

particular way

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Team Competencies Model

OrganizationalCharacteristics

Task and WorkCharacteristics

Team Comp.Requirements

Team TrainingRequirements

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What are the best strategies for medical team training?

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Training Sequence

• Skill acquisition proceeds in stages– Declarative knowledge (what to perform)

– Procedural knowledge (how to perform)

– Tactical knowledge (when, why to perform)

• Recommended sequence– Attitude change

– Knowledge

– Skill

– Meta-cognition

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Problems with Assessment

• Fragmentation• Context-dependence• Penalizing shortcuts• Stifling creativity• Testing test-taking• Lack of reliability in

small-scale assessments

• Time• Cost• Conflict of interest• Reliance on experts to

judge expertise• Assessing complex skills

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Miller’s Pyramid

Does

Shows How

Knows How

Knows

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What we know how to assess reliably-- de-contextualized factual knowledge

-- performance of specific maneuvers (Hx, PE)-- some interpersonal skills

What we typically assess-- descriptions of events rather than observed performance

Knowledge, skills-- individuals rather than teams

What we tend not to assess-- causes of common errors-- habits of mind, attitudes

-- systems, teamwork

KnowsKnows

Knows howKnows how

Shows howShows how

DoesDoes

Assessment in the Real World

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Why Some Trainees Get into Big Trouble

• Personality issues• Poor judgement• Boundary violations• Substance abuse

• Lack of motivation• Poor communication• Usually NOT lack of

knowledge or skill

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Making Assessments Useful

• Acquiring and using knowledge

• Variety of contexts

• Complexity, ambiguity and uncertainty

• Addressing public expectations

• Seamless incorporation of the “art of medicine”

• The right developmental level

• Using experts wisely

• Habits of mind

• Driving learning

• Driving values (tests as moral interventions)

• Feedback reinforces competence

• Simulation

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Patient Simulators

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Challenges to Medical Education Addressed by Simulation

• Training clinicians in risky procedures on real patients is less acceptable

• Limited opportunities to experience rare events and crises

• Apprenticeship means you have to wait for something to happen

• Training for teamwork is rare• Simulation is less costly

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Simulation: Experiential & Simulation: Experiential & Reflective LearningReflective Learning

Simulation: Experiential & Simulation: Experiential & Reflective LearningReflective Learning

• Emotional, cognitive, psychomotor synthesis• Understanding complexity and problem solving• Behavior change• Culture change• Metacognitive skills• Systems thinking• Teamwork• Nourishing safety culture

57www.patientsafety.med.miami.edu

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Grand Opening of The UM-JMH Center for Patient Safety

Mark your calenders! January 13th, 2005.

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Florida Patient Safety Network- A model for state efforts

UM/JMH led state wide effort

Legislation passed 4/2004.

First of its kind in the US

Patient Safety Corporation

Florida Near Miss Reporting System

Hospital Report Cards

Patient Safety Curriculum

IT Taskforce

http://anesthesiology.med.miami.edu/department/centers%20&%20divisions/patient%20safety/03_the%20projects/04_ahca.asp

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High-Reliability Systems:Creating Mindful Organizations

• Vigilance – focus on safety– assumption that systems tend to

fail

• Tolerance of complexity and ambiguity – reluctance to simplify– patient-centeredness

• Critical curiosity – mentoring + reflection

learning

• Sensitivity to operations– being in touch with reality– “let them not eat cake”

• Open communication – transparency of intent– non-punitive reporting

• Informed flexibility – commitment to resilience

• Deference to expertise– wherever it may reside

after Weick, 2001

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Principles that underpin redesign of care where students and residents learn

“Care” & “Curriculum” are separate

Patient safety ison the radar

Students and residentswork around the

patient care system

Patient care andmedical educationare tightly coupled

Patient safety is a key characteristic

All members of the care team are part

of a high performanceclinical microsystem

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Educational ConsultantsA man is flying in a hot air balloon and realizes he is lost. He reduces height and spots a man down below. He lowers the balloon further and shouts: "Excuse me, can you tell me where I am?"

The man below says: "Yes, you're in a hot air balloon, hovering 30 feet above this field."

"You must work in medical education" says the balloonist.

"I do," replies the man. "How did you know?"

"Well" says the balloonist, "everything you have told me is technically correct, but it's of no use to anyone."

The man below says "You must be an executive."

"I am" replies the balloonist, "but how did you know?"

"Well," says the man, "you don't know where you are, or where you're going, but you expect me to be able to help. You're in the same position you were before we met, but now it's my fault."

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New Web Site-www.PATIENTSAFETY.MED.MIAMI.EDU

Thanks!