An Educational Approach to Improving Healthcare Safety and Quality*
This article has been adapted from the following: Walton MM, L Elliott SL. Improving safety and quality: how can education help?MJA 2006; 184(10): S60-S64. © Copyright 2006. The Medical Journal of Australia– reproduced with permission.
Brendan Flanagan, Monash University, Victoria, Australia; Julia Harrison, Monash University, Victoria, Australia; Tim Shaw, University of Sydney, New South Wales, Australia; Chris Roberts, University of Sydney, New South Wales, Australia; Stewart Barnet, University of Sydney, New South Wales, Australia; Ranjit De Alwis, International Medical University, Kuala Lumpur, Malaysia; Mohamed Saad Al-Moamary, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Anas Eid, International Federation of Medical Students’ Associations (IFMSA); Rhona Flin, University of Aberdeen, Old Aberdeen, United Kingdom; Pierre Claver Kariyo, School of Medicine, Bujumbura, Burundi; Lorelei Lingard, University of Toronto, Toronto, Canada; Jorge Martinez, Universidad Del Salvador, Buenos Aires, Argentina; Chit Soe, Ministry of Health, Myanmar; Lee Young-Mee, Korea University College of Medical Education, Seoul, Republic of Korea; Mingming Zhang, Sichuan University, Chengdu, China; Amitai Ziv, The Israel Centre for Medical Simulation, Sheba Medical Centre, Tel Hashomer, Israel.
Introduction
There has been a dramatic increase in patient safety research and initiatives since the release of the Institute of Medicine's (IOM) 1999 report To Err is Human (1), and patient safety is now in the academic and public spotlight. Data collection, adverse events reporting, professional accountability, and multidisciplinary teamwork are all under intense scrutiny as global interest builds in relation to the safety and quality of health care. Improvement requires competent health professionals who deliver patient-centered care as members of inter-disciplinary teams and use evidence-based and ethical practice, quality improvement approaches, and information technology. These health professionals should know about organizational complexity, systems theory, human factors, professionalism, error recognition, management, and prevention.
Many of these concepts are new to medical education. The 1999 IOM report To Err is Human identified the urgent need for patient safety education for health care students (1), and in 2003 the IOM report Health Professions Education: A Bridge to Quality argued strongly for professional health education in order to improve health care quality (2). The 2003 report identified five core competencies deemed essential for health professionals: the capacity to provide patient-centered care, to work in interdisciplinary teams, to employ evidence-based practice, to apply quality improvement methods, and to utilize informatics.
Why educating doctors about quality and safety is necessary
Demands for change in medical education are no longer confined to the medical profession; governments and the community also want change as a result of publicized adverse events. Medical students themselves have also identified quality and safety of care as an important area of teaching (3), but medical schools continue to graduate doctors lacking sufficient patient safety knowledge, skills, and behaviors that are thought to be necessary to deliver safe care.
Retrospective medical record reviews in the United States, United Kingdom, Denmark, New Zealand, Canada, and Australia have revealed the extent of injury to patients as a result of their health care (4–10). Most medical educators acknowledge that problems are caused by poorly designed systems, but are uncertain about what needs to be taught about quality and safety, and how best to teach and assess it. More than a decade ago Leape alerted the health professions to the role of systems in adverse events (11), but the practical application of systems theory remains relatively undeveloped.
System theory is an inter-disciplinary field which studies systems as a whole and focuses on complexity and interdependence. System theorists argue that errors are more often caused by pre-existing organizational factors (poor processes, poor designs, poor teamwork, financial restraints, and institutional factors) than by human blunders or negligence. Health professionals are not routinely trained in systems language and concepts, nor do they use relevant tools to make sense of their workplace (12). Although many clinicians recognize the problems in the system of healthcare delivery, they do not know how to address them at the institutional or individual practice levels.
In Australia, a number of reports have focused attention on the educational needs of health professionals. A report on the health workforce by the Productivity Commission of Australia moved the supply of workforce and the environment in which physicians work and learn to center stage (13). Education and training were also emphasized by the National Health Workforce Strategic Framework, in which ensuring an appropriately skilled and competent workforce was one of seven action areas agreed on by Australian health ministers in 2005 (14) (Table 1).
| The Framework summarized seven key action areas: |
| • ensuring and sustaining health workforce supply; |
| • workforce distribution that optimizes access to health care and meets the health needs of all Australians; |
| • ensuring health organizations are places in which people want to work; |
| • ensuring the health workforce is always skilled and competent; |
| • optimal use of skills and workforce adaptability; |
| • recognizing that health workforce policy and planning must be informed by the best available evidence and linked to the broader health system; and |
| • recognizing that health workforce policy involves all stakeholders working collaboratively |
How and where should doctors learn?
Education of clinicians about quality and safety is best undertaken in the workplace, not in lecture halls. When training and education of healthcare workers are divorced from patients and the places they are treated (hospital, clinic, office, or the home), key learning spheres such as complexity of care, communication, teamwork, and patient engagement lose context and relevance.
Innovative workplace learning is designed around the learner's level and needs, valid assessment methods, and the use of local resources. Although competency- and performance-based education are becoming more common, much education and training is still structure- and process-based. Despite an apparent consensus that educational programs about safety need to move from didactic lecture style formats (15) to competency-based education, there remains a lack of shared understanding about what a competency is and how it can be demonstrated (16).
We need to adopt a range of innovative teaching and assessment strategies, and not just rely on the traditional expert clinician imparting their knowledge and skills at the bed- or chair-side, in the office, or in lecture halls. Available strategies for learning, teaching, and assessment include case studies, role-playing, professional mentoring, simulation (low and high fidelity), hypothetical scenarios, seminars, videos, films, project work, log books, inter-professional activities, teaching by patients (real, standardized, or simulated) and carers, peer review, and objective structured clinical examinations (OSCEs).
The patient's role in medical education has traditionally been a relatively passive one. Yet they are a valuable potential resource in education and, more specifically, in patient safety. Patients could be involved in discussion groups, problem-based learning groups, simulations, and interactive seminars on topics such as management of chronic diseases, risk communication, health education, and adverse events. They are increasingly becoming involved in the assessment of communication skills and could also be used in assessing risk communication.
What should be done?
Quality and safety training and education, having arrived, are yet to be successfully incorporated into undergraduate and postgraduate medical training. Major barriers have been the lack of an educational framework describing what health professionals need to know about patient safety, and curricula derived from such a framework that can easily be incorporated into existing health professional programs in either an integrated or modular form. In the last several years, great advances have been made towards overcoming these barriers with the publishing of the Australian National Patient Safety Education Framework (17) and the World Health Organization's (WHO) Patient Safety Curriculum Guide for Medical Schools (18).
The National Patient Safety Education Framework (Australia)
In 2005, the Australian Council for Safety and Quality in Health Care published the National Patient Safety Education Framework (NPSF) (17). The NPSF identifies the competencies that healthcare workers need to deliver safe health care (Table 2). It is designed to assist medical schools, vocational colleges, health organizations (private and public hospitals, nursing homes, and community health centers), and private practices in developing curricula and training programs for students, trainees, and staff. The NPSF recognizes that all health workers, not only doctors, are responsible for patient safety. As adverse events and poor quality are known correlates of poorly designed systems and inadequate communication, the NPSF was designed to apply to everyone working within the health system, not just health professionals.
| 1. | Communicating effectively |
| 1.1 | Involving patients and carers as partners in health care |
| 1.2 | Communicating risk |
| 1.3 | Communicating honestly with patients after an adverse event (open disclosure) |
| 1.4 | Obtaining consent |
| 1.5 | Being culturally respectful and knowledgeable |
| 2. | Identifying, preventing and managing adverse events and near misses |
| 2.1 | Recognizing, reporting and managing adverse and near misses |
| 2.2 | Managing risk |
| 2.3 | Understanding health care errors |
| 2.4 | Managing complaints |
| 3. | Using evidence and information |
| 3.1 | Employing best available evidence-based practice |
| 3.2 | Using information technology to enhance safety |
| 4. | Working safely |
| 4.1 | Being a team player and showing leadership |
| 4.2 | Understanding human factors |
| 4.3 | Understanding complex organizations |
| 4.4 | Providing continuity of care |
| 4.5 | Managing fatigue and stress |
| 5. | Being ethical |
| 5.1 | Maintaining fitness to work or practice |
| 5.2 | Ethical behavior and practice |
| 6. | Continuing learning |
| 6.1 | Being a workplace learner |
| 6.2 | Being a workplace teacher |
| 7. | Specific issues |
| 7.1 | Preventing wrong site, wrong procedure and patient treatment |
| 7.2 | Medicating safely |
The learning areas and topics of the NPSF were developed from relevant literature (19) and validated by national and international experts, and information gathered from wide consultation with health professionals, managers, and consumers across Australia. Each topic is accompanied by a set of competencies (knowledge, skills, and behaviors) relevant to one's level of responsibility for patient care.
The WHO Patient Safety Curriculum Guide for Medical Schools
In 2009, the WHO's World Alliance for Patient Safety published the Patient Safety Curriculum Guide for Medical Schools (WHO Curriculum Guide) (18). The WHO Curriculum Guide represents the evolution of a patient safety framework into patient safety curricula, with its content having been informed by the NPSF developed in Australia. It is an internationally applicable guide to patient safety competencies for medical students and the integration of patient safety education into any existing medical school curriculum. The WHO Curriculum Guide is comprehensive and is designed to build foundation knowledge and skills for medical students that will better prepare them for clinical practice.
Led by two of the authors of this paper, the WHO Curriculum Guide was developed for the WHO by an international expert group that included representatives from Argentina, Australia, Burundi, Canada, China, England, Israel, Malaysia, Myanmar, Palestine, Saudi Arabia, Scotland, and South Korea, and included representation of the International Federation of Medical Students’ Associations. The project focused on three main tasks: producing a comprehensive, flexible, ready-to-teach curricular guide on patient safety relevant for medical schools worldwide; supporting faculty and teachers in the implementation and delivery of patient safety education; and creating an evidence base to support use of the patient safety curriculum in medical schools (Table 3).
| Underpinning principles include: |
| 1. Capacity-building integral to curriculum change |
| 2. A flexible curriculum to meet individual needs |
| 3. Easily understood language for a targeted yet global audience |
| 4. A curriculum guide for all countries, cultures and contexts |
| 5. A curriculum guide that is based on learning in a safe and supportive environment |
| The aim of the curriculum is: |
| 1. To prepare medical students for safe practice in the workforce |
| 2. To inform medical students of the key topics in patient safety |
| 3. To enhance patient safety as a theme throughout the medical curriculum |
| 4. To provide a comprehensive curriculum to assist teaching and integrating patient safety learning |
| 5. To further develop capacity for patient safety educators in medical schools |
The WHO Curriculum Guide is divided into two sections (Table 4). The first part is aimed at increasing the skills and knowledge of the teachers, as well as building capacity to teach the subject. The second part focuses on the core patient safety knowledge and skills that should be taught to medical students. It is comprised of 11 topics, 10 of which were selected from the evidence-based National Patient Safety Education Framework (NPSF) developed in Australia. The 11 topics included in the WHO Curriculum Guide together cover 16 of the total 22 learning topics that make up the NPSF3. The one WHO Curriculum Guide topic not derived from the NPSF was selected to support learning in infection control targeted by the WHO's program to reduce infections through better infection control.
| Part A: Teacher's Guide |
| 1. Background |
| 2. How were the topics selected |
| 3. Aims and underpinning principles |
| 4. What a medical school needs to do to use this guide |
| 5. How to integrate patient safety teaching into existing curricula |
| 6. Educational principles essential for patient safety teaching and learning |
| 7. How to assess patient safety |
| 8. How to evaluate patient safety curricula |
| 9. Using tools and resources on the web |
| 10. Activities to assist patient safety understanding |
| 11. How to foster and engage a transnational approach |
| 12. Confronting the reality of health care |
| Part B: Curriculum Guide Topics |
| Topic 1: What is patient safety |
| Topic 2: What is human factors engineering |
| Topic 3: Understanding systems and complexity |
| Topic 4: Being an effective team player |
| Topic 5: Understanding and learning from errors |
| Topic 6: Understanding and managing clinical risk |
| Topic 7: Methods for quality improvement |
| Topic 8: Engaging with patients and carers |
| Topic 9: Minimizing infection through improved infection control |
| Topic 10: Reducing risks associated with invasive procedures |
| Topic 11: Improving medication safety |
The first edition of the WHO Curriculum Guide was published in 2008 after validation by a panel of medical educators and patient safety experts. Pilot testing began in early 2009, with the aim being to understand how implementable the WHO Curriculum Guide is, and to identify how it impacts on students’ knowledge of patient safety and associated skills. Pilot testing is occurring in each of the six regions of the WHO to ensure the complete spectrum of country income distributions and types of medical schools are considered. Plans are also underway to produce similar curriculum guides for other healthcare professions in the near future.
Commentary on learning topics
Communication
A consistent theme in the quality and safety literature is the importance of clear, accurate, and timely communication among clinicians, patients, care givers and management. The link between mistakes and inadequate communication (i.e. inadequate, wrong, or no communication) is firmly established (20–22). Treatment outcomes are also influenced by how well clinicians communicate with their patients and other healthcare workers (23–25). How do doctors engage with their patients? What is the best way to convey risk information? What steps must a doctor take to provide complete information after adverse events? How do doctors show respect for cultural differences? A competent doctor would demonstrate these competencies relative to their level of knowledge and experience.
Teaching communication skills is now firmly embedded within undergraduate programs; more challenging is learning how to communicate in complex environments where multiple people are involved in each patient's care. Simulator centers are used for training and assessment of team communication in emergency scenarios. However, there has been little attention paid to less acute settings, although regional general practitioner training programs are beginning to address these issues in primary care.
Identifying, preventing, and managing adverse events and near misses
Adverse events occur across the health system. Most health organizations have, or are implementing, methods for reporting and analyzing serious adverse events (26). Doctors need to recognize errors and system failures, understand the underlying factors causing them, and know how to make the necessary improvements to prevent them from reoccurring. Research shows that an understanding of the nature of errors and applying quality improvement concepts reduce errors, waste, and inefficiency (27, 28)
Using evidence and information
The constantly changing clinical environment requires doctors to regularly update their knowledge and skills. They can no longer rely on memory (29); they need to know how to formulate relevant clinical questions, how to efficiently find the best evidence, and how to incorporate the findings into practice (30). Many medical courses have addressed the need for graduates to have the skills required for evidence-based decision making and life-long learning.
Working safely as a team
Another common theme in the quality and safety literature is the role of the multidisciplinary team in improving quality and continuity of care. Communicating accurate information in a timely way to the right people can be complex and difficult due to the spread of clinical responsibility among members of the healthcare team (22, 31). Hospital clinicians will often identify others within the hospital-based medical team but may be less familiar with other teams responsible for patients, such as the general practitioner and community-based teams. Effective healthcare teams communicate with one another and combine their observations, expertise, and decision-making responsibilities to optimize patient care (2).
Effective team work is known to reduce errors caused by miscommunication, poor handover, and delayed diagnosis and treatment, particularly for those with a chronic illness (32–34). Yet the role of effective teamwork in reducing risks and improving continuity of care may not be readily appreciated by clinicians, as they are trained to accept individual responsibility. Nor is the role of human factors in reducing errors fully understood; otherwise, checklists and use of protocols would be the rule rather than the exception. Knowledge about organizational complexity and the different professional and organizational cultures is critical for understanding the influence of the environment and poorly designed systems on quality of care. This, too, is poorly understood; otherwise, multidisciplinary morbidity and mortality meetings, handovers, and clinical review meetings would be common. They are not.
Ethical practice
Medical ethics, clinical ethics, and ethical practice are now receiving greater attention in education and training due to increased use of technology, the range of care and treatment options, and greater demands for accountability by the public and the professional registration authorities. Reason argues that a systems approach to error management necessarily incorporates strong professional regulation (35). The perceived contest between individuals and bad systems as the cause of patient injuries temporarily confused many clinicians and managers, but individuals have always remained accountable when they act unprofessionally.
Professionalism is now a priority standard for most health professions, with health registration boards, health departments, hospitals, and other health services increasingly providing guidance to clinicians on the importance of professionalism. The term covers those attitudes and behaviors that promote and maintain the patient's best interests above and beyond all other considerations. An ethical health professional (irrespective of their position) would put patients’ interests above their own, avoid harm, respect patient autonomy, maintain competence and only work and practice within the bounds of their knowledge and experience.
Continuing teaching and learning
Teaching is a long recognized responsibility of clinicians, but the infrastructure to support clinician teaching is inadequate. Passing on skills and knowledge to the next generation was once relatively easy, with greater patient access and time for small group tutorials, but today clinicians are finding teaching difficult. Many have received little training in educational methods, and their teaching activities are often in addition to other duties. New and innovative methods, such as ambulatory teaching clinics, are urgently required to support clinical teaching.
The organization of health services and high workload in hospitals and private practice, coupled with rapid changes to health information, make it impossible for individuals to keep up-to-date using the traditional methods of reading journals or attending lectures and conferences. New competencies in workplace learning are required. Working in health care is a lifelong journey that requires the application of self-directed learning, self-monitoring, and self-assessment techniques, coupled with peer validation.
How should medical educators and trainers use the WHO Curriculum Guide?
The design of the WHO Curriculum Guide allows for flexibility and freedom in integrating learning topics into existing undergraduate and postgraduate curricula, but incorporating new content and activities requires an effective local “champion”, a collective commitment to reducing time allocated to pre-existing content, and the implementation of meaningful assessment. Adding another course to existing curricula is not usually practical or desirable. In an already overcrowded curriculum, patient safety should not be taught as a separate subject, but rather integrated as a theme into all existing coursework. Medical educators and clinicians may need help in building capacity and preparing academic and clinical staff to incorporate safety and quality into training and education programs (36). Part A of the WHO Curriculum Guide describes strategies for achieving these and other important capacity-building milestones.
Conclusion
The WHO Patient Safety Curriculum Guide for Medical Schools, based on the Australian National Patient Safety Education Framework (NPSF), is freely available to download from the WHO website (18). The integration of the topics from the WHO Curriculum Guide into a current medical school curriculum should produce graduates with knowledge and skills necessary for the provision of safe care and an ability to put this learning into practice. Improved patient safety with all the benefits that flow from safe care is the reason that both the NPSF and the WHO Curriculum Guide have been produced. Within the next year some early results from the evaluation of implementation at the pilot sites across the world should be available for publication.
