Presenter: Christel Mottur-Pilson, PhD
Institution: American College of Physicians
Introduction: As a large primary care membership organization the American College of Physicians (ACP) decided to focus its energy on the development of an ambulatory care curriculum. The project was funded by the Agency for Healthcare Research and Quality (AHRQ) as a three year grant, 1 U 18HS 12006-01, with the aim to disseminate the curriculum to ACP members. The curriculum is built on the 7 areas identified by the Institute of Medicine Report as essential for improving safety. The content of the curriculum spans Systems, Medication Errors, Electronics, Communication, the Role of the Patient, Idealized Office Design and Cognition. Though each module can stand on its own, there are 3 common themes that run through all modules, i.e., systems thinking, communication, and cognition.
Methods: Each module is built around clinical cases exemplifying the theoretical underpinnings. An overview of systems’ thinking, for example, its role and importance in patient safety, precedes the clinical cases. Each case represents several reasons of why safety was threatened. The cases have been designed so that a physician can identify with the case presented and feel that he or she has had a similar experience. When this happens the theoretical concept is transformed into concrete reality that becomes actionable. Immediately following the case is an analysis of what went wrong. Physicians have the opportunity to identify what went wrong and how to avoid a similar error in the future. Finally, each module comes with “take home points,” to enable physicians to implement patient safety changes in their offices immediately. The approach is to put into action tomorrow what is absorbed today.
ACP members are organized into regional Chapters. Each Chapter selects one of their members to attend the patient safety one-and a half-day training. As physicians learn best from their peers, these individuals take the knowledge back to their peers.
Attendees at Chapter patient safety presentations received pre- post and 6 months follow-up surveys to gauge the success of the material. To ensure greater validity of our findings we matched attendees with non-attendee cohorts.
Results: Physicians especially identify with the clinical cases in each module. They further like the take home points. The latter have been combined into a pamphlet covering all 7 modules. As expected, the most popular topic is the medication error followed by systems, idealized office design and communication. The least used modules are cognition and electronics.
Apart from Chapter dissemination, presenters have taken the material to a wide array of other venues, ranging from grand rounds, the lakeshore clinic of Kirkland, Washington, and other local and national medical societies.
Our survey results to date indicate that attendees are more aware of patient safety issues and acknowledge that adverse events can happen in their practice.
Discussion: Once familiar with the material, the patient safety “champions” (trainees) continually are looking for opportunities to present the modules to a wider audience. Since this is a three-year program, some Chapters have featured several patient safety sessions at their annual meetings. We expected the program to be successful with College Chapters but were pleasantly surprised by the wider dissemination based on the enthusiasm of the “champions.”
Patient Safety: The Other Side of the Quality Equation
