Thread by @Brian_M_Wong

The #ICRE2018 debate on the #BawaGarba case tightly links issues of #MedEd and #ptsafety — in the first 10 mins, have already heard about just culture, safe supervision, learning from mistakes, diagnostic uncertainty, systems failures & 2nd victim

Here are some more #MedEd #ptsafety topics being discussed at #ICRE2018 plenary:

Speaking up
Teamwork vs teaming
Handoffs
Fatigue and its impact on clinical performance
Psychological safety

Empirical data on patient safety incidents that involve residents:

Lack of supervision (~50%) and handoff problems (~20%) among the most common contributors to serious safety problems

Landmark article from 2007:
jamanetwork.com/journals/jamai…

#ICRE2018

Lots of talk about speaking up culture -- but it's complex.
The type of patient safety problem matters too -- residents more likely to speak up about systems problems than professionalism issues that contribute to #ptsafety problems @sginsburg1 #ICRE2018
qualitysafety.bmj.com/content/26/11/…

Here's another sobering reminder for how much work is needed -- in 1993, already a call for greater attention to improving clinical supervision for #ptsafety jamanetwork.com/journals/jama/… #ICRE2018

Now onto teamwork--in healthcare we from and disband teams multiple times a day, often working with new team members on a specific task and then sometimes never again.

We have to learn TEAMING skills (i.e., teamwork on the fly)

hbr.org/2015/12/the-ki…

#ICRE2018

Helpful mnemonic for how attending can make safe supervision explicit

S-set expectations for when to be notified
U-uncertainty a time to contact
P-planned communication
E-easily available
R-reassure to not fear calling
B-balance supervision and autonomy

ncbi.nlm.nih.gov/pmc/articles/P…

Was wondering when disclosure would come up -- we definitely need to prepare residents to discuss patient safety problems with patients and families -- because they are doing it already! (75% report they have disclosed in training)

jgme.org/doi/abs/10.430…

#ICRE2018

So powerful when #MedEd guru @ChrisWatling3 can articulate so clearly the importance of empowering residents to identify systems issues and gaps in care that need attention and finding ways to improve upon them -- lends legitimacy to importance of #QI in #MedEd #ICRE2018

Yesterday I had a chance to facilitate an #ICRE2018 session with @boedudley and we talked about structural changes in the learning environment to engage learners in systems change, #ptsafety, #QI....here are some concrete suggestions:

Resident quality and safety councils:

Key elements:
1) Put residents in charge / keep engaged
2) Make it multidisciplinary
3) Resources, resources, resources
4) Highlight resident work
5) Hospital-wide resident representation
6) Evaluate outcomes

jgme.org/doi/abs/10.430…

Chief Resident in Quality and Safety -- most mature program is through the @DeptVetAffairs #ICRE2018

va.gov/HEALTHCAREEXCE…

journals.lww.com/academicmedici…

Adding explicit language to promotions criteria to support advancement on basis of #QI, need to:

1) Add specific language
2) Expand definition of scholarship
3) Create framework to document evidence of impact

amjmed.com/article/S0002-…

#ICRE2018

Appoint bridging leaders (like @KCaverzagie) — individuals who have a formal role that bridges the clinical and educational institutions #ICRE2018 jgme.org/doi/10.4300/JG… #ICRE2018

Introduce resident-sensitive #QI metrics — patient outcomes that are sensitive to the work that residents do. One of my favourite papers by @DrDanSchumacher describes this concept further #ICRE2018 journals.lww.com/academicmedici…

Financial incentives to engage residents in #QI. @UCSF has been doing this for 10 years. They pay each resident up to $1200 per year if they achieve program-wide QI metrics #ICRE2018 journals.lww.com/academicmedici…