Training Initiatives
Residency (GME) Patient Safety Curriculum: Developing Faculty Leaders and Pioneers
Purpose: Develop faculty leadership at all VA facilities where medical residents train in order to pursue the objectives of the VA patient safety curriculum.
Target Audience: Physicians, clinicians, and managers in VAs or affiliate universities who provide education to residents. Patient safety managers/officers who would like to provide more education to residents and any stakeholder who wants to make a difference in providing patient safety education.
Why make the effort to develop faculty to teach patient safety?
- To prepare physicians who are able to diagnose and treat system ills before harm results.
- To meet ACGME required Core Competencies
- Systems-based practice: manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
- Practice-Based Learning and Improvement: that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
- Professionalism: manifested through a commitment to carrying out professional responsibilities and adherence to ethical principles
- To prepare for certification/recertification by American Board of Medical Specialties (ABMS)
- To support the VA and/or medical school philosophy regarding systems thinking and practice
- To meet guidelines and standards
- Federal guidelines and (indirectly) state regulations for VA (directives, mission)
- Federal and state regulations for university hospitals (e.g., CMS, new Florida law)
- To meet the requirements set by Joint Commission or other policy groups (residents are sometimes considered employees)
- To address the call for interdisciplinary teaching (med students with nursing students with pharmacy students) with multidisciplinary teaching sessions or case conferences
- It's the right thing to do.
Medical Team Training Overview and Materials
The Medical Team Training (MTT) program was developed to improve outcomes of patient care by implementing Crew Resource Management (CRM) communication tools in the clinical workplace. CRM was developed and applied in the aviation industry to address communication failure. We are advocating CRM applications to address communication failure in healthcare, which has been recommended by the Institute of Medicine and has face validity in the healthcare context. To participate in the MTT program, a VA Medical Center (VAMC) must make a commitment to the following:
- Host a full day learning session facilitated by MTT faculty
- Plan and prepare for the learning session
- Ensure maximum VAMC staff attendance at learning session
- Organize a multidisciplinary Change Team
- Engage in a MTT project involving briefings and debriefings for a minimum of one year following the learning session
- Participate in follow-up interviews and data collection with NCPS support for a minimum of one year
- Administer the Safety Attitude Questionnaire in staff meetings to learning session attendees one year follow the learning session
Healthcare Failure Mode and Effect Analysis (HFMEA) has been designed by the VA National Center for Patient Safety (NCPS) specifically for healthcare. HFMEA streamlines the hazard analysis steps found in the traditional Failure Mode and Effect Analysis (FMEA) process by combining the detectability and criticality steps of the traditional FMEA into an algorithm presented as a Decision Tree. It also replaces calculation of the risk priority number (RPN) with a hazard score that is read directly from the Hazard Matrix Table. This table was developed by NCPS specifically for this purpose.
A recent VA Alert standardizes the prescribing and dispensing of U-500 insulin within the VA according to ISMP guidelines. The attached educational material can be used to educate VA patients in the manner that U-500 insulin and associated needles will be dispensed to them. Caregivers and diabetic patients are encouraged to review these and familiarize themselves with the new procedures.
U-500 Insulin Brochure (PDF)
U-500 Insulin Slideshow (PPT)