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 in response to the Institute of Medicine's 1999 To Err is Human report that revealed inadvertent harm to patients through failures in team work and communication. The same report suggested that healthcare look to high-reliability industries, such as aviation, that were addressing these issues through their Crew Resource Management (CRM) programs. To improve outcomes of patient care, MTT adapted and implemented CRM communication tools and techniques in the multidisciplinary clinical workplace.
While the first roll-out of MTT was mandated for all VHA facilities that performed any surgical services, it is now voluntary and facilities have requested the training for a variety of services and areas. Facilities must commit to participate in all aspects of the program which include:
- Host a learning session facilitated by MTT faculty
- Plan and prepare for the learning session with the MTT faculty
- Maximize VAMC staff attendance at learning session (for 24/7 services, training may be offered on consecutive days)
- Organize a multidisciplinary Change Team
- Engage in at least one MTT project selected during the preparation process for a minimum of one year following the learning session. Each project has process and veteran-centered outcome measures.
- Participate in follow-up interviews and data collection with NCPS faculty for a minimum of one year
- Administer the Safety Attitude Questionnaire or Teamwork Questionnaire to all staff members of the targeted unit or service one year following the learning session
Clinical Crew Resource Management Overview and Materials
Within the past decade, health care organizations have adopted practices used in aviation to enhance safety, such as Crew Resource Management (CRM). Originating at NASA over 30 years ago, CRM provides a blueprint to help teams communicate effectively in dynamic situations, and manage the effects of human factors on operational safety.
Clinical Crew Resource Management (CCRM) is a comprehensive, interactive program that takes the tenets and concepts from CRM and applies them directly to front line clinical practice at all points of care. With a focus on systems, leader behaviors, assertive communication, and situational awareness, participants learn the tools necessary to reduce the risk of harm for hospitalized veterans.
While CCRM began with a nursing focus, it is a multidisciplinary program that can be applied in any venue where healthcare teams practice. For more information about CCRM, visit the CCRM page.
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)