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Saturation in Training

Abstract

Regardless of modest improvements in patient care, more needs to be done, and Wachter’s (2004; 2010) reports are now a renewed call for action and a move away from the often sporadic and incomplete manner in which we are preparing our health care teams. This article will discuss how those involved in patient safety and, specifically, in simulation-based instruction, can improve upon their methods and results.
Saturation in Training
On Jun 12, 2013
This article discusses how those involved in patient safety and, specifically, in simulation-based
instruction, can improve upon their methods and results.
Cite this article: Clapper, T. C. (2013, Spring). Saturation in Training. Patient Safety InSight.
http://magazine.nationalpatientsafetyfoundation.org/magazine/spring2013-saturation-in-training/
by Timothy C. Clapper, PhD
Introduction
Earlier this year, patient safety leader and advocate Bob Wachter wrote a post on his health
care blog, Wachter’s World, that caused many of us in the patient safety community to take
notice of our progress and shortcomings for making patient care much safer. Asking “Is the
Patient Safety Movement in Danger of Flickering Out?” he noted that the health care industry
has seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-
trained clinicians, and even better systems. Since the initial 1999 IOM report, To Err is Human
(Kohn, et al. 2000), and Wachter’s follow-up report (Wachter 2004), modest improvements
have been made, although they have been difficult to measure “because of our rudimentary
measurement capacity in safety” (Wachter 2010). Regardless of modest improvements, more
needs to be done, and Wachter’s (2004; 2010) reports are now a renewed call for action and a
move away from the often sporadic and incomplete manner in which we are preparing our
health care teams. This article will discuss how those involved in patient safety and, specifically,
in simulation-based instruction, can improve upon their methods and results.
TeamSTEPPS® and simulation
As noted by the Agency for Healthcare Research and Quality (AHRQ 2012), patient safety was a
fairly new field at the time that the groundbreaking IOM report emerged. AHRQ began to look
at systematic factors affecting patient safety, along with potential solutions that needed to be
implemented to address issues that caused unsafe practices. In 2006, two major AHRQ
initiatives unfolded that would have the potential to significantly address clinical error: Team
Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and the
Improving Patient Safety through Simulation Research Grants program.
TeamSTEPPS provides a comprehensive training program to improve the teamwork and
communication of clinical teams. It evolved from older Crew Resource Management concepts
and uses evidence-based teamwork and communication tools to address human factor and
other environmental issues affecting patient care (Clapper & Kong 2012). The Simulation
Research Grants program, still active today, encourages health care organizations to create an
environment for providers to acquire proficiency in clinical skills, particularly those procedures
where there is the high potential for error, including central venous catheter (CVC) infection
and complication and obstetric emergencies that can lead to poor patient care, injury, death,
and substantial cost to the health care system (AHRQ 2012; AHRQ 2013).
Seven Years Later
Over the past seven years, TeamSTEPPS has been adopted by many hospitals and health care
organizations, and some patient safety officers have made great progress in educating their
workers in the four competencies (leadership, communication, situational awareness, and
mutual support) that can be used to improve team performance (Clapper & Kong 2012).
Likewise, the simulation community has witnessed ongoing growth in the use of simulation to
prepare health care workers. Membership in organizations such as the Society for Simulation in
Healthcare has steadily increased as clinical educators adopt this training modality. Simulation
is certainly not new, but, in part because of innovative companies that are continually
improving the fidelity or realism of simulation equipment, health care educators are feeling
more comfortable about replacing a great deal of bedside teaching with simulation-based
instruction.
Health care organizations such as AHRQ require evidence to support the human and fiscal
resources that go into efforts to improve patient care and reduce medical error through these
two major initiatives (AHRQ 2013). In turn, the leaders of health care organizations, including
patient safety officers, will turn to simulation educators and TeamSTEPPS trainers and ask them
to show resultsnot in terms of number of learners trained, but rather, results in patient care.
While progress has been made in each of these areas, many educators and administrators are
using ineffective approaches to put these initiatives into practice (Clapper & Ng 2012). The
following sections highlight three significant changes that will need to be made: truly move
away from outdated teaching methodologies, standardize curriculum content, and apply the
theory of Saturation in Training (Clapper & Ng 2012).
Fully immerse learners in standardized curriculum
Simulation educators must move away from outdated, ineffective learning methodologies. For
example, some simulation centers conduct summertime “simulation boot camps” in airway
management and CVC placement for new residents where groups of residents rotate through
skill stations. I have observed that the teaching methods in these circumstances are similar to
the “see one, do one, teach one” method: only one of the residents had an opportunity to have
hands-on practice of the procedure while the rest of the group observed before rotating to the
next station. As a result, many of the learners would not have the opportunity to learn by
working through the experience, and by making errors that are sometimes a part of the
learning process. To make an analogy, this is akin to fitting an old engine into a new car. If it
continues, while simulation is a potentially powerful resource, it will not be used to its fullest
extent.
Another needed change involves simulation educators teaching from a standardized, research-
based curriculum because of the variance in skill and knowledge among both educators and
learners. The curriculum needs to be based on research and “best-practices,” include detailed
information to assist the learners with understanding the content, and be facilitated in a
standardized, student-centered manner that is conducive to good curriculum and instruction
design principles. For example, when developing simulation-based instruction for multiple
public hospitals in New York City, I used the four-phase, brain-based lesson plan developed by
Williams and Dunn (2008) that allowed learners to inquire, gather, process, and apply the
content being learned in the classroom. The four phases mirror the way the brain prefers to
process information for long-term retention and application. In addition, the instructional
content was thoroughly researched to include the latest information, and all learners were
required to practice and apply the procedures. The facilitator was prepared to facilitate this
course, provided a detailed demonstration with explanation, and made few assumptions
concerning the level of knowledge of the learner. We always have to ask ourselves “how do
they know it?” and “where/how did they learn it?” Many educators themselves may not have
learned all of the declarative or procedural knowledge in their own learning process, and when
teaching others, some will leave out important information (Crispen 2010; Sullivan et al. 2008).
Saturation in training
As a researcher-educator, I have led simulation courses that were supported by research and
best practices and packaged according to the four-phase lesson plan that I introduced to the
simulation community. However, my team encountered problems with the central venous
catheter (CVC) course, the first standardized course that we introduced. Essentially, the
problem was the same one that many simulation educators have today, and the impetus
behind this very article: training was sporadic across departments and, as a result, it was
relatively ineffective for making any real difference (Clapper & Ng 2012).
As I expressed to my supervisor at the time, if we continued to train small groups of people
over a longer period of time, most likely those people would revert back to the practice existing
in the department. Instead, we put into practice my theory of Saturation in Training (Clapper &
Ng 2012), with the goal of changing culture. The Saturation in Training theory holds that if we
train the greatest number of people in the shortest period of time we can change the practice
and culture of a department. And in our case, it worked.
After we trained an entire emergency department in CVC placement in just a couple of weeks,
the ED director observed the practice of his attending physicians and reported that they were
using the CVC bundle “correctly” (my emphasis) and, using the ultrasound, achieving one-stick
placement. Using the ultrasound during CVC placement allowed the provider to align the
needle with the vein and visualize the needle as it moved into its proper place in the center of
the vein. Relying on landmarks alone could cause the provider to blindly stick multiple times,
increasing the risk of complication, and providing multiple sites for infection.
TeamSTEPPS was also added to every course I developed and facilitated, and the adjunct
instructors I trained were shown how to apply it to that particular topic. Learners practiced the
CVC procedure with one another and learned that lost guide wires occurred even as a second
person looked on. They learned how to speak up, be supportive, and use CUS (I’m Concerned,
Uncomfortable…for Safety reasons, I am Stopping the line) if necessary to prevent an error
from occurring. These were not “show and tell” courses, but rather complete 4-hour courses
where the learner was immersed in the declarative and procedural knowledge in a student-
centered environment. Another part of the saturation process is making the time to facilitate
the training the right way, the first time.
The Saturation in Training approach was applied to other courses, including the Shoulder
Dystocia Teamwork and Skills course, the Cardiac Code Team course, and the Advanced Airway
Course. We trained entire OB, emergency, and medicine departments in 6 to 8 weeks, with
physicians, physician assistants, midwives, and nurses training together in their particular
course. In addition, learners received an overview of the TeamSTEPPS competencies and were
able to practice them in the context of their particular clinical setting. As with the CVC course,
we began to receive immediate, positive results, especially testimonials from department leads
who observed a definite change in individual and team skills at the departmental level.
Conclusion
As noted by Wachter (2013), we are in danger of looking at the time after the 1999 IOM report
as a “Golden Era of Patient Safety.” We cannot adopt this view because, while we have made
some improvement, we have not yet made our mark in patient safety, nor fully justified the
costs associated with the major health care initiatives. If we apply Kirkpatrick’s (1994) four
levels of education outcomes (reaction, learning, transfer of the new behavior, and results) to
patient safety, we know that instruction can lead to: 1) greater efficacy by the health care
provider to perform a skill or apply knowledge; 2) a change in knowledge, as perhaps measured
by a course pre/posttest; 3) an observed change in the practice in the healthcare setting; or 4)
at the highest level, a noted change in direct patient care, which may be measured in numerous
ways including reduced rates of litigation, infection, and complications.
We do not need more research to assess whether nurses or residents are more confident after
simulation-based instruction or whether they can work as a part of an interprofessional team.
There is already an abundance of this Level 12 research and even studies showing that brain-
based learning can be effective for changing the knowledge and skill level of health care
workers (Clapper et al., 2012). Simulation can be used to improve the skills, communication,
and teamwork of our health care workers, but patient safety will not be fully realized unless
simulation educators can show improvement at the highest levels of education outcomes
changes in the actual department and direct patient care (Kirkpatrick’s levels 3–4). If a
difference is going to be made for patient safety, the Saturation in Training theory must be
applied to practice.
Wachter (2013) saw two major forces slackening the response to patient safety: clinician
burnout and strategic repositioning of health care resources to deal with the Affordable Care
Act. I see a third one, and that is the reliance on ineffective and status quo facilitation practices
for TeamSTEPPS and simulation-based instruction. Our health care workers and our patients
deserve better, and we can change our facilitation methods to achieve the best learning
outcomes.
Timothy C. Clapper, PhD, is adjunct professor with the University of Colorado at Colorado
Springs and Education and Simulation Consultant with TC Curriculum & Instructional Design,
LLC. Contact him at timothy.clapper@gmail.com.
References
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Copyright © 2013 All Rights Reserved Patient Safety InSight is Published by National Patient
Safety Foundation | ISSN 2326-0467
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The Institute of Medicine's 1999 report on medical errors galvanized the public and health professionals. Before then, providers, health care organizations, and policymakers lacked the understanding and incentives to generate the changes in culture, systems, training, and technology to improve safety. Since 1999 there has been progress, but it has been insufficient. Stronger regulation has helped, as have some early improvements in information technology and in workforce organization and training. Error-reporting systems have had little impact, and scant progress has been made in improving accountability. Five years after the report's publication, we appear to be at "the end of the beginning".
Article
The purpose of this study was to determine if a cognitive task analysis (CTA) could capture steps and decision points that were not articulated during traditional teaching of a colonoscopy. Three expert colorectal surgeons were videotaped performing a colonoscopy. After the videotapes were transcribed, the experts participated in a CTA. A 26-step procedural checklist and a 16-step cognitive demands table was created by using information obtained in the CTA. The videotape transcriptions were transposed onto the procedural checklist and cognitive demands table to identify steps and decision points that were omitted during traditional teaching. Surgeon A described 50% of "how-to" steps and 43% of decision points. Surgeon B described 30% of steps and 25% of decisions. Surgeon C described 26% of steps and 38% of cognitive decisions. By using CTA, we were able to identify relevant steps and decision points that were omitted during traditional teaching by all 3 experts.
Is the patient safety movement in danger of flickering out? Wachter's World
  • R M Wachter
Wachter RM. 2013. Is the patient safety movement in danger of flickering out? Wachter's World. Feb. 18, 2013. Retrieved April 18, 2013 from http://community.thehospitalist.org/2013/02/18/is-the-patient-safety-movement-in-danger-of-flickering-out/.