An Interdisciplinary Team-Based Learning Experience in Ambulatory Patient Safety

Erik W. Black, PhD

Department of Pediatrics

University of Florida College of Medicine

PO BOX 100291

1600 SW Archer Road

Gainesville, FL 32610

Phone: (352) 273-5322

Email:

Richard Davidson, MD, MPH

Department of Medicine

University of Florida College of Medicine

Eric I. Rosenberg. MD, MSPH

Department of Medicine

University of Florida College of Medicine

Almut Winterstein, RPh, PhD

Department of Pharmaceutical Outcomes and Policy

Unversity of Florida College of Pharmacy

Ann Snyder, PharmD, MEd

Department of Pharmacotherapy & Translational Research

Unversity of Florida College of Pharmacy

Wayne T. McCormack, PhD

Department of Pathology, Immunology & Laboratory Medicine

University of Florida College of Medicine

Table of Contents

Purpose ……………………………………………………………………………………………………... / 2
Objectives …………………………………………………………………………………………………... / 2
Conceptual Background …………………………………………………………………………………….. / 2
Learner Preparation ………………………………………………………………………………………… / 2
Facilitation Schema ………………………………………………………………………………………… / 2
Team Assignments ………………………………………………………………………………………….. / 4
Readiness Assurance Test (RAT)
RAT Items …………………………………………………………………………………………. / 5
Facilitation Guide ………………………………………………………………………………….. / 6
Application Exercise
Patient Case ………………………………………………………………………………………... / 9
Application Exercise Questions ……………………………………………………………………. / 10
Facilitation Guide ………………………………………………………………………………….. / 12
Discussion Points and Outcomes …………………………………………………………………... / 12
Appendix A: Introduction to Atrial Fibrulation ……………………………………………………………. / 15
Appendix B: Appeals Form ………………………………………………………………………………... / 16

Purpose

Students from multiple health colleges will review barriers to health care quality in ambulatory care. They will prioritize shortcomings in healthcare delivery and discuss approaches to improve health care quality and public health while developing an appreciation for the complexity of healthcare delivery and impediments to quality health care.

Objectives

  1. Given a problem scenario, individuals will collaborate as an interdisciplinary team to identify and examine causes that contributed to the etiology of medical error;
  2. Teams will collaborate to analyze, evaluate and report risks to patient safety within a specific scenario;
  3. Teams will collaboratively appraise and justify approaches to preventing systemic errors associated with a specific scenario.

Conceptual Background

This team-based learning experience was designed and implemented as a component of a large, required longitudinal interdisciplinary learning activity for first and second year students at a large Southeastern US Academic Health Science Center. Team-based learning was adopted as an instructional methods based on its ability to promote discourse and involvement and to accommodate the limited number of faculty facilitators at our disposal. More information on team-based learning can be found via the Team-Based Learning Collaborative (

Learner Preparation

Prior to engagement in this activity, learners should be provided the following matierals. Due to limitations associated with copyright, users must access the Sarkar et al. and Kohn et al. articles via their institution’s library system. The introduction to atrial fibrillation is included within this document as Appendix A. It is required that students read only the executive summary of Kohn et al. It should be suggested that students may benefit from reading the entire document.

  1. Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care. Joint Commission Journal on Quality and Patient Safety. 2009;35(7):377–83.
  1. Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Vol. 6., Joseph Henry Press, 2000.
  1. Introduction to Atrial Fibrillation (Appendix A)

Facilitation Schema

This material was developed as a half-day learning experience, which was the first of three interdisciplinary learning experiences during the academic year. Subsequent sessions addressed patient care ethics and health systems & inequalities.

The Individual Readiness Assurance Test (IRAT) consists of seven (7) multiple choice questions answered on a Scantron or other quiz sheet. The Team Readiness Assurance Test (TRAT) consists of the same seven (7) multiple choice questions. These questions should be answered on an Immediate Feedback Assessment Technique (IF-AT) card (Epstein Educational Enterprises). The Application Exercise consists of multiple interactive problem solving questions. To facilitate inter-team discussion, a set of four answer cards (A-D, printed on cardboard of four different colors), was used for simultaneous reporting of team answers on multiple choice discussion questions. We recommend that two or more facilitators should be assigned to this activity; one will be designated a primary facilitator. Students should be assigned to enumerated tables prior to the session. Ideally, each table will have either six or seven students. There will be two different colored folders on each table at the beginning of each session. The firstfolder (e.g., red) will contain an Individual Readiness Assurance Test (IRAT) for each student; IRAT answer sheets for each student; a single IF-AT form for the Team Readiness Assurance Test (TRAT);and a sheet that has a description of the appeals process if a group wants to challenge one of RAT questions. The secondfolder (e.g., blue) will hold a copy of the Patient Filler Case, a patient narrative which will be incorporated into this activity, for each student; a set of colored cards (labeled A through D); and a set of five Application Exercise Questions. Each application exercise question should be printed on a separate sheet of paper. These folders should be explicitly colored for easy identification. Extra copies of all materials, including the individual answer sheets and IF-AT forms, should be on hand.

Example Schedule of Events:

1:00 PM / 15 min / Welcome, overview of objectives, TBL and agenda
1:15 PM / 10 min / Individual Readiness Assurance Test
1:25 PM / 15 min / TeamReadiness Assurance Test
1:40 PM / 5 min / Discussion of appeals process
1:45 PM / 10 min / Introduce application activity (read case)
1:55 PM / 10 min / Application activity question one
2:05 PM / 10 min / Discuss question one
2:15 PM / 15 min / Application activity questions two and three
2:30 PM / 15 min / Discuss questions two and three
2:45 PM / 15 min / Application activity questions four and five
2:55 PM / 15 min / Discuss questions four and five
3:15 PM / 10 min / Application activity question six
3:25 PM / 10 min / Discuss question six
3:35 PM / 20 min / Summary, review of objectives, open question and answer

Implementation Advice Based on Lessons Learned:

  1. Provide name tags for learners.
  1. Use candy/nominal prizes as rewards for team performance/participation.
  1. Implement an interactive icebreaker activity prior to beginning the “content”, this is particularly useful when students have not worked together prior to this experience.
  1. Specific instruction to students to eliminate working ahead, or as an alternative, releasing each application exercise question as they are discussed. One method of doing this would be to print each application exercise question on a different colored sheet of paper.
  1. Establish a website or learning management system (LMS) course shell for the experience. Host pre-reading materials and information about the exercise on the LMS. For learners who may be new to team-based learning, we recommend including links to to the Team Based Learning Collaborative website and two helpful videos:
  1. It may be useful to furnish the patient case ‘Filler Case’ to learners prior to the experience. This case is quite lengthy and contains specific details.
  1. Suggested talking points to introduce the activity:

Welcome: This is a collaborative, interdisciplinary team-based learning exercise that includes students from across the health science center.

Teams: Healthcare is delivered in interdisciplinary teams. The purpose of this experience is to allow you to work together as an interdisciplinary team to make decisions about complex problems related to healthcare.

Format: This experience will employ Team Based Learning. We will begin our learning experience by taking an individual readiness assurance test, followed by a team readiness assurance test. Both of these tests are based upon the pre-reading assignments. After we have completed these tests we will move to our application exercises.

Team Assignments

The class size was too large to divide into teams in a public fashion as is traditional for team-based learning. Teams were created by the course director in advance, and remained together for three interdisciplinary TBL sessions throughout the academic year. Teams consisted of 6-7 learners each. Each team had representation from 5-6 health professions (Table 1). Given the varying sizes of the professions, pharmacy and medicine were represented in all groups, other professions did not have enough participation for uniform coverage in all 95 small groups.

Table 1: Student Participants
Health Profession / N / Year
Audiology / 10 / 1
Dental / 81 / 2
Master of Public Health / 26 / 1
Medicine / 133 / 2
Nursing / 64 / 1
Occupational Therapy / 45 / 1
Pharmacy / 127 / 2
Physical Therapy / 55 / 2
Physician Assistant / 60 / 1
Speech and Hearing / 32 / 1
Total: / 633

Readiness Assurance Test

1. According to the Institute of Medicine, optimal medical error reporting systems should:

  1. hold health care providers accountable for performance.
  2. be voluntarily implemented by care providers.
  3. analyze the information they gather and identify ways to prevent future errors from occurring.
  4. integrate into existing electronic medical records systems in a seamless manner.

2. Efforts to build an organizational culture that encourages recognizing and learning from errors would be hindered by the:

  1. intrinsic motivation of health care providers.
  2. implementation of a system that can identify and provide immediate corrective action for providers who are responsible for medical errors.
  3. actions of purchasers and consumers of medical care in demanding safety improvements.
  4. implementation of executive patient safety rounds in which organizational leaders visit clinical sites to discuss safety issues.

3. According to your reading on atrial fibrulation, management of atrial fibrillation is a challenge because:

  1. patients treated with either warfarin or dabigatran must have their coagulation monitored regularly.
  2. anticoagulants put patients at significant risk of bleeding, which may be serious and potentially life threatening.
  3. the major risk of untreated atrial fibrillation is cardiovascular disease, which may be asymptomatic.
  4. both of the treatment approaches discussed in the reading have significant risks.

4. In ‘Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care”’, Sarkar et al. describe a critical omission in the Institute of Medicine’sdefinition of patient safety. What was this omission?

  1. The exclusion of patients as active participants in their care.
  2. The indistinguishability of patient safety and quality.
  3. Failure to define errors of commission.
  4. Failing to acknowledge the role of interdisciplinary teams in providing safe care.

5. Patient safety issues encountered in hospital (acute) care settings differ from those encountered in ambulatory settings because:

  1. aggressive safety interventions have been employed with greater frequency in ambulatory settings.
  2. patients in the acute care setting must actively navigate the health care system and make critical self-care decisions more frequently than those in ambulatory settings.
  3. reporting systems are more highly developed in ambulatory settings as compared to acute settings.
  4. diagnostic delays are more prevalent in ambulatory settings as compared to acute settings.

6. Compared to individuals with a single chronic condition, patients with multiple chronic conditions may be at greater risk for medical error. A common contributory cause of this risk is that individuals with multiple chronic conditions:

A.are less likely to read patient medical information than those with a single disease.

  1. are more likely to seek care in hospitals that have a higher incidence of medical error than those with a single disease.
  2. are more likely to be less health literate than individuals with a single disease.
  3. tend to have multiple providers and transitions between them are complex.

7. A patient with no known drug allergies has an allergic reaction to a drug that is administered in an ambulatory setting. This is an example of an adverse event because it:

  1. is not due to the underlying condition of the patient.
  2. is preventable.
  3. is the same as an medical error.
  4. is ameliorable, meaning, the incident’s severity could have been reduced if different procedures has been followed.

Readiness Assurance Test - Facilitation Guide

The RAT is currently formatted for Epstein Education IF-AT form # B023.

IRAT instructions to learners: Learners will have a specific answer sheet to hand in, but remind them to mark what their answers were on the questions themselves, which they will keep. Individuals should be instructed to select the single BEST answer. At the end of the IRAT, please instruct the students to select one individual to return their answer sheets to the front of the room and place them in the manila envelope; all IRAT score sheets from the room will go in that one envelope. After that is done, the groups will begin the TRAT using the scratch-off sheet (15 minutes).

TRAT instructions to learners: The questions for the TRAT are exactly the same questions as the IRAT but are answered after discussion among the team. This is one way to introduce the scratch-offs to the students:

“Your next assignment is to discuss each question, one at a time, within your team and decide which one is the best answer. We are going to use the scratch off card to record your answer. If your team thinks A is the best answer scratch off A. If you scratch off A and find the star (sometimes it is in the middle, other times it is on the right or left) your team receives 4 points. If you do not find a star and it is blank, discuss the answers again and choose another answer. If you scratch it off and find a star your team will receive 2 points. If you do not find a star discuss again and scratch off another answer. If you find a star you will receive 1 point. If you scratch off all the answers to find the star you will receive no points. Everyone on the team gets the same score on this test. This is still a closed book test. Does anyone have any questions?” Following the TRAT, a team member must bring the TRAT answer sheet to the front of the room where it should be placed in the same single manila envelope as the IRAT scoresheets. We usually ask the teams how they scored, but there isn’t time to go into this in detail.

Questions about the correct answers should NOT be discussed in class; rather, we strongly recommend encouraging appeals. Following the collection of TRAT forms, facilitators can briefly introduce the appeals process, one way of phrasing it might be: “If you want to appeal an answer to a question, a detailed instruction sheet was given to you. The correct answers are based on the literature and readings assigned but if you feel it is incorrect after re-reading the assigned prereadings, please fill out the appeal sheet (Appendix B). Please site your source and provide evidence from the literature to support your team answer. This is a team-based appeal.”

1. According to the Institute of Medicine, medical error reporting systems should:

  1. be implemented to hold health care providers accountable for performance.
  2. be voluntarily implemented by care providers.
  3. analyze the information they gather and identify ways to prevent future errors from occurring.
  4. integrate into existing electronic medical records systems in a seamless manner.

In the IOM Executive Summary, page 7, the authors describe the manner in which medial error reporting systems can enhance our understanding of errors and factors that contribute to them. It is stated in paragraph 4 that the goal of reporting systems “is to analyze the information that they gather and identify ways to prevent future errors for occurring.” The authors are explicit that just collecting data is not enough, this data much be analyzed and resources must be brought to bear in order to address issues that are identified.

2. Efforts to build an organizational culture that encourages recognition and learning from errors would be hindered by the:

  1. intrinsic motivation of health care providers.
  2. implementation of a system that can identify and provide immediate corrective action for providers who are responsible for medical errors.
  3. actions of purchasers and consumers of medical care in demanding safety improvements.
  4. implementation of executive patient safety rounds in which organizational leaders visit clinical sites to discuss safety issues.

In the IOM Executive Summary, paragraph 3 of page 5, the authors promote that a major force for improving patient safety is the intrinsic motivation of health care providers, shaped by professional ethics, norms and expectations. But the interaction between factors in the external environment and factors inside health care organizations can also prompt the changes needed to improve patient safety. Factors in the external environment include availability of knowledge and tools to improve safety, strong and visible professional leadership, legislative and regulatory initiatives, and actions of purchasers and consumers to demand safety improvements. Factors inside health care organizations include strong leadership for safety, an organizational culture that encourages recognition and learning from errors, and an effective patient safety program.

3.According to your reading on atrial fibrulation, management of atrial fibrillation is a challenge because:

  1. patients treated with either warfarin or dabigatran must have their coagulation monitored regularly.
  2. medications used for anticoagulation cause a significant number of side effects including sudden death.
  3. the major risk of untreated atrial fibrillation is cardiovascular disease, which may be asymptomatic.
  4. both of the treatment approaches discussed in the reading have significant risks.

The answer to this question can be found in the Introduction to Atrial Fibrillation (a. fib.) document, page 1, sentences 4-8: “The treatment of a. fib. is usually one of two choices: give the patient medications that attempt to convert the a. fib. into a normal sinus rhythm, which will decrease the risk of stroke; or leave the patient in a. fib. and give them medications to control their rapid heart rate, and in addition, treat them with anticoagulation to prevent clots from forming. Neither treatment approach is ideal. The medications used to convert patients into normal rhythm can be dangerous and cause many side effects, including worsening of heart rhythms and sudden death; anticoagulation requires monitoring of the blood on a regular basis and requires very careful attention to adherence to the prescribed medication, which traditionally has been Warfarin.

4. In “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care”, Sarkar et al. describe a critical omission in the Institute of Medicine’sdefinition of patient safety. What was this omission?

  1. The exclusion of patients as active participants in their care.
  2. The indistinguishability of patient safety and quality.
  3. Failure to define errors of commission.
  4. Failing to acknowledge the role of interdisciplinary teams in providing safe care.

In the “Refocusing the Lens: Patient safety in Ambulatory Chronic Disease Care” article, page 377, column 2, sentence 3 specifically states that the IOM definition of patient safety does not explicitly include patients as active participants in their care. Many argue that in the context of ambulatory care of chronic diseases, highlighting the patient’s central role in safe care is imperative.