Gerontology & Geriatrics Education, 36:45–57, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2014.966903
A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students SARA M. BRADLEY Brookdale Department of Geriatrics & Palliative Medicine; and Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
DENNIS CHANG Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
ROBERT FALLAR Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
REENA KARANI Brookdale Department of Geriatrics & Palliative Medicine; Samuel Bronfman Department of Medicine; and Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement Address correspondence to Sara M. Bradley, Brookdale Department of Geriatrics & Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1070, New York, NY 10029, USA. E-mail: [email protected] 45
46
S. M. Bradley et al.
a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete. KEYWORDS geriatrics education, patient safety, transitions of care
INTRODUCTION Every year, a significant number of patients are harmed due to health care (Agency for Healthcare Research and Quality, 2012). Older adults represent 13% of the population but account for 40% of acute care hospitalizations (Centers for Disease Control and Prevention, 2013). The elderly also have longer lengths of stay in hospitals and are more likely to experience multiple transitions of care posthospitalization with up to 30% of Medicare beneficiaries having two or more transitions (Coleman, Min, Chomiak, & Kramer, 2004). Given that older adults spend more time in the hospital and in transitional care, they are consequently the most vulnerable to adverse events while hospitalized and after discharge (Thomas & Brennan, 2000). Research shows that almost 20% of all hospitalized patients experience an adverse event after discharge, most commonly related to medications, but also due to poor follow-up of tests or appointments in periods of transition (Forster, Murff, Peterson, Gandhi, & Bates, 2003). Many of these adverse events result from breakdowns in communication, including providers’ failure to recognize low health literacy (Kripalani et al., 2010). The Association of American Medical Colleges (AAMC), The National Patient Safety Foundation, and other organizations have recognized patient safety and transitions of care as key components of high-quality patient care and noted that there is an unmet need for medical education in these areas (National Patient Safety Foundation, 2010). In the 2006 Clerkship Directors in Internal Medicine Survey, only 25% of respondents reported their school had explicit patient safety curricula (Alper, Rosenberg, O’Brien, Fischer, & Durning, 2009). In another survey conducted in 2010, 72% of medical school deans reported that their curriculum included teaching about health literacy, but that the majority of such teaching occurred in the first 2 years and not in the context of real clinical encounters with patients (C. A. Coleman & Appy, 2012). Additionally, although communicating key components of a safe discharge plan is one of the AAMC Geriatric Competencies for medical students, most geriatric medicine education interventions traditionally have focused on teaching about geriatrics syndromes rather than issues of patient safety, transitions of care, and health literacy that particularly affect the elderly (Leipzig et al., 2009).
A Patient Safety and Transitions Curriculum
47
A systematic review of quality improvement (QI) and patient safety training found that most curricula focused on internal medicine and family medicine residents rather than medical students (Wong, Etchells, Kuper, Levinson, & Shojania, 2010). Moskowitz, Veloski, Fields, and Nash’s (2007) one-day interclerkship program for 3rd-year medical students on medical errors and patient safety demonstrated improvement in learner attitudes and knowledge. Henley (2002) developed a weekly QI curriculum for 30 thirdyear medical students on a family medicine clerkship that students felt was moderately effective and useful. However these curricula were not focused on QI and patient safety as these relate to older adults or within a geriatric medicine rotation. Similarly, most educational initiatives about care transitions have focused on teaching residents rather than medical students. Ouchida, LoFaso, Capello, Ramsaroop, and Reid (2009) developed Fast Forward Rounds, a multimodal educational intervention for medical students that increased knowledge, confidence, and self-reported behaviors surrounding discharge planning and care transitions. Postdischarge visits are another innovative approach to teach these topics. Bray-Hall, Schmidt, and Aagaard’s (2010) Transitions in Care Curriculum (TICC) for 3rd-year medical students and Lai, Nye, Bookwalter, Kwan, and Hauer’s (2008) postdischarge followup visits for medicine and pharmacy students included experiential learning through a patient visit after hospitalization in addition to traditional didactic sessions. This approach resulted in improved student knowledge, attitudes, and confidence in skills in transitions of care (Bray-Hall et al., 2010; Lai et al., 2008). However these previously published curricula did not include specific instruction on patient safety and health literacy that are crucial for preventing adverse events during care transitions. This study describes a clinically relevant curriculum on patient safety and transitions of care for 3rd-year medical students during an Integrated Internal Medicine-Geriatrics Clerkship (IMGC). The curriculum includes a postdischarge visit to a patient the student cared for in the hospital following interactive didactic sessions on the core principles of these important topics and an opportunity to debrief and reflect following the patient visit. The specific objectives of this study are to evaluate the effectiveness of the curriculum on students’ knowledge, skills, and attitudes about patient safety and transitions of care and to identify the barriers to implementing a curriculum that includes a postdischarge visit for all students.
METHOD Participants and Setting Participants were all 3rd-year medical students at an urban medical school enrolled in the IMGC during the 2012 to 2013 and 2013 to 2014 academic
48
S. M. Bradley et al.
years. The IMGC is a 12-week clerkship broken into three sections that include 4 weeks of inpatient medicine at a quaternary hospital, 4 weeks of inpatient medicine at a community hospital, and 4 weeks of geriatric medicine. The geriatric medicine section includes 2 weeks in a hospitalbased ambulatory geriatrics practice, one week of palliative medicine, and one week with a home visits program. Approximately 36 to 39 students rotate on the clerkship at a time with 12 to 13 students on each section. This study was registered with the Grants and Contracts Office of (blinded) and determined exempt from Institutional Review Board (IRB) review. Students were informed this was a research study to evaluate the patient safety and transitions of care curriculum that has been added to the IMGC. They were told participation (completion of pre and posttest and the evaluation of the curriculum) was voluntary however, attendance to all didactic sessions and completion of assignments was mandatory.
Curriculum Description The curriculum includes didactics covering an introduction to patient safety, health literacy, and discharge planning and transitions of care. Two 60minute interactive didactic sessions occur on the first day of orientation to the entire clerkship along with a traditional geriatrics discussion session on the hazards of hospitalization. A third 60-minute case-based discussion occurs during the inpatient medicine month at the quaternary care hospital. The Patient Safety didactic session is based on content from the World Health Organization (WHO) Patient Safety Curriculum Guide and uses practical case examples (Walton et al., 2010). Topics covered include a summary of the harms caused by health care errors, review of common terms used in patient safety literature, description of situations with increased risk of errors and individual factors that contribute, strategies to learn from errors and reduce their occurrence, and specific factors contributing to medication errors. The curriculum for the Health Literacy session is based on the health literacy educational toolkit developed by the American Medical Association Foundation (2007) and includes a video trigger tape of real patient experiences . Topic covered include a definition of health literacy and associated adverse health outcomes, red flags suggesting limited literacy, validated questions to screen for low health literacy, and demonstration of communication techniques. Content for the discharge planning session was drawn from published literature and the Society for Hospital Medicine’s (n.d.). Better Outcomes for Older adults through Safe Transitions (BOOST) program. Topics covered include a discussion of adverse events that occur at discharge and during transition, the importance of a high-quality discharge and its components, and review of a discharge discussion checklist.
A Patient Safety and Transitions Curriculum
49
The curriculum also includes a formal postdischarge visit made by the students to a patient they cared for during their inpatient medicine month at the quaternary care hospital. Guidelines for the visit are reviewed with students at orientation including strict safety instructions to go during daylight hours, carry all contact numbers, and notify clerkship directors before and after the visit. Students also go in pairs to see one another’s patient and never alone. Students are expected to visit their patient at home or in a nursing home or rehabilitation setting as long as it is within one hour of travel time and are encouraged to choose to visit patients older than age 65 whenever possible. The visit occurs during the geriatrics month that immediately follows the inpatient month at the quaternary hospital. Students having inpatient at the quaternary hospital in the last section go on the postdischarge visit during the same month. Students are given a template of questions to review with the patient during the visit that focuses on the patient’s understanding of the reason for hospitalization, medications, follow-up appointments or tests, and home care services. Students are also asked to write answers to three reflection questions after the visit. The visits and answers to the questions are reviewed at a 60-minute group debriefing session after the postdischarge visits attended by the 12 to 13 students in the section and led by the clerkship directors.
Program Evaluation Participants completed pre- and postintervention assessments of knowledge, skills, and attitudes, and an evaluation of their satisfaction with the curriculum. The preintervention assessment was completed at clerkship orientation, and the postintervention assessment and evaluation of the curriculum were completed after the postdischarge visit debriefing session. The 18-item assessment included 10 questions about attitudes and confidence in skills rated using a 5-item Likert-type scale (strongly disagree to strongly agree) and eight multiple-choice knowledge questions. Five questions about attitudes toward patient safety, errors, and disclosure were from the validated Attitudes to Patient Safety Questionnaire (APSQ) developed by Carruthers, Lawton, Sandars, Howe, and Perry (2009). Five questions about confidence in skills were similar to those used in previously published studies of such curricula (Bray-Hall et al., 2010; Carruthers et al., 2009; Lai et al., 2008; Ouchida et al., 2009). Please see Table 1 for individual questions about attitudes and confidence. The eight multiple-choice knowledge questions were developed by the authors from material covered in the interactive didactic sessions. Please see Table 2 for individual knowledge questions. The curriculum evaluation included a rating of each didactic session and activity on a 5-point scale (poor to excellent) and seven other questions
50
S. M. Bradley et al.
TABLE 1 Comparison of Attitudes and Confidence in Pre- and Postassessment Question: Please assess the following statements using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) Learning about patient safety should be an important priority of medical school curricula. Even the most experienced doctors make errors. It is only necessary to report errors which result in adverse outcomes for the patient.a I would feel comfortable reporting any errors I had made, no matter how serious the outcome had been for the patient. I would feel comfortable reporting any errors other people had made, no matter how serious the outcome had been for the patient. I feel comfortable assessing a patient’s health literacy. I am confident in my ability to perform an accurate medication reconciliation. I am confident in my ability to provide the patient and/or caregiver education regarding medication and side effects. I can identify important barriers patients face when transitioning from the inpatient setting. I can identify several topics to review at a follow up visit to confirm a safe transition from the inpatient setting. a
Answered agree or strongly agree Pre # (%) N = 252
Post # (%) N = 265
p Value
239 (94.8)
252 (95.1)
0.8953
250 (99.2)
264 (99.6)
0.5333
215 (85.3)
237 (89.4)
0.1582
115 (45.6)
135 (50.9)
0.2273
58 (23.0)
95 (35.8)
0.0014
111 (44.0)
210 (79.2)
A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students SARA M. BRADLEY Brookdale Department of Geriatrics & Palliative Medicine; and Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
DENNIS CHANG Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
ROBERT FALLAR Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
REENA KARANI Brookdale Department of Geriatrics & Palliative Medicine; Samuel Bronfman Department of Medicine; and Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement Address correspondence to Sara M. Bradley, Brookdale Department of Geriatrics & Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1070, New York, NY 10029, USA. E-mail: [email protected] 45
46
S. M. Bradley et al.
a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete. KEYWORDS geriatrics education, patient safety, transitions of care
INTRODUCTION Every year, a significant number of patients are harmed due to health care (Agency for Healthcare Research and Quality, 2012). Older adults represent 13% of the population but account for 40% of acute care hospitalizations (Centers for Disease Control and Prevention, 2013). The elderly also have longer lengths of stay in hospitals and are more likely to experience multiple transitions of care posthospitalization with up to 30% of Medicare beneficiaries having two or more transitions (Coleman, Min, Chomiak, & Kramer, 2004). Given that older adults spend more time in the hospital and in transitional care, they are consequently the most vulnerable to adverse events while hospitalized and after discharge (Thomas & Brennan, 2000). Research shows that almost 20% of all hospitalized patients experience an adverse event after discharge, most commonly related to medications, but also due to poor follow-up of tests or appointments in periods of transition (Forster, Murff, Peterson, Gandhi, & Bates, 2003). Many of these adverse events result from breakdowns in communication, including providers’ failure to recognize low health literacy (Kripalani et al., 2010). The Association of American Medical Colleges (AAMC), The National Patient Safety Foundation, and other organizations have recognized patient safety and transitions of care as key components of high-quality patient care and noted that there is an unmet need for medical education in these areas (National Patient Safety Foundation, 2010). In the 2006 Clerkship Directors in Internal Medicine Survey, only 25% of respondents reported their school had explicit patient safety curricula (Alper, Rosenberg, O’Brien, Fischer, & Durning, 2009). In another survey conducted in 2010, 72% of medical school deans reported that their curriculum included teaching about health literacy, but that the majority of such teaching occurred in the first 2 years and not in the context of real clinical encounters with patients (C. A. Coleman & Appy, 2012). Additionally, although communicating key components of a safe discharge plan is one of the AAMC Geriatric Competencies for medical students, most geriatric medicine education interventions traditionally have focused on teaching about geriatrics syndromes rather than issues of patient safety, transitions of care, and health literacy that particularly affect the elderly (Leipzig et al., 2009).
A Patient Safety and Transitions Curriculum
47
A systematic review of quality improvement (QI) and patient safety training found that most curricula focused on internal medicine and family medicine residents rather than medical students (Wong, Etchells, Kuper, Levinson, & Shojania, 2010). Moskowitz, Veloski, Fields, and Nash’s (2007) one-day interclerkship program for 3rd-year medical students on medical errors and patient safety demonstrated improvement in learner attitudes and knowledge. Henley (2002) developed a weekly QI curriculum for 30 thirdyear medical students on a family medicine clerkship that students felt was moderately effective and useful. However these curricula were not focused on QI and patient safety as these relate to older adults or within a geriatric medicine rotation. Similarly, most educational initiatives about care transitions have focused on teaching residents rather than medical students. Ouchida, LoFaso, Capello, Ramsaroop, and Reid (2009) developed Fast Forward Rounds, a multimodal educational intervention for medical students that increased knowledge, confidence, and self-reported behaviors surrounding discharge planning and care transitions. Postdischarge visits are another innovative approach to teach these topics. Bray-Hall, Schmidt, and Aagaard’s (2010) Transitions in Care Curriculum (TICC) for 3rd-year medical students and Lai, Nye, Bookwalter, Kwan, and Hauer’s (2008) postdischarge followup visits for medicine and pharmacy students included experiential learning through a patient visit after hospitalization in addition to traditional didactic sessions. This approach resulted in improved student knowledge, attitudes, and confidence in skills in transitions of care (Bray-Hall et al., 2010; Lai et al., 2008). However these previously published curricula did not include specific instruction on patient safety and health literacy that are crucial for preventing adverse events during care transitions. This study describes a clinically relevant curriculum on patient safety and transitions of care for 3rd-year medical students during an Integrated Internal Medicine-Geriatrics Clerkship (IMGC). The curriculum includes a postdischarge visit to a patient the student cared for in the hospital following interactive didactic sessions on the core principles of these important topics and an opportunity to debrief and reflect following the patient visit. The specific objectives of this study are to evaluate the effectiveness of the curriculum on students’ knowledge, skills, and attitudes about patient safety and transitions of care and to identify the barriers to implementing a curriculum that includes a postdischarge visit for all students.
METHOD Participants and Setting Participants were all 3rd-year medical students at an urban medical school enrolled in the IMGC during the 2012 to 2013 and 2013 to 2014 academic
48
S. M. Bradley et al.
years. The IMGC is a 12-week clerkship broken into three sections that include 4 weeks of inpatient medicine at a quaternary hospital, 4 weeks of inpatient medicine at a community hospital, and 4 weeks of geriatric medicine. The geriatric medicine section includes 2 weeks in a hospitalbased ambulatory geriatrics practice, one week of palliative medicine, and one week with a home visits program. Approximately 36 to 39 students rotate on the clerkship at a time with 12 to 13 students on each section. This study was registered with the Grants and Contracts Office of (blinded) and determined exempt from Institutional Review Board (IRB) review. Students were informed this was a research study to evaluate the patient safety and transitions of care curriculum that has been added to the IMGC. They were told participation (completion of pre and posttest and the evaluation of the curriculum) was voluntary however, attendance to all didactic sessions and completion of assignments was mandatory.
Curriculum Description The curriculum includes didactics covering an introduction to patient safety, health literacy, and discharge planning and transitions of care. Two 60minute interactive didactic sessions occur on the first day of orientation to the entire clerkship along with a traditional geriatrics discussion session on the hazards of hospitalization. A third 60-minute case-based discussion occurs during the inpatient medicine month at the quaternary care hospital. The Patient Safety didactic session is based on content from the World Health Organization (WHO) Patient Safety Curriculum Guide and uses practical case examples (Walton et al., 2010). Topics covered include a summary of the harms caused by health care errors, review of common terms used in patient safety literature, description of situations with increased risk of errors and individual factors that contribute, strategies to learn from errors and reduce their occurrence, and specific factors contributing to medication errors. The curriculum for the Health Literacy session is based on the health literacy educational toolkit developed by the American Medical Association Foundation (2007) and includes a video trigger tape of real patient experiences . Topic covered include a definition of health literacy and associated adverse health outcomes, red flags suggesting limited literacy, validated questions to screen for low health literacy, and demonstration of communication techniques. Content for the discharge planning session was drawn from published literature and the Society for Hospital Medicine’s (n.d.). Better Outcomes for Older adults through Safe Transitions (BOOST) program. Topics covered include a discussion of adverse events that occur at discharge and during transition, the importance of a high-quality discharge and its components, and review of a discharge discussion checklist.
A Patient Safety and Transitions Curriculum
49
The curriculum also includes a formal postdischarge visit made by the students to a patient they cared for during their inpatient medicine month at the quaternary care hospital. Guidelines for the visit are reviewed with students at orientation including strict safety instructions to go during daylight hours, carry all contact numbers, and notify clerkship directors before and after the visit. Students also go in pairs to see one another’s patient and never alone. Students are expected to visit their patient at home or in a nursing home or rehabilitation setting as long as it is within one hour of travel time and are encouraged to choose to visit patients older than age 65 whenever possible. The visit occurs during the geriatrics month that immediately follows the inpatient month at the quaternary hospital. Students having inpatient at the quaternary hospital in the last section go on the postdischarge visit during the same month. Students are given a template of questions to review with the patient during the visit that focuses on the patient’s understanding of the reason for hospitalization, medications, follow-up appointments or tests, and home care services. Students are also asked to write answers to three reflection questions after the visit. The visits and answers to the questions are reviewed at a 60-minute group debriefing session after the postdischarge visits attended by the 12 to 13 students in the section and led by the clerkship directors.
Program Evaluation Participants completed pre- and postintervention assessments of knowledge, skills, and attitudes, and an evaluation of their satisfaction with the curriculum. The preintervention assessment was completed at clerkship orientation, and the postintervention assessment and evaluation of the curriculum were completed after the postdischarge visit debriefing session. The 18-item assessment included 10 questions about attitudes and confidence in skills rated using a 5-item Likert-type scale (strongly disagree to strongly agree) and eight multiple-choice knowledge questions. Five questions about attitudes toward patient safety, errors, and disclosure were from the validated Attitudes to Patient Safety Questionnaire (APSQ) developed by Carruthers, Lawton, Sandars, Howe, and Perry (2009). Five questions about confidence in skills were similar to those used in previously published studies of such curricula (Bray-Hall et al., 2010; Carruthers et al., 2009; Lai et al., 2008; Ouchida et al., 2009). Please see Table 1 for individual questions about attitudes and confidence. The eight multiple-choice knowledge questions were developed by the authors from material covered in the interactive didactic sessions. Please see Table 2 for individual knowledge questions. The curriculum evaluation included a rating of each didactic session and activity on a 5-point scale (poor to excellent) and seven other questions
50
S. M. Bradley et al.
TABLE 1 Comparison of Attitudes and Confidence in Pre- and Postassessment Question: Please assess the following statements using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) Learning about patient safety should be an important priority of medical school curricula. Even the most experienced doctors make errors. It is only necessary to report errors which result in adverse outcomes for the patient.a I would feel comfortable reporting any errors I had made, no matter how serious the outcome had been for the patient. I would feel comfortable reporting any errors other people had made, no matter how serious the outcome had been for the patient. I feel comfortable assessing a patient’s health literacy. I am confident in my ability to perform an accurate medication reconciliation. I am confident in my ability to provide the patient and/or caregiver education regarding medication and side effects. I can identify important barriers patients face when transitioning from the inpatient setting. I can identify several topics to review at a follow up visit to confirm a safe transition from the inpatient setting. a
Answered agree or strongly agree Pre # (%) N = 252
Post # (%) N = 265
p Value
239 (94.8)
252 (95.1)
0.8953
250 (99.2)
264 (99.6)
0.5333
215 (85.3)
237 (89.4)
0.1582
115 (45.6)
135 (50.9)
0.2273
58 (23.0)
95 (35.8)
0.0014
111 (44.0)
210 (79.2)
