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"Culture can feel like fog. You can’t really touch it, but you know it’s there."
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Learning Patient Safety Culture: Turning Fog to Concrete

By IHI Team | Thursday, September 8, 2022
Learning Patient Safety Culture Turning Fog to Concrete Photo by Haneen Krimly | Unsplash

The situation could have been a disaster. In a hospital emergency department in Texas, a fourth-year medical student was suturing up a patient’s hand. When he finished the stitches, he realized that he had forgotten to adequately irrigate the wound. Optimal irrigation helps to clean the wound and boosts healing, and skipping this crucial step leaves the injury susceptible to developing an infection.

Once he realized his error, the student excused himself from the patient and found the attending physician. He said, “I just sutured up an unclean wound. I need to reopen the wound, clean it, and re-suture it. I also need to explain what happened to the patient and family and apologize.”

The attending physician was so impressed that he later called Dr. Frank Filipetto, the dean of the student’s school, the University of North Texas Health Science Center (HSC) at Fort Worth’s Texas College of Osteopathic Medicine (TCOM), and said, “Whatever you’re doing at TCOM, keep it up. You are producing great patient safety providers.”

What is TCOM doing to encourage such humility and dedication to preventing patient harm? For one, they are offering a patient safety course specifically designed to prepare medical students to sit for the Certified Professional in Patient SafetyTM credential (CPPS) exam, the first school in the United States to do so. The student who admitted and apologized for his error had taken the CPPS patient safety course in his third year at TCOM.

“Medical students can be timid,” said Lillee Gelinas, DNP, RN, CPPS, FAAN, Assistant Professor & Patient Safety Section Director at TCOM. “They often don’t want to rattle the cage or appear to be contrarians.” For Gelinas, these tendencies make teaching about a culture of safety so important in medical school. “Think about the courage it took for him to admit that he had not provided the best and safest care,” she explained. “That is psychological safety in action.”

In 2018, inspired by students who were interested in earning the CPPS credential, Gelinas and her colleagues started working with IHI to create the certification prep course. Almost four years later, over 500 third- and fourth-year TCOM medical students and residents have earned the CPPS credential. In the following interview, Gelinas describes the importance of prioritizing a thorough understanding of patient safety in medical education.

On the process to develop the patient safety course

I was at the IHI National Forum in December of 2018 with five students from HSC who had received scholarships to attend the Forum and present their safety posters. The students saw the CPPS certification material at the IHI booth and said, “We need to know about patient safety. Can we sit for the exam?” At the time the answer, of course, was no. We had a conversation with [IHI Vice President] Patricia McGaffigan and [former IHI Vice President] Frank Federico. Patricia said, “Make us a proposal. Tell us what you would like us to do.”

By the summer of 2019, using the Model for Improvement, we worked with IHI to develop a pilot with 10 medical students. We had a curriculum that used the CPPS review course, and we supplemented it with content about the science of safety. Of the 10 medical students, nine passed the certification exam the first time. We knew we were onto something. We used the learnings from that first PDSA cycle to create a faculty development course. We had four PDSA cycles between December 2018 and the full implementation of this curriculum in July of 2020. It’s now a mandatory course for all third-year medical students, and we have 26 TCOM faculty and clerkship directors who are all CPPS-certified.

On the challenges of reforming medical school education

We had what we needed to develop the course. The roadmap was outlined in the Lucian Leape Institute report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care.  In addition, we used the CPPS review course, the IHI Patient Safety Essentials Toolkit and the IHI Quality Improvement Essentials Toolkit. It was like Santa Claus had arrived. We utilized these materials in a rigorous academic way to get the approvals of TCOM’s curriculum committee and the university. The hardest part was getting buy-in from other faculty and buy-in from students because this course was so new. In the end, there was tremendous acceptance of such innovative curriculum to reform medical education and improve patient care.

Leadership support has been essential. At HSC, our chancellor and president at the time we started the course, Dr. Michael Williams, is a huge supporter. Dr. Filipetto, TCOM dean, is CPPS-certified, and the chair of the Department of Medical Education and Health Systems Science, Dr. Albert Yurvati, is CPPS-certified. They took the course and sat for the exam to understand what the students were going to experience. That’s leadership.

On the benefits of the specialized patient safety course for medical students

In addition to helping them to be changemakers for better patient care in the future, achieving the CPPS credential and having the patient safety course on their transcript gives our students great talking points. According to those who have been matched to their preferred residency program, that’s all the directors wanted to talk about during their residency interviews. One of our residents shared that, on the very first day of orientation, the chief medical officer recognized the CPPS pin he was wearing on his lab coat, walked up to him and said, “I know what that is. I know what knowledge you have. Please join our Patient Safety and Quality Committee.”

On the importance of learning practical culture of safety skills

What they learn about culture is one of the things students say they value the most about the course. Culture can feel like fog. You can’t really touch it, but you know it’s there. They learn to turn fog into concrete. Culture becomes a concrete concept for them because we not only teach about a culture of reporting and a culture of safety, but we teach how to apply these concepts. We use activities, exercises, and simulations because it’s one thing to read a lesson or see a video about it, but it’s another thing to practice talking about something tough to disclose.

On what’s next

At TCOM, patient safety is a focus in all four years. We’re currently developing safety curriculum for years one and two so that, by the time they come into the third-year course, they’ve been exposed to, for instance, the IHI Open School Patient Safety 101 course. This way, they will have foundations on which to build so that their learning in the third year is not so cognitively dense. All fourth-year students will be required to earn the IHI Basic Certificate in Quality and Safety by completing the 13 courses required to achieve it. And I want to create either electives or courses in their fourth year that allow them to apply more of what they learned in their third year.

Working with IHI, we want to spread this important and innovative curriculum. We are seeing clinical excellence break out everywhere our students are going. We are in conversations with some medical schools and other health professions schools that are interested. That’s why we’re trying to develop the spread methodology because you can’t just plug and play exactly what we did with our curriculum. Each medical school will have to devise a timeline and the curriculum changes that are right for them. But we’re hoping to create a playbook or facilitator’s guide so that others can learn from our journey. We want to shorten the four years it took us — the three development years and then the fourth year of implementation — so others can approach teaching safer care in the way we did more quickly. I remember I was at an IHI meeting and Dr. Bob Waller from the Mayo Clinic at the time said, “We want the best care for every patient, every day. Our patients deserve nothing less.” At the end of the day, the faster we can spread this course, the better for everyone in the health care system and the communities around them.

Editor’s note: This interview has been edited for length and clarity.

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