Managing patients’ risk for injury while they are receiving care in healthcare organizations is a national priority in the U.S. While this has been true for at least five years - ever since the National Academy of Sciences’ Institute of Medicine (IOM) reported that medical errors were the 4th to 8th largest cause of preventable death - not much progress has been made preventing them.
The difficulty is that large gaps exist between what should be happening to train medical team members in patient safety in their healthcare environments and what actually is. In a February 2005 meeting, prominent patient safety leaders met as the Governing Council for the Patient Safety Education Project to discuss two of these gaps. First, while high quality patient safety curricular materials have been produced by a variety of key, highly regarded organizations, no consensus currently exists about what a general curriculum for the field of patient safety should be in the U.S. Second, huge numbers of various professional and paraprofessional medical team members have not been trained in the basics of safety science, high reliability engineering, or patient-centered care, so clearly, a strong need for such training exists.
To craft a comprehensive, end-learner friendly, high quality, patient safety curriculum, the Patient Safety Education Project (PSEP) has adapted curricular material and resources from Australia’s National Patient Safety Education Project (also called the Australian Framework). Funded by the Australian Council for Safety and Quality in Health Care and using a nationally coordinated, collaborated approach, this project has identified skills, knowledge and behaviors/attitudes in a framework to guide patient safety education for healthcare workers at all levels within healthcare in Australia. Co-principals Merrilyn Walton, PhD, and Tim Shaw, PhD, from the Centre for Innovation in Professional Health Education and Research at the University of Sydney were instrumental in this phase of the development.
The second prime element of PSEP relates to the Education in Palliative and End-of-life Care project (EPEC), begun in 1997, which uses a curriculum-driven approach grounded in adult learning methodology to teach content about palliative and end-of-life care to physicians and other medical team members. Another EPEC focus is to teach the best adult teaching methodologies and practices to course attendees so that they can return to their home institutions and teach others what they have learned. Extensive resources are provided for these teachers. Using them, they may easily adapt the materials to what best suits their end-learners’ needs and particular organization’s work culture. PSEP uses train-the-trainer conferences, various Web-based interactions, such as distance learning modules, email, and listserv announcements to foster an interactive Patient Safety Virtual College (PSVC).
Critical to the success of this initiative is the buy-in of important patient safety leaders. Therefore, the Governing Council for PSEP is a who’s who of internationally known thought-leaders in patient safety including such luminaries as: Harvey Fineberg, MD, President, Institute of Medicine; Lucian Leape, MD, MPH, Harvard School of Public Health; and Donald Berwick, Institute for Healthcare Improvement. With input from an Advisory Group, a high-level team of editors and writers have built the curriculum.
Using the above-described Australian Framework, EPEC approaches to adult learning and dissemination, and other specially selected, high-quality curricular materials, PSEP has built a strong patient safety curriculum, which it seeks to widely disseminate and evaluate using controlled trials. Our initial 'Become a Patient Safety Trainer' (BPST) Conference in Pittsburgh in May 2008 trained mixed groups of administrative and clinical teams from Pittsburgh hospitals, as well as international participants.
The BPST Conferences are 2½ day immersion conferences that teach both patient safety content areas and the techniques on teaching others using the PSEP Curriculum. Conferences run from Friday morning to Sunday midday, allowing busy professionals to take only one day out from the working week and still be home within the weekend. Participants are encouraged to come in teams from their institution, including at a minimum one doctor, one nurse and one administrator. There is also a half-day executive track on the last day for those institutions that have their chief executive officers (CEOs) and/or chief medical officers (CMOs) attend.
PSEP has been funded by the California Healthcare Foundation, Commonwealth Fund, Zell Center for Risk Research, Jewish Healthcare Foundation and the Health Research and Educational Trust and is a not-for-profit entity. We have developed a strategy to allow PSEP to be self-sufficient based on a partnership and registration revenue model that provides training for partner institutions and for individuals on a cost-recovery basis.