Education's Role in Quality and Patient Safety

Podcast Transcript

Dr. Jamie Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education, and amplifies the tremendous work of our educators across the enterprise.

Dr. Steven Kawczak:

Hello, welcome to today's episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. I'm your host, Dr. Steven Kawczak Co-Medical Director of the Center for Continuing Education here in beautiful Cleveland Ohio. And today, I'm very pleased to have Doctor Eduardo Mireles, Director of the Medical Intensive Care Unit, and Medical Director of the Simulation and Advanced Skills Center, as well as Doctor Cecile Foshee, Co-Chair of the Office of Interprofessional Learning, and Director of the Master of Education in Health Professions education program, here to join us. I welcome you both to the podcast.

Dr. Eduardo Mireles:

Thank you.

Dr. Cecile Foshee:

Thank you.

Dr. Steven Kawczak:

So, first, Eduardo, what role does education play, at Cleveland Clinic, in advancing quality and patient safety in healthcare?

Dr. Eduardo Mireles:

Thank you, Steven. I would say it's essential. It's a key part of what we do every day. When you sent us the questions, you made me think about stories that actually have told us of how this gets implemented. And I would start with a couple of them that will put them into framework of how we use education here at the clinic. I think that they will highlight where we're going.

The first one is related to intubation. So, this is a critical part of how we take care of our patients in the ICU, and years ago, around a decade ago, we had a protocol that was very old, and a group of our physicians joined to discuss that we were not doing things at the quality level that we wanted. So, this interprofessional sat, designed, redesigned the whole process, and we started training our fellows, instead of training actually the staff, we started with the fellows which were the ones that were doing the implementation. And this led rapidly to a change in how we were implementing intubation in the ICU, but more interestingly is that it changed the way that our staff were intubating, because suddenly, they saw that there was a different way that was being implemented, and instead of having to start from the top, trying to change everything on the bottom, we started from the bottom and changed up, and now everybody does the same way, which was major. Actually, when people leave the ICU, and they go work elsewhere, they usually ask us for extra copies of our protocol, because it's so meaningful for them, because it changes the spirit in the room. So, that is one in which was actually implemented, went, used simulation, and trained everybody.

The second one is a little bit different, and talks about, how the daily education that we do. So, years ago also, there was a change in the way that we resuscitate patients, and they told us, "Well, there seems to be a signal that if you use this other type of solution of IV fluid, patients may have worse outcomes." And there was a couple of publications that were strong enough, and we did a couple of journal clubs, and then we invited the author of that article in one of our major meetings to just talk to us. That's it. Then we measured the change of how we were resuscitating our patients, we just went and saw the change on administration of that solution, and without any operational dictum, or having people do it, and auditing, we went from using that solution 20 percent of the time, to using it 80 percent of the time, just by those types of education that happen. So, that's how you implement education to achieve change, and if you don't continue to do that, it will not happen without education. So, I think that of, when you ask me what's the role, I think it's essential, and that these two examples highlight that.

Dr. Steven Kawczak:

Oh, thank you. Those are, those are great examples that showcase how education shaped and created the change that you desired. I appreciate that. So, next, let's turn to Cecile. Cecile, could you elaborate on how interprofessional learning helps impact quality in patient safety, and perhaps share an example of how you've applied that?

Dr. Cecile Foshee:

Yeah, of course. So, I'm happy to be here with Eduardo, who is our co-creator for the example I'm going to give you. So, we have a program in the MICU that is called SMILE, and SMILE stands for strengthening minds by leveraging education. And this is not necessarily a quality in patient safety, curriculum, but it is something around learning how to work with one another, how to be better at coordinating each other's roles and responsibilities, and so I think that is really linked directly to quality and safety, and, you know, minimizing errors.

So, this program kind of was born late 2018, Eduardo and I just started working together, and we were involved in many different professions, and the program kind of evolved over time. But really, we started out with very basic things, we even did a focus group, remember that? We did a focus group, and we invited residents, we invited nurses and fellows, and, I think PAs, and pharmacists, I think were part of the focus group. It's been a while; I don't remember exactly who participated. But it was interesting that the one thing everybody was really fussy about was roles and responsibilities, right?

People assume that everybody knows what everybody does, and so, a huge component of SMILE was exactly that, just making sure we're bringing awareness around what people do, and being more explicit about what everybody is responsible for, and then we get comments from people talking about how they're going to be more intentional about eliciting people's roles, and how that alone improves the quality of the care that they do. Then over time, we kind of expanded the curriculum to be more include also psychological safety, which is, you know, more around speaking up, and, you know, making sure that people feel comfortable enough to voice their opinions.

Then we added another component, which is actually, I really like that one, remember the Day in the Life of? And that one was really around developing a sense of empathy for other professions, right? So, when people know about their roles, that's one piece, but also understanding how busy everybody else is, right, and how much everybody's pulled in different directions, and all of those pieces, when you are aware, there was this one comment from someone that said, "I will actually go out of my way to check in with the person and ask them how is their day going, and what can I do to make it better." Those things seem unrelated to quality, but I think, you know, they're just linked, right, you can't have one without the other.

Then we did our final piece that we did for that curriculum was adding a teaming component, which more around the efficiency, you know, the clear communication, doing huddles and briefs and things of that sort. So, it's been a great experience, it has been, you know, it has evolved, like I said, through the years, and it wouldn't have happened without Eduardo's support, and champion.

Dr. Eduardo Mireles:

I would add to, the SMILE program, it started in 2018, and we went for actually practically uninterrupted. It's half an hour every week, and we were training a lot of providers. By that time, I think by the time that COVID hit us in 2020, we had trained probably around 600, 700 providers. And I would say, from my standpoint, we would not have had the response, and the dynamics within the team if we had not created that, because it opened a lot of channels to highlight that, even though the topic was not essentially quality and safety, it talked about how the team actually behaved, and that it fosters quality and safety.

Dr. Steven Kawczak:

Oh, thank you Cecil, and Eduardo. Yeah, I think you're underscoring that healthcare's a team sport in all aspects, and as educators, we need to be creative in how we're going to consider interprofessional teamwork in ways that we can bring those teams together, and teach them to perform better. And, that's wonderful outcomes that you've had, that you've been able to teach over 600 caregivers to, know what they do, and to work better together, and that's led to improvements in quality of care and more safe care, which is the goal that we're all after.

So, question for both of you, what challenges do you face when you want to create an implement educational activity that deal with quality and safety?

Dr. Cecile Foshee:

We're laughing, right? Time is the biggest barrier, you know, logistics. Um, so for example, in that SMILE program, we require that four professions are present, not four people, four professions represented, right? So that if you're trying to create something that's interprofessional, you can't have just the residents, and you can't have just the nurses, right? You need to be able to hear everyone's voices. And, you know, making sure that you pick a day that is good for everybody, or a time that is good for everybody. And it's not just the participants, it's also the facilitators right, even though it's only a half an hour, it's every week, which, you know, speaks actually to the commitment that Eduardo has made to the program to be able to pull people away from their clinical duties for half an hour. But it's a logistical nightmare. It really is, right?

Dr. Eduardo Mireles:

Yeah. Absolutely. The other challenge I would say is identifying the best practices. It's very easy to be reactive to an event, but really sitting down with the quality and the safety team, and the clinical team, and figuring out what do you want to teach, and what is going to be what you want them to retain? And that requires some knowledge on educational theory and how to design appropriate educational events, so that the people come out. So, we don't train everybody just with simulation, for example, there's things that are better with a case discussion in front of the table, or watching a video or doing simulation. So that a key part, identifying and using the right strategy, because I would say that it's very costly to educate people, and so if you're going to devote the amount of time for them to go through any education, you better choose appropriately so that they come out with the outcome that you want.

Dr. Steven Kawczak:

Thanks to both of you for that answer. I think you've identified many practical tips, and reminded educators that you have to be very thoughtful in your education design, that's foundational, and you have to consider the complexity of implementation. So, you're teaching a very busy audience here, of learners, and so how do you overlay that education in a way that's not disruptive, but helpful, and considers the facilitators as well? Because it's tricky to be able to design and implement activity that leads to the outcomes that we're after. So, thanks for the great example, and the great reminders of how to overcome those challenges.

So, Cecile, do you have another example that you could share with the audience of initiative you've created that helps address quality and safety through education?

Dr. Cecile Foshee:

Sure, so a lot of what we have done in the office of interprofessional learning has actually built from the lessons that we learned through SILE in the MICU. So, we opted to go with a different strategy, and that's coaching, right? So, rather than delivering information that is general, and applicable to everybody, we decided we would focus on, okay, what are the specific challenges, you know, specific teams are dealing with, right?

So, we gather information from a team about where they are right now, and where they would like to be. And then we use that information to tailor discussions, and, you know, we really open up a conversation, right? So, we provide the platform for them to say, "Okay, you know what, Eduardo, when you do this, it makes me feel this way, you know? When you do that." You know, so it really is more about guiding the discussions, rather than a teaching strategy, it's really a true coaching experience. And I think that is even more effective, however, it's more challenging, right?

As we were talking about, the barriers for education, you know, even finding the right time, and the right place is challenging. Now imagine trying to coach a team, and trying to find something that works for everybody. And you obviously cannot have a conversation if not everybody's present, right? So that becomes a huge logistical issue. So, there needs to be buy-in from the leadership to make sure that they, "Yes, we're committed to doing this, and we're going to do that." And it's not an easy thing to implement, but I think there's a lot of potential for, you know, complementing education efforts with, you know, a coaching component so that people have more buy-in about their solutions, right? Because they're coming up with their own solutions, they're saying, "This is what's really important to me," instead of us going and saying, you know, "You have to work on this, because we think this is important." So, it's a little bit of a flip on, you know, just traditional education.

Dr. Steven Kawczak:

Yeah, thank you for sharing about that strategy. So, education isn't episodic, right? We're tending to an environment and a culture here, and you've created some great educational activities, but how do you sustain the change? And, and I think coaching is a fantastic example how longitudinally you can help those learners stay accountable to the commitments to change they're making when you had everyone get together for the activity. So, thanks for elaborating on that.

So, let's shift and talk a little bit more about simulation. So, simulation at Cleveland Clinic, we're blessed to have lots of fantastic and innovative space. There's over 10000 square feet at our main campus dedicated to simulation. Many of our clinical areas have small embedded simulation centers really close to the point of care, we have an area that's dedicated just to task based simulators. And the sim center offers many courses throughout the year that are tailor created to, to meet the needs of our learners here at our organization.

And it doesn't stop in Cleveland, we've got facilities throughout our health system that, are connected to our sim center, and we've got spaces in each of those regional hospitals as well. So, with that as our backdrop, Eduardo, so how, how do you use all of this great space, and tools and team of educators to ensure that simulation helps achieve that goal of quality and patient safety?

Dr. Eduardo Mireles:

There's a structural behavior here, which is essentially, you have to be available to all the institutes, and all the caregivers, so that they have a way to reach into the simulation space to ask for support. And you have to embed, actually, people within the quality and safety structure to ensure that they have an ear, into the table, because if there's no voice at that table, they may not know that that resource is available within the structure.

There's a healthy behavior that occurs here which is within every institute there's a quality officer, and there's also an educational group within each one of the institutes, and we actually have representatives of several of these institutes within the Simulation and Advanced Skills Center. So, I'll give you an example of how we use simulation under the circumstances, at least in our institute.

We had an issue with central line acquired bloodstream infections, and that's a major item, and I believe that happens across all centers right now, this is a key area for us to focus. And we wanted to ensure that our team was placing the line in a sterile fashion. And we had sent, you know, you can send as many emails as you want, you can say it as many times as you want in a huddle, but in reality, you need to have somebody to be able to see how, how they're doing. And we created we asked the sim center for support, they supported with a simulation operation specialist, an education specialist, and we created a mini curriculum in which essentially our team members, while they were working, we will have them go through, and then on a manikin, will attempt to perform the procedure.

But the issue was not performing the procedure, it's how they prepared all the way, and how they were communicating. And so, we had a checklist, and now the trainers, and the team in the unit, so actually the nurse at the bedside that is supposed to be observing and guiding the team was actually the instructor, so we gave them the checklist that they are supposed to use and watch the clinician to create a psychological safe environment. Because one of the challenges is they don't feel safe telling a physician, you know, "You touched your head with the glove," which it's a major breach, right? So, we used that to, at the same time address the issue of psychological safety, to ensure that everybody knew the steps of how to achieve the things. And finally, that help us to kind of the state of where we were.

So, that's one of the ways that we use it, but in general, there multiple examples of how we do this through that structure that feeds into the sim center as a resource for the institutes to use.

Dr. Steven Kawczak:

Oh, thank you for sharing, appreciate that. So, a final question to both of you do you have any other tips or advice to share with educators that are listening in of how they can utilize education to achieve goals of quality care and safe care in their own environments?

Dr. Cecile Foshee:

I think I would start with you have to provide support, right? So, if you want to engage people to education and to move the needle in any direction, in any topic, you have to provide them with the support, right? You have fabulous educators in every unit, but not all of them, as Eduardo had mentioned earlier, have the understanding of educational theory, for example, right?

So, what we tend to do is we create faculty guides for people to be able to facilitate the information, so that when you engage people to, you know, to try to teach around quality and safety, or whatever other project you have, you know, they be able to, to do it for you in a consistent manner. In addition to that, then you have the facilitator itself, and that's just personal attributes, like Eduardo's an amazing facilitator. He's just, like, he has this ability to engage people and draw them in, and I think it's because of his, he's a genuine person, right? So, you come in and you really, like, you tap people on the shoulder, and they actually like you, and then you, you know, you talk to them as human beings, right? And I think that's something that sometimes educators feel like they're, like, the experts, and they got to deliver information, rather than, you know, "We're one on one, were learning from one another, let me hear from you," and really be honest in those inquiries, right, really want to listen to them and what their need are so then you can really speak to them. I think that's critical, especially in this space of safety, right? If you want to improve that, you have to be really transparent and honest, and really invite their participation. Without their engagement, you're not going to have anything.

Dr. Eduardo Mireles:

Thank you for the kind words, Cecile. I would say the other tip is that there's always so much that you want to teach, so you have to pace it. And you have to have a global view of what are the key items that you need the team to be aware, and how to get them there. There's all these priorities that keep coming through, and if you try to teach them all of them, you end up confusing them more and more and more. So, having blocks, and chunks where you focus on this, and actually this is a direct communication with leadership, because they have different expectations, right? So, you have to say, "Well, we're getting there, this is the areas," and then try to establish the structure of how the unit operates that requires the least amount of education, so the, the number of things that happen automatically, and the other ones that you need to teach, use them to teach so that their brain doesn't get overwhelmed.

Dr. Steven Kawczak:

Well, thank you. Those are fantastic tips, and, and insights, and I thank both of you so much. For the listeners here, I really feel honored to sit down with Doctor Mireles, and Doctor Foshee, they're amazing master educators, and I have a lot to learn from them, and they're great examples to me. And I think you've offered some really sound advice to listeners about how to design education effectively, think of that first. If you're going to have good outcomes, it's had to be thoughtfully designed. You have to make sure your faculty are trained and developed so they can, they can teach well, and you simply want to, space this. You don't want to overwhelm anybody, you want this to happen over time, so you can see the learning occur, and the learning applied. And to think about the team, right? So,have the team get together to learn by, and from, and with each other, and as much as you can, practice it, right? So, use those simulation methods, and facilities if you have them available, but the more you can do that in a replicated environment, you know, the better chance you're going to see it applied in practice.

So, I think listeners can take away from this podcast that education is essential, as you started out with, Eduardo, to ensuring a quality and safe healthcare environment, and so, encourage all the listeners to apply these things. And thinking of our listeners, I thank you for tuning into this podcast. I hope you have a wonderful day, and we'll look forward to having you come to the next one.

Dr. Jamie Stoller:

This conclude this episode of MedEd Thread. A Cleveland Clinic education Institute podcast. Be sure to subscribe to hear new episodes via iTunes Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.