Oct 26, 2010

Goin' Out West... to UC Denver

I've been at IHI for over two years now; working with the IHI Open School since it was first dreamed up. I've made appearances at a few of our events (2009 IHI National Forum, 2010 Student Quality Leadership Academy) but for the most part I've been behind the scenes to our Chapter Network. About two weeks ago I had the opportunity to venture out west with, my colleague Shannon, to the University of Colorado - Denver to see what's been going at one of these Chapters, something I don't typically see.

Now I know you must be thinking "leaving the cold of Boston just to visit the cold of Colorado?" It couldn't be further from the truth. 70+ and sunny, we began our day exploring the separate schools that make up UC - Denver's campus as well as shared halls often used for interprofessional learning. We also saw a few simulation centers, including a unique home-care simulation. Later in the day, we were able to return to the simulation centers to watch four nursing students and one medical student work through a sepsis simulation. It was great seeing this type of collaboration between professions in their training, watching each team member take on a different role, and working together to assist the septic patient.

The main reason we visited UC - Denver was to attend the Chapter's workshop on debriefing a medical error. Before the workshop, approximately fifteen students were assigned a different roles to recount the event. Based on a true story where a chest tube was removed from the wrong patient due to many lapses in communication, about 20 students and faculty were assigned roles and worked through the event review. Another 20 or so watched and participated in the discussion that followed. Using an SBAR format, the Chief Quality Officer and Patient Safety Specialist from The Children's Hospital led the group through a thought-provoking discussion. Where was the miscommunication? What could have been done better? Who was responsible? The parents were told, but were they told everything? Is it the hospital's job to discuss the error even after the patient is home safe and making a full recovery? All of these and more were discussed. Who knew that so much could be be packed into an hour-long workshop. In the end, they suggested important communication tools and ideas such as repeat back, critical language, difficult conversations, and a Just Culture.

After the workshop, we watched the nursing student simulation followed by informal rounds at the Children's hospital with the Chief Quality Officer. They're doing a lot of great work on fall prevention, interdepartmental communications, and correct labeling of blood samples. The hospital staff also repeatedly mentioned the initiative to use at least two patient identifiers at all times.

After a busy day, it was time to fly back to Boston. A huge thanks to Wendy Madigosky, Jamie Dhaliwal, Nicholas Bishop, Dan Hyman, and to the Chapter Steering Committing for making the day possible. It's exciting to see what the Chapter has done, how engaged the students are, and how dedicated the faculty are to teaching students about quality and safety. I could not have asked for a better first Chapter visit.