There are a number of options that have been considered by the authors to challenge the status quo and effect change. This paper discusses four specific changes that should be made relating to tools and resources for curricular development, teaching and assessment, as follows:
1. Increased formal education and training in patient safety should be incorporated into the curricula of undergraduate medical education (UGME) and PGME and continuing professional development (CPD) programs.
2. Teaching tools should be developed and disseminated.
3. Assessment strategies and methods should be developed and disseminated.
4. Faculty development is needed to create a cohort of on-site experts in patient safety who will teach and serve as role models for students.
Subsequently, the authors also discuss the need for overarching approaches and principles to address the hidden curriculum and promote a culture of patient safety. First, there is a need for increased formal education and training in patient safety that weaves through training — starting at the undergraduate level through PGME to CPD — and is embedded in the Maintenance of Certification (MOC) cycle. Patient safety should be ideally taught at every clinical encounter, rather than only as episodic stand- alone, didactic sessions,22-26 and faculty development in teaching patient safety should be incentivized in order to promote and further a safety culture in the learning and working environments.
In particular, it must become an imperative that PGME programs incorporate The Safety Competencies into their curricula. The Royal College is in a unique position both to mandate that all programs teach and assess the competencies outlined in The Safety Competencies framework and to take ownership of incorporating The Safety Competencies into the CanMEDS framework in a more easily identifiable manner.
However, one must recognize that the introduction of such curricular materials without the necessary supports will not have the intended positive impact on Canadian programs. The introduction of a new framework or approach requires tools, resources, and faculty development and support at the program level. Prior experiences with the launch of major endeavours, such as the original CanMEDS framework in 1996, have demonstrated very clearly that this need increases considerably in times of innovation and implementation of a new system.27 As such, the introduction of this imperative must be supported by practical tools to help medical educators and program directors embed the patient safety content into their existing curricula. As such, the authors’ second recommendation concerns the development of teaching tools.
For example, the document, Situational Awareness and Patient Safety - A Short Primer, developed by the Royal College, is an excellent example of the type of teaching tool that should be developed and disseminated.28 In particular, the authors recommend the development of a tool kit that is accessible and easily implementable, and that contains tools that are customizable to address discipline- and context-specific needs. The Royal College may also consider existing tools, such as the CanMEDS “What Works” inventory, to provide educators with concrete examples of initiatives that have been successful in similar programs.
A broad range of teaching tools should be explored, including teaching at the bedside and at hand-offs, in the form of “what if” conversations, formal and informal
discussions of real-life incidents,29 case-based learning (CBL),30 grand rounds,31 patient safety rounds,32 mortality and morbidity (M&M) rounds,33 journal club,34 practice objective structured clinical examinations (OSCEs),35,36 and simulation sessions.37 Moreover, systematic reviews of continuing professional development efforts to include quality and safety for practising clinicians have revealed that well-established adult learning techniques, such as experiential learning, are key to the successful implementation of these skills.38 Consequently, educational tools, such as simulation, that promote a teaching environment which advances patient safety themes, professionalism and interprofessionalism, while maintaining the patient problem at their centre, need to be identified and utilized. Other teaching strategies to generate authentic and meaningful discussions of patient safety include the use of narrative,39 reflective practice,40-43 and presentations by physicians and patients themselves of real-life incidents,44 all of which appear to be valued by students as they see these strategies as helping them to learn about and practise patient safety competencies.29 In addition to including a variety and broad range of strategies, the authors recommend that those developing the teaching tools consider recent, innovative strategies, including online curricula.45 These include the IHI’s Open School,46 the US Department of Veteran Affairs’ Patient Safety Curriculum47 and the WHO Patient Safety Curriculum Guide for Medical Schools.48 The Canadian Medical Protective Association (CMPA) recently launched its “Good Practices Guide,” a patient safety curriculum created for medical students as an online self-study tool that is supplemented with teaching aids for faculty to facilitate student learning.49 In addition, the online, interactive, case-based ”PCC Curriculum on the Go” was developed — through the collaboration of the CPSI, the Paediatric Chairs of Canada (PCC) and program directors from national paediatric residency programs — based on The Safety Competencies framework.50 This curriculum was designed to be flexible, so that it can be tailored to sessions of varying lengths as required by users.
Third, assessment strategies and tools will be needed in addition to the teaching tools and strategies for curriculum planning. Assessment of resident performance should include the use of validated tools for assessing patient safety competencies. One such tool is the Anaesthetists’ Non- Technical Skills (ANTS) rating system that is used to assess teamwork performance.51 Methods of assessment may include direct observation in the workplace, in a simulated environment or of a group task, as well as multisource feedback from members of the interprofessional team and from the patients and families.52 Assessment methods may also include the assessment of group or team performance in addition to the assessment of an individual’s performance.53-56 Direct observation, practice OSCEs and simulation scenarios are also valuable formative assessment strategies to help identify the learning needs of trainees and health care providers with regard to the knowledge, skills and attitudes that comprise The Safety Competencies in the clinical setting.57 The value of implementing patient safety OSCEs includes the ability to evaluate the impact and effectiveness of the patient safety curricula taught to and accessed by trainees.58 In terms of summative assessment, it is believed that the explicit assessment of patient safety competencies in the Royal College certification exams would be a powerful driver to encourage their inclusion in PGME curricula (e.g., the Obstetrics and Gynecology examination included a disclosure OSCE in 2010). In the United States, the American Board of Medical Specialties began, in 2003, to encourage its individual specialty member boards to introduce patient safety material into certification examinations.59
Dissemination of both teaching and assessment tools is critical. Developing a “repository” of available resources for teaching and assessment will facilitate faculty access to the needed tools, and enable faculty to share expertise and experiences, and will help them avoid “recreating the wheel.” One approach to dissemination is to develop platforms — such as awards, grants, fellowship and diploma programs, and academic recognition — to support, foster and celebrate excellence in the teaching and assessment of patient safety competencies. Another
approach to dissemination is to acknowledge scholarly patient safety and QI projects initiated and undertaken by residents and faculty. These strategies would
highlight the importance of the competencies, as well as interprofessionalism, in training, throughout practice and in lifelong learning.
Fourth, it is also critical that a cohort of on-site experts in patient safety is developed. These individuals can apply the tools to teach and advise the next generation of physicians, and will act as champions for safety.60 Patient safety may be ideally taught in an interprofessional setting61 with the acknowledgement of two significant and consistent challenges: logistics barriers and the lack of qualified instructors who are “trained, knowledgeable, have adequate experience in this field, and are able to effectively educate and mentor.”17,62-64 The capacity to creatively embed this content in Canadian training and professional development is still small, and the reluctance on the part of practising clinicians to include patient safety content as part of their own learning plans contributes to the challenges experienced in the learning environment. As such, there needs to be faculty development to increase capacity to teach patient safety in formal, informal and incidental encounters.17,26,62,65,66 Moreover, to be truly effective, faculty will need to consider strategies to embed patient safety and QI into undergraduate and postgraduate training and, concurrently, to ensure that patient safety is being taught at the sharp end of providing patient care.67 For example, a layered approach to teaching patient hand- off might start with a formal didactic session, followed by a small-group session that incorporates discussion around a case and role play, with a subsequent simulation scenario or practice OSCE accompanied by immediate feedback followed by feedback on work-based assessment.
Faculty development will also ensure that faculty and other members of the interprofessional team model appropriate practices. Such teaching embedded in the daily practice of medicine is a necessary complement to formal instruction. These situations also ensure that learners are provided
with an opportunity to put into practice that which they have learned in the formal setting and then are given direct, immediate feedback by their role models and further opportunities to integrate feedback to improve subsequent performance.
The Royal College has an important role to play in national faculty development. The Royal College’s national mandate with respect to specialty medical education lends it a unique perspective and an opportunity to develop a national faculty development program. [See the Faculty Development paper.] Toward this end, the Royal College and CPSI collaboratively developed a four-day faculty development workshop — ASPIRE (Advancing Safety for Patients in Residency Education) — to teach faculty how to: incorporate patient safety content into faculty development and residency training programs; develop and facilitate patient safety training; play a leadership role in patient safety activities; and identify and develop local champions at individual institutions. In addition to such initiatives, the Royal College may consider the development of a fellowship program or a national diploma program in patient safety to build the cadre of experts within medical education. The development of a community of patient safety and QI clinician teachers, educators, experts and education scholars, the dissemination of patient safety curricula — including both episodic teaching encounters and longitudinal programs — and the development of assessment tools will likely all contribute to the development of a patient safety culture.