The University of Michigan Department of Anesthesiology

Patient Safety Resident Education: Application of Root Cause Analysis and Action

A major focus in healthcare is the development and use of tools that equip providers and institutions to respond to patient safety events in a timely and coherent fashion. One such tool is the Root Cause Analysis and Action (RCA-squared), which allows healthcare providers to investigate how and why errors have occurred, and provides a framework for the implementation of preventative actions. A leader in the development of the RCA process, Dr. James Bagian is now the Director for the Center for Healthcare Engineering and Patient Safety (CHEPS) at the University of Michigan and faculty member in the Department of Anesthesiology. Tools which were initially developed during his time as the Director for the Veterans Affairs National Center for Patient Safety have been adapted for the University of Michigan Health System and adopted for the innovative patient safety curriculum in the Department of Anesthesiology. The curriculum is led by several faculty members of the Department of Anesthesiology who have combined interest in patient safety and education, along with the expert help and guidance of Dr. Bagian and his colleagues from CHEPS.

The main focus for patient safety education within the University of Michigan Department of Anesthesiology Residency Program takes place during the second clinical year (CA2) when the residents participate in a clinical event review (Root Cause Analysis and Actions, RCA). However the education process actually begins during the Clinical Base Year. Interns complete modules in quality and patient safety from the Institute for Healthcare Improvements, and the participate in seminars where these topics are discussed with examples of areas of potential quality improvement and patient safety concerns related to local clinical practice. These seminars are organized in conjunction with other clinical departments at the University of Michigan and have been realized as a great opportunity for multidisciplinary discussions.

The RCA takes place during the CA2 year. Residents are assigned into groups of approximately 5 members, with a group mentor. The cases are selected by members of the department’s Committee for Quality Improvement, and assigned to the group for review. The residents and their mentor are then guided through the process of RCA with a combination of on-line learning modules and workshops. The workshops are led by a core team of faculty members in the department with the combined interest in patient safety and education. During the workshops, time is spent reviewing the process of the RCA as well as giving feedback to the groups to ensure that their work product meets the quality standards of an RCA. A key component of the RCA process is presentation by the group of the completed RCA project to the members of the Committee for Quality Improvement and Patient Safety (CQIPS) and department as a whole. Actions and outcome measures are recommended by the residents to department leadership and members of CQIPS.

The final component is an evaluation of the effectiveness of the RCA curriculum. Tools are being developed which will evaluate the completed work of the RCA group, and compare that with the expected level of work defined by the Center for Medicaid and Medicare Services as being both credible and thorough. We will also assess how well involved residents understand the RCA process along with their confidence in using the patient safety/RCA tools they have been taught.

Intern Research Rotation

In 2008 the Department of Anesthesiology at the University of Michigan introduced an American College of Graduate Medical Education approved innovative research program for incoming interns. This one month program is designed with the following objectives in mind:

In order to attain these goals interns are required to attend a series of lectures/tutorials by the Anesthesiology research faculty. These didactic sessions include discussions on: hypothesis testing and power analyses, how to conduct a literature review, study design (i.e., descriptive, observational, interventional, and meta-analyses), how to critically review the literature, diagnosis and screening, statistics (i.e., selecting a test, measures of association, regression analyses), and research and evidence utilization. Additional tutorials include discussions regarding informed consent and the IRB and the manuscript submission process.

At the heart of the program is a research practicum in which groups of interns are required to develop a research idea and formulate a research plan. This practicum is presented for review and approval by the Chair at the end of the rotation. In addition, each intern is paired with a faculty mentor that assigns an article for presentation at one of the departmental journal clubs.

In addition to these core requirements, interns are required to attend weekly departmental Grand Rounds and clinical research meetings. Successful certification in the Program for Education and Evaluation in Responsible Research and Scholarship (PEERRS) is also required.

In an attempt to measure the effectiveness of the program, each individual intern is evaluated for improvement in knowledge using the Berlin Evidence-Based questionnaire prior to and following exposure to the program together with and assessment of their overall satisfaction with the learning experience. Intern practicums that have resulted in peer-reviewed publications are also tracked. Results from these evaluations indicate that the program has been well received and has resulted in improvements in knowledge of research methodology and the ability to critically synthesize the research literature. A manuscript describing the program and its evaluation has been published (Freundlich R, Newman J, Tremper K, Mhyre J, Kheterpal S, Sanford T, Tait AR. The impact of a dedicated research education month for Anesthesiology residents. Anesthesiol Res Pract, doi: 10.1155/2015/623959, 2015).