Patient Safety in the Outpatient Setting: Using Standardized Patients to Assess and Improve the Quality and Effectiveness of Patient Education Skills and Practice Behaviors Project Summary The goal of this proposal is to improve patient safety by using Unannounced Standardized Patient (USP) visits as an innovative, uniquely effective method for 1) assessing practice behaviors central to outpatient safety, namely patient education and counseling skills;2) isolating the impact of Standardized Patient (SP) "announced" examinations and feedback (Objective Structured Clinical Examination, OSCEs) on patient education and counseling practices;and 3) teaching trainees these critical skills. Patient education and counseling was selected because such skills are central to "activating patients" to follow recommendations, ask questions, provide needed information, and monitor and respond to symptoms, all critical ingredients for outpatient safety. "Unannounced" patients are actors who are integrated, incognito, into the care system as "real patients" and are trained to consistently and accurately assess physician and system performance. In this study, we introduce 3 USP visits into the outpatient clinics for 44 2nd Year Medicine residents (36 Categorical and 8 Primary Care for 3 years =132 residents). These residents also all participate in a multi- station OSCE (the "gold standard" in competency assessment) and so we then assess the relationship between patient education and counseling skills measured in this examination and actual patient education and counseling practice with USPs, identifying the degree to which OSCE skills transfer to actual practice as well as the learner and setting characteristics that may affect transfer. Learning characteristics include attitudes toward simulation and patient education, risk perceptions, and reflective practice abilities. Characteristics of the setting, including ease of navigation, busyness, patient-centeredness, and safety culture, are expected to influence physicians'transfer of skills as well as patients'activation. A second study then takes advantage of the quasi-random scheduling of residents'rotations to conduct a natural experiment that explores the degree of learning associated with patient-safety focused OSCEs with feedback by comparing the USP-assessed patient education and counseling practice of residents who already completed the OSCE with those who have not yet completed it. Finally, a third study explores the degree to which learning and skill development is associated with participating in a USP visit by comparing the patient education and counseling performance in a high-stakes OSCE of 3rd year medical students whose ambulatory care rotation includes a USP visit (n=30 students) with that of students whose rotation does not include USPs (n=72) during the same time period. These simulation-based assessment and teaching methods are essential for focusing on the elements of physician-patient interactions that contribute to outpatient safety. Results are expected to help determine the degree to which OSCEs assess and contribute to residents'mastery of core clinical skills central to patient safety, to explore the potential of USP visits for enhancing education and counseling skills, and to help disseminate the use of USPs for patient safety.
Study results will be used to identify training needs of internal medicine physicians and medical students in the area of patient education and counseling skills, skills that are essential to providing high quality, effective care, especially to vulnerable populations who may lack the education and experience necessary for understanding complex conditions and treatment plans. Better understanding of how performance in simulated settings translates to real world outpatient practice will allow us to identify resident physicians who need additional training in order to provide safe care, target training to focus on critical links in th learning process, and pinpoint health system characteristics that interfere with physicians'abilities to provide safe care and activate patients. Rigorous evaluation of simulation-based educational experiences will determine how best to translate evidence-based patient education and counseling practices into actual care and ensure widespread dissemination of patient-activating physician practices which are expected to substantially improve the health of the large numbers of patients who get the majority of their care in the outpatient setting. .