The right care, every time: improving adherence to evidence-based guidelines.

Guidelines are integral to reducing variation in paediatric care by ensuring that children receive the right care, every time. However, for reasons discussed in this paper, clinicians do not always follow evidence-based guidelines. Strategies to improve guideline usage tend to focus on dissemination and education. These approaches, however, do not address some of the more complex factors that influence whether a guideline is used in clinical practice. In this article, part of the Equipped Quality Improvement series, we outline the literature on barriers to guideline adherence and present practical solutions to address these barriers. Examples outlined include the use of care bundles, integrated care pathways and quality improvement collaboratives. A sophisticated information technology system can improve the use of evidence-based guidelines and provide organisations with valuable data for learning and improvement. Key to success is the support of an organisation that places reliability of service delivery as the way business is done. To do this requires leadership from clinicians in multidisciplinary teams and a system of continual improvement. By learning from successful approaches, we believe that all healthcare organisations can ensure the right care for each patient, every time.

Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development.

STATEMENT: Better debriefing practices may enhance the impact of simulation-based education. Emerging literature suggests that learner-centered debriefing may be effective in helping instructors identify and address learner needs while building learner's engagement and sense of responsibility for learning. This contrasts with instructor-centered approaches to debriefing, where instructors maintain unilateral control over both the process and content of the debriefing, thus limiting input and direction from learners. Although different approaches to debriefing for simulation-based education exist, the simulation literature is largely mute on the topic of learner-centered debriefing. In this article we will (1) compare and contrast learner- versus instructor-centered approaches to teaching; (2) provide a rationale for applying more learner-centered approaches to debriefing; (3) introduce a conceptual framework that highlights the key dimensions of learner- versus instructor-centered debriefing; (4) describe key variables to consider when managing the balance between learner- and instructor-centered debriefing; and (5) describe practical learner-centered strategies for various phases of debriefing.

Validation evidence of the paediatric Objective Structured Assessment of Debriefing (OSAD) tool.

Introduction: Debriefing is essential to maximise the simulation-based learning experience, but until recently, there was little guidance on an effective paediatric debriefing. A debriefing assessment tool, Objective Structured Assessment of Debriefing (OSAD), has been developed to measure the quality of feedback in paediatric simulation debriefings. This study gathers and evaluates the validity evidence of OSAD with reference to the contemporary hypothesis-driven approach to validity. Methods: Expert input on the paediatric OSAD tool from 10 paediatric simulation facilitators provided validity evidence based on content and feasibility (phase 1). Evidence for internal structure validity was sought by examining reliability of scores from video ratings of 35 postsimulation debriefings; and evidence for validity based on relationship to other variables was sought by comparing results with trainee ratings of the same debriefings (phase 2). Results: Simulation experts' scores were significantly positive regarding the content of OSAD and its instructions. OSAD's feasibility was demonstrated with positive comments regarding clarity and application. Inter-rater reliability was demonstrated with intraclass correlations above 0.45 for 6 of the 7 dimensions of OSAD. The internal consistency of OSAD (Cronbach α) was 0.78. Pearson correlation of trainee total score with OSAD total score was 0.82 (p<0.001) demonstrating validity evidence based on relationships to other variables. Conclusion: The paediatric OSAD tool provides a structured approach to debriefing, which is evidence-based, has multiple sources of validity evidence and is relevant to end-users. OSAD may be used to improve the quality of debriefing after paediatric simulations.

Supporting colleagues to improve care: educating for quality improvement.

Clinicians at the front line of healthcare delivery are very well positioned to identify and improve the system in which they work. Training curricula, however, have not always equipped them with the skills or knowledge to implement change. This article looks at educational approaches to support clinicians to be actively involved with quality improvement (QI). It looks at the role of doctors in postgraduate training (DrPGT) and their educational supervisors and builds on the topics discussed throughout the 'EQUIPPED' article series. Factors for success of a QI education programme and practical ideas for overcoming barriers to supporting clinicians in QI are discussed. We present examples of educational initiatives and a framework for evaluating such programmes, and we examine the role of faculty development to help inspire and support colleagues to improve care.

Development of a tool to improve performance debriefing and learning: the paediatric Objective Structured Assessment of Debriefing (OSAD) tool.

BACKGROUND: Simulation is an important educational tool to improve medical training and patient safety. Debriefing after simulation is crucial to maximise learning and to translate the lessons learnt to improve real clinical performance, and thus to reduce medical error. Currently there are few tools to improve performance debriefing and learning after simulations of serious paediatric situations. PURPOSE: The purpose of this study was to develop a tool to guide and assess debriefings after simulations of serious paediatric situations, applying the current evidence base and user-based research. STUDY DESIGN: A literature review and semistructured interviews (performed in 2010) to identify important features of a paediatric simulation debriefing. Emergent theme analysis was used to identify key components of an effective debriefing which could be used as a tool for assessing debriefing effectiveness. RESULTS: The literature review identified 34 relevant studies. Interviews were carried out with 16 paediatricians, both debriefing facilitators and learners. In total, 307 features of a debriefing were identified. These were grouped into eight dimensions representing the key components of a paediatric debriefing: the facilitator's approach, learning environment, engagement of learners, reaction, descriptive reflection, analysis, diagnosis and application. These eight dimensions were used to create a tool, the Objective Structured Assessment of Debriefing (OSAD). Each dimension can be scored on a five-point Likert scale containing descriptions for scores 1, 3 and 5 to serve as anchors and aid scoring. CONCLUSIONS: The study identified the important features of a paediatric simulation debriefing, which were developed into the OSAD tool. OSAD offers a structured approach to paediatric simulation debriefing, and is based on evidence from published literature and views of simulation facilitators and learners. OSAD may be used as a guide or assessment tool to improve the quality of debriefing after paediatric simulation.

Developing future clinical leaders for quality improvement: experience from a London children's hospital.

INTRODUCTION: Medical training does not necessarily prepare graduates for the real world of healthcare in which continual improvement is required. Doctors in postgraduate training (DrPGT) rarely have the opportunity to develop skills to implement changes where they work. Paradoxically they are often best placed to identify safety and quality concerns and can innovate across organisational boundaries. In order to address this, educational programmes require a supportive educational environment and should include experiential learning on a safety and quality project, alongside teaching of quality improvement (QI) knowledge and systems theory. METHOD: Enabling Doctors in Quality Improvement and Patient Safety (EQuIP) has been designed for DrPGT at a London children's hospital. The aim is to prepare trainees for the future of continual improvement to ensure safe and effective services are developed through effective clinical microsystems. This paper describes the rationale and design of EQuIP with evaluation built in the evolving programme. EQuIP supports DrPGTs through a QI project within their department, aligned to the Great Ormond Street NHS Foundation Trust's objectives. This changes the way DrPGTs view healthcare as they become quality champions for their department. A three-level approach to the programme is described. The innovation involves a peer-designed programme while being work-based, delivering organisational strategies. RESULTS: Results of the preprogramme and postprogramme evaluations demonstrate an improvement in knowledge, skills and attitudes. Benefits to both the DrPGTs and the organisation are emphasised and key factors to achieve success and barriers identified by the participants. DISCUSSION: The design and evaluation of EQuIP may inform similar educational programmes in other organisations. This capacity building is crucial to ensure that future clinical leaders have the skills and motivation to improve the effectiveness of clinical microsystems.

Objective structured assessment of debriefing: bringing science to the art of debriefing in surgery.

OBJECTIVE: : To identify the features of effective debriefing and to use this to develop and validate a tool for assessing such debriefings. INTRODUCTION: : Simulation-based training has become an accepted means of surgical skill acquisition. A key component of this is debriefing-yet there is a paucity of research to guide best practice. METHODS: : Phase 1-Identification of best practice and tool development. A search of the Medline, Embase, PsycINFO, and ERIC databases identified current evidence on debriefing. End-user input was obtained through 33 semistructured interviews conducted with surgeons (n = 18) and other operating room personnel (n = 15) from 3 continents (UK, USA, Australia) using standardized qualitative methodology. An expert panel (n = 7) combined the data to create the Objective Structured Assessment of Debriefing (OSAD) tool. Phase 2-Psychometric testing. OSAD was tested for feasibility, reliability, and validity by 2 independent assessors who rated 20 debriefings following high-fidelity simulations. RESULTS: : Phase 1: 28 reports on debriefing were retrieved from the literature. Key components of an effective debriefing identified from these reports and the 33 interviews included: approach to debriefing, learning environment, learner engagement, reaction, reflection, analysis, diagnosis of strengths and areas for improvement, and application to clinical practice. Phase 2: OSAD was feasible, reliable [inter-rater ICC (intraclass correlation coefficient) = 0.88, test-retest ICC = 0.90], and face and content valid (content validity index = 0.94). CONCLUSIONS: : OSAD provides an evidence-based, end-user informed approach to debriefing in surgery. By quantifying the quality of a debriefing, OSAD has the potential to identify areas for improving practice and to optimize learning during simulation-based training.