CPME 2005/161 EN TITLE / TITRE EMSA Warsaw Declaration - European Core Curriculum in Patient Safety
AUTHOR / AUTEUR EMSA
CONCERNING / CONCERNE
PURPOSE / OBJET DECISION
KEYWORDS / MOTS CLEFS EMSA
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MEDICAL EDUCATION IN EUROPE
An Outcome-based Core Curriculum In Patient Safety A policy statement from participants of the 2nd meeting of the European Medical Students’ Council WARSAW, POLAND, 10-13TH FEBRUARY 2005 Outcome of the EMS Council plenary meeting Organised by the European Medical Students’ Association Representing medical students across Europe
Background to the Core Curriculum The EMS Council European medical students have been increasingly active over the last few years discussing educational reforms and policy decisions which have a direct bearing on medical training1&2. Both the International Federation of Medical Students’ Associations (IFMSA) and the European Medical Students’ Association (EMSA) have worked in tandem to forge policy statements and assist in the spreading of awareness about European-wide educational policy reforms. EMSA has as its stated mission to improve the health and quality of care of the citizens of Europe by acting as a conduit for increased interaction and sharing of knowledge between European medical students in the areas of medical education, ethics and science. One way to achieve this mission is to help the numerous national organisations of medical students throughout Europe find a united voice. The European Medical Students’ Council (EMS Council) is a body created by EMSA as a communication forum for action and improvement. It meets once a year to discuss current issues of importance for medical students.
The Goal of the EMS Council 2nd Meeting The goal of this Council meeting was to determine what it is that we as medical students need in order to protect the patient. What do we need to know? What do we need to learn? What do we need to be able to do or perform? What should be included in a medical school’s core curriculum on Patient Safety? The intent was to summarise the answers to these questions in a common core curriculum that is outcome-based. We drew a distinction between outcomes and objectives, the latter being that which most core curricula are based upon and describe what the teacher intends to
teach without relevance to the ultimate endpoint – the newly minted doctor. In contrast, outcomes describe the product – what the student should be able to demonstrate upon leaving the system. Concisely put, outcomes are concerned with what a student achieves instead of what a teacher intends to teach3.
Why Patient Safety? The area of Patient Safety was chosen for two reasons: 1. The EU has, as a primary concern, safe medical treatment for all, to the same quality standards throughout. So while the statement “First, do no harm” is one of the standing pillars of medicine, it is becoming ever more apparent that healthcare systems have not paid enough attention to the prevention of those injuries caused by medical error. It is an increasingly grave issue. In the United States, medical error accounts for more deaths than breast cancer, motor vehicle accidents or AIDS4. Unfortunately, the phenomenon is not just a geographical anomaly. Pioneering research in Denmark5, the United States6 and a few other countries have given validity to these startling statistics on the number of patients who are directly injured by the same system that is supposed to help alleviate and cure their suffering7. Further evidence of the relevancy of the topic has been demonstrated by the recently released Luxembourg Declaration on Patient Safety8. 2. This topic is not often taught in medical schools, yet is highly relevant and of major concern to current and prospective medical students in Europe. The Context Europe is discussing how to best and appropriately implement the Bologna Declaration9,10. Follow-up debate on the feasibility of implementing the action lines in medical education has focused heavily on the idea of creating a standardised core curriculum with well defined educational goals throughout Europe. Regardless of the specific local variations at different medical schools, it is of benefit to patients, medical students, and healthcare systems that a minimum level of competency (defined as knowledge, skills, and attitudes) is established for newly graduated doctors. The World Federation for Medical Education (WFME) has compiled a document that can be seen as the first step towards a European Core Curriculum. If we can define such a minimum level based on what the outcomes of a portion of the medical curricula ought to lead to, we have come a long way in achieving the hopes and dreams of the original signatories of the Bologna Declaration. We hope that through the implementation of the proposed minimum requirements below, Europe will take its first steps towards becoming the safest healthcare system in the world.
The Method Thirty-five students, including official representatives of National Medical Student Organisations from around Europe, met for four days in Warsaw, Poland. Through innovative pedagogical methods including discussions, brainstorming, reflections, and dynamic teaming, as well as the presentation of research results from the field of Patient Safety, a list of competencies was developed. These were then categorised, further discussed and refined. Finally, they were rewritten as outcomes, i.e. what the student is expected to know at the culmination of his/her medical education.
An Outcome-based Core Curriculum in Patient Safety The outcomes are organised into seven categories. Each describes the competencies (knowledge, skills, and attitudes) that a newly graduated medical doctor can be expected to demonstrate. The newly graduated doctor can:
1. Prioritise the Patient •
Demonstrate through action that the safety of the patient stands at the centre of every action performed.
2. Awareness of Patient Safety and the Intention to Improve • • • • •
Continuously search for (latent) hazards, risks and near misses. Actively work for the development and implementation of guidelines and checklists. Work to prevent mistakes in the system at all levels through discussion and further reading. Teach and share knowledge about Patient Safety with others. Follow the recommendations of the European Working Time Directive.
3. Learn from Error • • • •
Identify the multiple root causes behind an error. Evaluate a medical error from all levels of the organisation. Aim for maximum transparency through talking to other doctors and members of the healthcare team about a medical error. Apply knowledge from previous actions to prevent further error through an error reporting system (for the support of the doctor and his/her patients).
4. Attitude and Character • • •
Demonstrate an attitude based on a system of values that is supportive towards every patient. Ask for help or advice in any circumstance without hesitation or being afraid. Understand and be aware of his/her personal limitations.
5. Team and Communication • • • • •
Each health professional working in a team should have a defined job description, with defined limits, which forms the basis for interaction. Respect other’s opinions and exchange constructive criticism. Understand when to be assertive or when to defer to a more experienced senior colleague. Communicate clearly with patients and colleagues in a professional manner that is respectful, non-aggressive and diplomatic. Demonstrate an attitude of tolerance without prejudice or clouding of judgement, with respect to gender, sexual orientation, race, disability, personal differences, etc.
6. Stress Management •
Recognise his/her physical and mental limitations. 3
Use basic stress-reduction and relaxation techniques. Understand and explain the effects stress and/or lack of sleep has on his/her individual performance.
7. Guidelines and protocol • • • • •
Acknowledge the importance of good and comprehensive guidelines. Request an introduction to the local standards and protocol. Apply the European/national standards and guidelines for life-saving procedures. Understand the working time regulations and how they apply to the healthcare system. Understand that the European Working Time Directive, when applied to the healthcare sector, is about the safety of the patients.
The European Working Time Directive This Council notes a lack of common standing with regard to the European Working Time Directive. The number of working hours varies within Europe and this needs to be addressed and, where feasible, standardised throughout the continent. Furthermore, there is debate within Europe over whether each physician should be able to opt out of the Working Time Directive and this Council moves to strongly reject this idea. It is recognised that there are long waiting lists and a current shortage of doctors and, indeed, there are financial implications which arise from the idea of limited working hours. However, it must be acknowledged that the individual performance of a doctor has huge implications for Patient Safety – which is, worryingly, something that the majority of doctors do not admit to11. Given the effect that sleep deprivation and stress have on working performance, there is an indisputable need for regulatory checks and implementation of limited working hours, just as in the aviation industry. Each health care professional should have the right to refuse to work any more hours than those stipulated in the Working Time Directive without any negative consequences. The proposed “Opt-out” initiative would not ensure this and can only be described as a loop-hole. In essence, opting out of the European Working Time Directive should not be an option, as it may prompt financial, social and/or peer pressure. This Council would argue that this would not in any way benefit the worthy aims of the guidelines, since it would only undermine its recommendations.
Summary of Recommendations This Council calls for the defined Core Competencies to be realised and implemented into every medical curriculum throughout Europe in order to guarantee a minimum level of quality for the newly graduated doctor, irrespective of the European medical faculty at which they were trained. An outcome-based European Core Curriculum is the most desirable and feasible method. This will also help to improve the quality of medical education and further facilitate mobility within the EU. This Council is aware that the objectives and priorities of each individual national healthcare system must invariably influence the curricula in their respective medical faculties. And while these may vary somewhat from country to country, we feel that there exist certain pillars in medicine, such as “First, do no harm” which are universal and therefore most cer4
tainly an adage for all of Europe. Thus, it is with hope for a safer health care system (in line with the Luxembourg Declaration) that the EMS Council present the outlined recommendations for a standardised European Outcome-based Core Curriculum in Patient Safety. For reasons of Patient Safety, the maximum number of working hours recommended to each health care professional need to not only be standardised across Europe, but most importantly, implemented without exception. If the healthcare industry is serious about following the maxim of Galen, “First, do no harm”, then this Council argues that the only way forward is to follow the lead of the aviation industry and adopt the necessary guidelines and core curriculum. Patient Safety must be our undisputed priority.
Further Reading The above outcomes and discussion on the working time directives were written based on research finding from a variety of different groups and institutions. For more information on the arguments behind each outcome and for an introduction into the area of Patient Safety, we recommend a start by looking at some of the following articles and books: Institute of Medicine: www.iom.edu To Err is Human Crossing the Quality Chasm The Leapfrog Group for Patient Safety http://www.leapfroggroup.org/ The Luxembourg Declaration on Patient Safety http://europa.eu.int/comm/health/ph_overview/Documents/ev_20050405_rd01_en.pdf Berwick, D. A Primer on Leading the Improvement of Systems. BMJ 1996;312:619-22. Leape, LL. Error in Medicine. JAMA. 1994;272:1851-1857. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320:745-9. 1
EMSA and IFMSA: The Bologna Declaration and Medical Education: A policy statement from the medical students of Europe. Medical Teacher. 2005; 27:1, 83-85.
London Policy Statement (EMSA Council, August 2004)
For a concise discussion about the differences between objectives and outcomes, see A Practical Guide for Medical Teachers by John A. Dent and Ronald M. Harden; ISBN 0 443 06273 0 4 See the Institute of Medicine’s report: To Err is Human. www.iom.edu 5 See www.patientsikkerhed.dk/About 6 See for instance www.ihi.org/ihi or www.iom.edu/topic.asp?id=3718 on healthcare quality. 7 For a European discussion on the subject, see: Zavitsanos X, Petridou E, Kakavouli A, Kedikoglou S: An Initiative for the Collection of Data Regarding Injuries in the Consumer Services Sector. Final Report, March 2004. Prepared for the European Commission. http://europa.eu.int/comm/health/ph_projects/2002/injury/fp_injury_2002_frep_03_en.pdf 8 See: http://europa.eu.int/comm/health/ph_overview/Documents/ev_20050405_rd01_en.pdf 9 See: www.bologna-berlin2003.de/pdf/bologna_declaration.pdf 10 See: 2www.bologna-berlin2003.de/pdf/Communique1.pdf 11 Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320:745-9.