Using the health-care matrix to teach and improve patient safety culture in an OB/GYN residency training program

To assess the utility of health-care matrix in teaching patient safety in terms of the Institute of Medicine Aims for health-care improvement and Accreditation Council for Graduate Medical Education competencies.

As part of residency education, health-care matrix conference is held monthly. A multidisciplinary team is invited. Residents choose cases and develop a draft matrix under faculty supervision. The matrix is presented, and consensus action plan is generated after discussion. Approximately 2 years after initiation of the program, residents completed an anonymous 15-item survey.

The study included 26 health-care matrix conferences from 2007 to 2009. Main reasons for residents' selection of cases were management issues (42%), bleeding complications (35%), and medication errors (23%). Major contributors to patient safety concerns by Institute of Medicine Aims were timeliness (65%), and those by Accreditation Council for Graduate Medical Education competencies were system issues (77%), medical knowledge (69%), and communication issues (66%).Residents agreed that the program was useful. No resident thought that the program should be cancelled. Only 39% feel their communication skills were improved, 48% felt that preparation was time consuming, and 29% felt awkward presenting errors of superiors. Review of action plans developed after each matrix showed that implementation of recommendations was initiated in 92% of the cases.

The health-care matrix curriculum can be used to teach patient safety culture, assess system processes, and improve patient care. This report highlights the importance of system issues, timeliness, medical knowledge, and communication for patient safety concerns.