developing an effective serious harm event review process for residential care
DESCRIPTION
This presentation was delivered in session D1 of Quality Forum 2014 by: Warren Hill Consultant, Quality Improvement and Patient Safety Fraser HealthTRANSCRIPT
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Quality Forum, 2014 February 27, 2014
Elizabeth Finlay, RN, MEd, Clinical Director, Residential Care & Assisted Living Larry Gustafson, MD, Program Medical Director, Residential Care & Assisted Living Michelle Merkel, RN, MSc, Project Leader, Residential Care & Assisted Living Karim Suleman, MBA, Managing Consultant, Patient Care Quality Office Warren D. Hill, PhD, Consultant, Quality Improvement and Patient Safety
Developing an effective serious harm event review process for Residential Care
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The Issue
Avalanche of safety reports Event follow-up isolated & inconsistent Siloed learnings Review processes are fragmentary
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Why is this an issue?
Lack of standardized follow-up leads to practice variability Learnings are not aggregated in PSLS Learnings are not widely disseminated
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Improvement Aims
To build a sustainable monthly, multidisciplinary team review process To develop tools to support improving the
efficiency and quality of the review process and follow-up actions
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Change Concept
Monthly review of all PSLS serious harm events by a multidisciplinary panel (QRC) Develop review tool to collate event info Follow-up queries and actions to handlers
made within the PSLS system Each event remains “open” until follow-up is
completed and panel closes event
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Review Process: Serious Harm Events
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Monthly Review
Moderate & Serious Harm
Events
Secondary
Review/ Actions
Tertiary Critical Patient Safety Review
Follow-up with Review Committee
Results to Review Committee & Leadership Group
Organization-wide Learning
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The RCAL Experience: Initial Process
Excel spreadsheet created from PSLS reports that listed event details and description Event ID# was cut and pasted from
spreadsheet as a new search in PSLS The event was then loaded (live) in PSLS
and the follow-up was reviewed by the committee
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The Tool: Questions to Consider
How can we review this data?
How can we see, at a glance, the follow up plans to mitigate risk?
How do we know if and what actions are being taken? How do we take the learnings and
make quality improvements?
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The PSLS Review Tool
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Results
RCAL average number of events reviewed increased by 64%: Mar thru Sept meetings (1st meeting): 21 events Sept(2nd meeting) thru Nov meetings: 33 events
Participants like having all event information on one page
Follow-up was recorded in PSLS, reducing follow-up on email or by phone (i.e. one stop shopping)
Request to handlers for additional information decreased after several months as follow-up became standardized
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Events Presented at RCAL QRC
0
5
10
15
20
25
30
35
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MARCH APRIL MAY JUNE SEPT (1ST) SEPT (2ND) OCT NOV
ONGOING
CLOSED
New review tool implemented
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Sustainment and Spread
RCAL uses tool for each QRC meeting Medicine Program began using tool Oct 2013 Other programs being trained on process
and tool, with goal to spread to all programs
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Challenges and Lessons Learned
Review process & tool provided consistency and standardization of learning Improved follow-up increased number of
events reviewed and closed Event volume in acute care programs
presents some challenges
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Questions?