Society for Health Systems/ASQ Healthcare Division ConferenceFebruary 27, 2010 in Atlanta Georgia

Mark Montgomery M.D., MMM Douglas Dotan MA, CQIA

History of Incident ReportingHistory of Incident Reporting

1970 Institute of Medicine (IOM) was created as an additional component of the National Academy of Sciences 

1976 Dr. Don Mills conducted one of the first studies  on patient safetyon patient safety 

Reviewed over 20,000 medical charts

Found that 1 out of 20 patients wasFound that 1 out of 20 patients was 

harmed by treatment 

Crossing the Quality Chasm: A NewCrossing the Quality Chasm: A New Health System for the 21st Century

p

“Care is based on continuous healing 

relationships”“Needs are anticipated”

“Care is customized according to patient needs 

and values”

“

“Transparency is necessary”

“The patient is the source of control”

“Knowledge is shared and information flows freely”

“Decision making is  “Waste is continuously

“Safety is a system t ”

gevidence‐based”

Waste is continuously decreased”

“Cooperation among li i i i i it ”property” clinicians is a priority”

National Quality ForumNational Quality Forum 

Est. in 1998 by President’s Advisory Commission onEst. in 1998 by President s Advisory Commission on Consumer Protection and Quality

Provides guidelines for Quality care for patients 

Protection for workers and consumers 

Classified 27 events which outline criteria for                              adverse event reporting

National Patient Safety QualityNational Patient Safety Quality Improvement Act 

Public Law 109‐41 was est. in 2005

Intended to improve patient safety through use of voluntary p p y g yand confidential adverse event reporting

Created Patient Safety Organizations                                       which aid in

Gathering and analyzing general patient safety and                                      adverse event information 

Importance of Reporting SystemsImportance of Reporting SystemsAllows Communication among 

providers concerningproviders concerning potentially harmful events

Provides info. which gives providers opportunity to learn from past mistakes

Can be used to establish protocols that prevent events from reoccurring

The urgency of improved patient safety and healthcare quality can be facilitated through the use of comprehensive web based reporting systems

Factors Impeding the SuccessfulFactors Impeding the Successful Use of Reporting Systemsp g y

MisunderstandingFear of punitive repercussions

“Blame and shame” culture

Misunderstanding the nature of adverse events 

reporting

I ti ti I id t R tiInvestigating Incident Reporting

Reporting to colleagues vs. Doctors gsuperiors

Doctors engaging in adverse

Reporting to superiors if event was caused by 

adverse events 

reporting violation of protocol

reporting

B i f I id t R tiBarriers of Incident Reporting

Lack of knowledge pertaining to  events 

appropriate for Fear of blame

reporting 

Confusing Infrequent feedbackConfusing reporting processes

Infrequent feedback concerning 

outcomes of report

National Patient Safety Agency ofNational Patient Safety Agency of England

Investigated relationship between hospital culture and error reporting of 148 hospitalsp g p

Perceived positive 

lculture

Increased event 

reporting &

Safer hospitals

reporting & patient safety

hospitals

Web Based Reporting SystemsWeb Based Reporting SystemsWeb based systems increase adverse events reportingWeb based systems increase adverse events reporting

of events 2001

2002

Num

ber o

Study used educational tools to inform employees of the purpose behind reporting, the importance of it, and the operational fundamentals of the electronic system

Web Based Reporting SystemsWeb Based Reporting SystemsResearchers in Japan found similar results                                           pafter implementing a system that wasVoluntary

Non punitiveNon punitive

Web based 

Nurses monthly reporting increased from 45 to 177

Knowledge from these increased reports lead to improvements inDrug searching methods for computer prescriptions

Elimination of “look alike” drugsg

Operation of syringe pumps

Error detecting systems for blood transfusions

A Q t f E llA Quest for Excellence

St Joseph Health SystemSt. Joseph Health SystemEst in 1936 SJHS of Bryan includesEst. in 1936, SJHS of Bryan includes

St. Joseph Regional Health Center

St. Joseph Rehabilitation Center

Two long‐term care facilities

Three critical access hospitals

Eight rural health clinics

A managed care division

St. Joseph Foundation

Property companyProperty company

SJHS serves an extended 7‐ county area of Brazos Valley

Sponsored by the Sisters of Saint Francis of Sylvania, Ohio  

SJHS J t E llSJHS Journey to ExcellenceMalcolm Baldrige National Quality Award

Management framework supporting performance excellence

Ever improving value and healthcare quality to patients and stakeholders supporting organizational sustainability

Improved organizational effectiveness and capabilities

Organizational and personal learning

Core values and concepts‐learningCore values and concepts learning

Award criteria

Manage organizational knowledge

C ll ti d t f f kf k l dCollection and transfer of workforce knowledge

Rapid identification, sharing, and implementation of best practices

Key terms

Knowledge assets

Texas Award for PerformanceTexas Award for Performance Excellence

Received the TAPE in 2007

Effective knowledge transfer mechanismEffective knowledge transfer mechanism                                from top down, but not bottom up, not                             between facilities

Paper based event reporting system adversely affecting patient safety communication

C ll b d i h CRG M di l l l iCollaborated with CRG Medical to employ electronic event recording and analyzing system

St Joseph Health SystemSt. Joseph Health SystemFocuses on patient safety and improved health care byFocuses on patient safety and improved health care by learning from 

adverse events that harm patients

events with no harm

near misses

analysis begins with all stakeholders at the point of service

Addresses health care workers concerns regarding openness and transparency in health care deliverytransparency in health care delivery

CRG MedicalCRG MedicalCRG Medical approach follows the Toyota Production concept 

of Kaizen or “continual improvement” p

Plan & Design

Kaizen ImplementAssess/

Reassess

Evaluate

CRG M di l C tBuilding institutional knowledge gained                                            

CRG Medical Concept

from the knowledge workers who are                                                      the experts on their process

Knowledge Workers own the processes                                               and know best how to implement them

Knowledge workers can identifyProcess weaknesses

Potential failures

“Work‐arounds”Work‐arounds

CRG Medical’s KBCore

KBCore is a Patient Safety Knowledge Building platformy g g p

Caregivers can communicate issues of 

concern in real time

Condition or event is analyzed at                                                point of delivery of care by the caregiver

Caregivers provide solutions or recommendations for improvement

OD/Process ManagementOD/Process ManagementResults Triad

CRG Medical’s solutions allow you to improve quality and reduceCRG Medical s solutions allow you to improve quality and reduce risk in a systematic process

Gather Refine Understand Act

Claims Analysis

E t A l i

Claims Analysis

E t A l i

Knowledge Builder Software

Knowledge Builder Software

Decision‐making Dashboards

Decision‐making Dashboards

FeedbackFeedbackEvent Analysis

Gap Analysis

Event Analysis

Gap Analysis

Software

Knowledge Management Model

Software

Knowledge Management Model

Dashboards

Knowledge Builder ad‐hoc reports

Dashboards

Knowledge Builder ad‐hoc reports

Facility Training 

Train‐the‐Trainer

Facility Training 

Train‐the‐Trainer

Challenge of ChangeChallenge of ChangeEncourage management and caregivers to not only recordEncourage management and caregivers to not only record 

harmful events but also near misses and events without harm

“Want to” Record and 

“Have to” Report and 

ImproveBlame

Going PaperlessReporting systems do not prevent errors only people do

However, an online paperless process trumps paper for several reasons:

Replaces paper with electronic notification

Allows immediate routing to managementAllows immediate routing to management

Provides rapid sharing of knowledge

Going PaperlessInvolves front line workerPulls tacit knowledge from the front line into explicit knowledgeknowledge Provides caregiver analysis of problems at the point of careProvides an easy way for front line workers to submit ideas to fix identified problemsS t d th d t f t d tiSystem does more than document facts and narrative‐ a Mini ‐ RCA

Essential ElementsEssential Elements

Requires commitment from the top (a given but must be said)

Requires one person who owns the project

Enterprise rollout plan: main hospital, clinics, CAH, long term care facilities (requires additional material for stateterm care facilities (requires additional material for state reporting)

R fl C lReflects CultureSJHS basic culture & tenets were incorporated into the S S bas c cu u e e e s e e co po a ed o eproject: trust and transparency

As a matter of principle:There is no limiting of access to data entry

There is no limiting of access to individual case reports 

All managers can run reports on any event type, follow‐up comments, or unit 

As one Director noted this was a massive change fromAs one Director noted, this was a massive change from the hard copy system.

Fl ibili i D lFlexibility in Development

Requires a "core" set of fields and values but the ability to customize/modify is critical

S S difi d h d f h S SSJHS modified the order of the STEPS

SJHS modified the organization of the contributing factors

SJHS customized the module by adding the interventionsSJHS customized the module by adding the interventions already in place for falls and PU

SJHS customized the module by adding a specific type of follow up report

All modifications had to be tested  and a pilot for problem identificationidentification.

R i d EffRequired EffortDue to other enterprise wide projects, a massive training program was not possible. Therefore a unit by unit "just in time" training was initiated

Requires ongoing maintenance of user data base

Requires one person who has an enterprise wide view to route, track, and monitor  trends.

Requires whoever looks at all events, looks for completeness, accuracy, and review of follow‐upp , y, p

OOutcomes ‐ Success is not 100%!SIX MONTHS INTO IMPLEMENTATION

• Main hospital three CAH all clinics on boardMain hospital, three CAH, all clinics on board

• System being customized for LTC reporting requirements

Staff are using the system despite follow‐up from administration

Managers do not always document their follow‐up

Not all areas are as compliant as others 

O t i ?Outcomes – any surprises?

We did expect to learn what is happening in the organization and to obtain the direct care giver perspective on the “why and how” 

Suggestions from front line workers

Going Paperless ‐ OutcomesHow is it working?How is it working?

Events ratio tends tends to be SJRHC's has 43% falls and 57%Events ratio tends tends to be 40+% falls  and 40+% medication variances

SJRHC s has 43% falls and 57% other (separate medication system). 

Contributing Factors: many times the "CF" is "patient”

SJ's indicates 35% "patient" with communication, environment, equipment,environment, equipment, documentation.

Intervening Factors ‐ we hope  SJ's has 50% in these for the following: equipment, protocol, team and family

selections

O t I f tiOutcomes Information From the FrontlineFrom the Frontline 

• Reasons for events can be shared across event types and units

• Contributing Factors provide a “mini RCA”

• Intervening factors provide data on what was done to stop an event from worsening

• Category Specific Intervening Factors (falls and PU) provide data on what prevention mechanism did not work in these caseswork in these cases

OutcomesBenefits for ManagersBenefits for Managers 

Managers have instant access to their own data

Fall data was ratio by unit.  Now Nursing has content re: falls

G t th "j t th f t “ t th tGet more than "just the facts“, get the reporters assessment of the reasons‐contributing factors.

Login

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Entering Events in KBCoreEntering Events in KBCore

37

Case typeCategory by “Case type”: what type of events are reported?

with harm? 

without harm? 

near miss?

Case type allows comparisons between near misses and other event types

Measuring Case type is a proxy for the culture of reporting

39

45

Recording in KBCoreStandard reports with defining criteria allows the staff person to start doing reports without creating their own. Using the criteria  provides a broad range of reports, both bar and run charts, from the same templateReports are web‐based, that is, do not require download to Excel or AccessExports all data elements to ExcelExports all data elements to Excel

22 Standard Reports

Looking at Data‐Looking at DataStandard Data capture

Count by Quarter: All category types  ‐ a trend report‐how many and what categories?y gCount by Category: All category types ‐ how many of each event type

b /Category by Unit : department and unit/areaCategory by Clinical Service for physiciansSeveritySeverity

Category by Severity Category by Injury TypeCategory by Injury TypeInjury by Severity 

Drilldown CapabilityCategory by Unit Drilldown to different administrative levels

fCategory by Contributing Factor‐ looking at detail of one CF across all categories

Looking at detail of one category but drilling down intoLooking at detail of one category but drilling down into detail of CF's

Lowest level:Lowest level:

drilldown  by unit, category subtypes x factor subtypes (ex, fall subtypes x CF subtypes)

Use of Case type forUse of Case‐type forMeasuring CultureMeasuring Culture

Case‐type allows comparison of events that have not harmed patients to events that have harmed patientsProvides an early warning systemMeasuring ratio of near misses to events that reach a patient provides a proxy measure of culturepatient provides a proxy measure of cultureComparing RCA contributing factor to current event contributing factors indicates status of performance improvement efforts

L i bLearning more about Events and Near MissesEvents and Near Misses

Contributing Factors‐ what started the eventgLearn what CF are the same or different between categories of events/areas/units/demographics of patients

Compare and contrast without doing a specific studyCompare and contrast without doing a specific study

What are the differences between misses and hits?

Intervening Factors‐ what stopped the event from g ppbecoming worseWhat Interventions relate to which categories

Wh t I t ti l t t hi h C t ib ti F tWhat Interventions relate to which Contributing Factors

Going paperless‐What did we learn?Going paperless What did we learn?Simple charts lead to further review

S ff     Staff report more events without harm than with harm (positive culture)(p )

Note:  Event to RCACompares past to presentpresent

Going paperless‐What did we learn?Going paperless What did we learn?Contributing Factors from the Frontline

“Common Cause” Common Cause  may be identified across event types

Staff spend time on their selections, and are willing to  check Management and Organizational factorsfactors

Going paperless What did we learn?Going paperless‐What did we learn?Prevention mechanism in place prior to fall

Customized for the facilities’ Safecare Fall prevention programprogram

Mini RCA without chart review

Note: these Note: these mechanisms worked for patients who did not fall

Going paperless What did we learn?Going paperless‐What did we learn?Fall specific Contributing Factors= Mini RCA

For each type of fall, what are the Contributing factors? factors? 

Mini RCA without chart review

How to Create Charts from the Data Collected in KBCore

Export Raw Data from KBCore from KBCore

into Excel

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Reason

Evans, S.M., Berry, J.G., Smith, B.J., Esterman, A., Selim  P., O’Shaughnessy, J., DeWit, M (2006). Attitudes and barriers to incident reporting: a collaborative hospital study. Quality safe health care, 15, 39‐43

Hutchinson, A., Young, T.A., Cooper, K.L., McIntosh, A., Karnon , J.D., Scobie,  S., Thomson, R.G. (2009). Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System.  Quality and Safety in Health Care., 18, 5‐10.

Institute of Medicine (2001).Crossing the Quality Chasm: A New Health System for the 21st Century

Kingston, M.J., Evans, S.M., Smith, B.J., (2004). Attitudes of doctors and nurses towards incident reporting: a li i   l i  M di l J l  f  A i   8   6qualitative analysis. Medical Journal of  America, 181, 36–9.

Lawton, R., & Parker, D. (2002). Barriers to incident reporting in a healthcare system.  Quality Safe Health Care, 11, 15‐18.

Nakajima, K., Kurata, Y.,  Takeda, H. (2005) A web‐based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital  Quality and Safety in Health Care  2  collaborative projects for patient safety in a Japanese hospital. Quality and Safety in Health Care, 2, 78‐79.

Nash, D.B. (2003). Tracking medical errors: enter the private sector. Health Policy Newsletter, 16,1–3.

Tuttle, D., Holloway, R., Baird, T., Sheehan, B., & Skelton, W.K. (2003). Electronic reporting to improve patient safety. Quality and Safety in Health Care 13 281‐286Quality and Safety in Health Care, 13, 281 286.

Whitson ,T., Garten , B., & Lewis ,Jon.(2009). Indiana medical error reporting system. Indiana State Department of  Health

www.IOM.eduhttp://wwwhcqualitycommission gov/http://www.hcqualitycommission.gov/http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.7695

Contact Information

Mark Montgomery M.D., MMM Douglas Dotan MA, CQIA

mmontgomery@st-joseph.orgTel: (979) 776-25982801 Franciscan Drive

ddotan@crgmedical.comTel: (713) 825-7900 2630 Fountain View Drive Ste 4082801 Franciscan Drive

Bryan, Texas 77802-2544www.st-joseph.org

2630 Fountain View Drive, Ste 408Houston, Texas 77057www.crgmedical.com