Incident Analysis Learning Program - Module Seven

Recommendations Management March 7, 2013

Welcome

Sandi Kossey Ioana Popescu Erin Pollock Tina Cullimore Nadine Glenn

What happened? How and why?

What can be done?

What was learned?

Learning Program

Comprehensive Concise

Multi-incident

Learning Objectives

• Develop high-leverage recommended actions

• Manage recommended actions to more effectively make care safer

• Explore tools: hierarchy of effectiveness, Larsen scale, heat map, monitoring tables

• Give examples of effective recommended actions • Evaluate recommended actions

Agenda

3-parts

• Knowledge expert + Q&A

• Practice leader + Q&A

• Facilitated discussion (learn from each other)

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Introducing: WebEx

9-Apr-13 6

We will use: - Raise Hand & Checkmark - Chat - Pointer & Text

About You

0 How many RA are sitting on your organization’s shelf 600

collecting dust?

Presentation

Amir Ginzburg, Faculty

Background

• A word on words: o Recommended actions (RA) Recommendations

o What can be DONE to reduce the risk of recurrence and MAKE care safer

• Why managing RA matters?

o A few, well thought-out, high-leverage RA a lengthy list of low-impact recommendations

• Where do RA come from? Where do they go?

o Incident management continuum; system levels

Developing and Managing RA

• Develop RA • Key features of effective RA • Suggest an order of priority for RA • Consult on the draft RA • Prepare and hand-off report

• Manage RA

• Validate RA from strategic & operational perspectives • Confirm actions • Assess validity • Approve and set guidelines for implementation

• Delegate RA for implementation; empower implementation

Features of Effective RA

• Address the risk (findings) • Utilize the most effective solution

• Hierarchy of effectiveness • Long term solution

• Are “SMART” • Are targeted at the right system level • Assign responsibility at the appropriate level • Have minimum “unintended” consequences • Are based on evidence • Provide enough context

Hierarchy of Effectiveness

Testing the Effectiveness of RA

Will it have the desired effect and impact?

Use Human Factors (Appendix N,p.128) • Cognitive walk-through • Heuristic evaluation • Usability testing

Eliminate – control – accept the risk

Suggest an Order of Priority

Why prioritize RA? Criteria:

• Risk of not implementing • Severity assessment score (p.38) • Heat map (p.59)

• Opportunity for immediate implementation • Quick wins empower implementation

• Couple with existing mechanisms • Complementary ongoing improvement efforts • Build and maintain an inventory

• Distribute RA at different system levels • Estimated effort: resources and timelines

Example

Table to summarize and prioritize RA

Almost Done Developing RA

Consult on the draft RA • To ensure impact in making care safer • Consult with

• Patients/ families • Providers from the area where the incident occured • Experts

• Mention that their suggestions will be considered but may not be acted on - explain reasons

Prepare and hand-off report • Add RA to tracking mechanism

Example Tracking Tool

Larsen Scale

Managing RA

The individual/group receiving the report • Validate RA - strategic and operational perspective

• Confirm actions • Ensure alignment with strategic and operational risks and

priorities • Merge RA from analysis report with RA from other sources

• Build on the inventory discussed earlier

• Assess if it can be done (validity) • Ensure RA are attainable, feasible, cost-effective

• Approve and set guidelines for implementation • Order of priority • System level targeted – may spread to other areas • Timelines, accountability, success measures, milestones,

reporting

Finally…

Delegate and empower implementation • Hand-off to the team/ individual responsible for

implementation • Via in-person meeting (ideal) • Show support

o Expect resistance to change o Allocate sufficient resources

• Get status updates o Empower again o Remove barriers

What’s Next?

Follow-through • Implementation • Monitor and assess the effectiveness of RA

Close the loop

• Share what was learned • Internally • Externally

• Global Patient Safety Alerts

• With the public

• Reflect on and improve the analysis process

Questions?

Real-life Experience

Tamara Kennedy-MacDonald, Faculty

Managing Recommendations to Improve Quality & Safety

The Fraser Health Experience

Tamara Kennedy-MacDonald, MSc

Special thanks to Jane Mann

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Introduction

“We’ve received a report…” Patient Safety Review

Patient Care Quality Review

Board Coroner’s Report

Accreditation Canada Report External Review

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“…with recommendations to…” Improve communication between…

Replace existing equipment with…

Develop a policy on…

Provide training on…

Revise the guidelines for…

Involve patients in…

Establish a new procedure to…

…and more!

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Current “system” It’s hard to know…who is responsible for what? What is the status of recommendations? Are they done yet? Also…are the recommendations sound? Will they fix the problem? Should we implement them? Who should we assign them to…and how? And…are we sure the changes were made? Are they being sustained? Did they fix the problem? Oh, and could you put a report together on that? And…haven’t we done this before?

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2005: Patient safety reviews using Root Cause Analysis framework

Single site: 18 reports with 90 recommendations

2007/08: 115 patient safety reports with 646 recommendations

2008: Joint audit with Canadian Patient Safety Institute Developed an “auditing” tracking database Adopted Larsen’s Utilization Scale to track implementation

status Identified need for a robust tool to manage recommendations

2008/09: 105 patient safety reports with 510 recommendations

2009/10: 68 patient safety reports with 340 recommendations Identified need to track accountability for implementation of

recommendations and assess impact on quality and patient safety

Fraser Health’s Journey

Fraser Health Principles in Recommendation management

Track recommendation review and approval process Assign recommendations to owners (i.e. programs) Track recommendation implementation status Facilitate status reporting by the programs …and… Evaluate strength of recommendations pre-implementation Assess effectiveness of changes post-implementation Support analysis of report topics, actions taken Share learning

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Recommendation Development Writing a Recommendation - S.M.A.R.T.E.R. Tool Is the recommendation based on a “key” finding

of the analysis supported by more than one source of data?

Is the language of the recommendation objective, clear, actionable, non-threatening?

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Recommendation Development Guidelines

Specific - What exactly are you trying to correct/improve? Measurable - Will you know if the recommendation has been implemented and if it

achieved the desired outcome? Accountable (Attainable) - Put a name and date to the recommendation lead/can

it be done? Reasonable (Realistic) - Consider local, regional and provincial implications.

Timely - Break the job down and assign a reasonable time period for completion Effective - Recommendation should reduce both the severity and frequency of a

future incident. Reviewed - Has the recommendation been implemented, achieved the desired

outcome, any unintended consequences ? 30

Examples the good, the bad, & the ugly(impossible!)

Set up a meeting to discuss the implementation of a checklist for….

Education sessions for staff regarding when to call code blue in.......

Physicians should communicate more effectively to nursing staff

All C.diff patients should have fecal transplants

Change the Mental Health Act 31

Making it SMART(er)

Modify the FH “Level of Observations” policy in the context of the RCH site and the inability of the psychiatric inpatient units to provide a more secure environment including a staff member assigned to monitor those patients restricted to the unit while a shift report is taking place

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File Handler

Workflow

Accountable Leader

Board Committees Recommendation

Owners Action Owners 33

Recommendations Module List all review reports

Contributing Factor/Recommendation

A little bit about…… PSLS Rec Module Scoring tool

>1 year in development in partnership with BC PSLS Central Office

Components are from evidenced based practices and tested for validity

Tested with other Health Authorities

Two sections: • Effectiveness (how effective it will be to address the risk?)

• Support (is there organizational support to be successful in implementation?)

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Recommendation Scoring Tool Why score a recommendation?

History: lots of recommendations with little evidence of the difference it made

• Can’t implement: not feasible/no support/barriers

• Won’t implement: does not make sense

• Will not address the main issues of cause

Recommendations are opinions…… More objective feedback mechanism whose

components are evidenced based

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Scoring Tool

Scoring tool – Hierarchy of Effectiveness

Scoring tool – Organizational Support

Support Scoring tool – Resources

Auto-notification Sample Email

Recommendation Owner Email You have been assigned as handler for Datix

recommendation 218.

Description: [09/05/2012 10:31:37 Jane Mann] repair alarm door Please go to

https://tst.bcpsls.ca/index.php?action=element&recordid=218 to view it.

Completed Recommendation

Recommendations Module: Post-implementation assessment guide

• Measurement used (type of evidence) • Impact of change on risk or hazard

Recommendations Module: Recommendations Report

Thank you!

Contact for more information Fraser Health: Quality Improvement & Patient Safety

• Tamara Kennedy-MacDonald (until May 2013) • tamara.kennedy-macdonald@fraserhealth.ca

• Jane Mann • jane.mann@fraserhealth.ca

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Questions?

Learn from Each Other

Learn From Each Other

Option 1: Evaluating RA • 2 small groups • Discuss or critique recommended actions

(Inadvertent Administration of Insulin to a Nondiabetic Patient)

Option 2: Group Discussion

• Additional Q&A • Whiteboard A: Developing RA • Whiteboard B: Managing RA

o Participants to discuss if and how it is done in their organization, what works, what can be improved

Some participants will “move” to breakout rooms

Breakout Session

Some participants will stay in the main room

- No phone next to

your name

- Say no when invited to breakout

Large Group De-Briefing

Highlights from small group discussion Nuggets from the Q&A

Recap and Next Steps

End of session evaluation Follow up survey

The last webinar: March 28th Follow-through and share what was learned

Resources

Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningProgram/Pages/Session-Recordings-and-Documents.aspx

Incident Analysis Tools

http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Pages/Tools.aspx

Thank You

Mulţumesc