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Developing an Effective Serious Harm Event Review Process for Residential Care
 

Developing an Effective Serious Harm Event Review Process for Residential Care

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This presentation was delivered in session D1 of Quality Forum 2014 by:

This presentation was delivered in session D1 of Quality Forum 2014 by:

Warren Hill
Consultant, Quality Improvement and Patient Safety
Fraser Health

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    Developing an Effective Serious Harm Event Review Process for Residential Care Developing an Effective Serious Harm Event Review Process for Residential Care Presentation Transcript

    • Developing an effective serious harm event review process for Residential Care 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 warren.hill@fraserhealth.ca 1 1
    • The Issue  Avalanche of safety reports  Event follow-up isolated & inconsistent  Siloed learnings  Review processes are fragmentary 2
    • 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 3
    • 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 4
    • 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 5
    • Review Process: Serious Harm Events 6
    • Results to Review Committee & Leadership Group Tertiary Critical Patient Safety Review Follow-up with Review Committee Seconda ry Review/ Actions Monthly Review Moderate & Serious Harm Events Organization-wide Learning 7
    • 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 8
    • 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? 9
    • The PSLS Review Tool 10
    • 11
    • Results  RCAL average number of events reviewed increased by 64%:  Mar thru Sept meetings (1st meeting):  Sept(2nd meeting) thru Nov meetings: 21 events 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 12
    • Events Presented at RCAL QRC 40 35 30 New review tool implemented 25 ONGOING 20 CLOSED 15 10 5 0 MARCH APRIL MAY JUNE SEPT (1ST) SEPT (2ND) OCT NOV 13
    • 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 14
    • 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 15
    • Questions? 16