The document provides an overview of Module Seven of an Incident Analysis Learning Program on recommendations management. The module aims to help participants develop high-impact recommended actions, manage recommendations effectively, and explore tools to prioritize and monitor recommendations. It covers developing recommendations using SMART criteria, managing the recommendation process through tracking, assigning owners, and assessing effectiveness. The agenda includes a knowledge expert, practice examples, and a facilitated discussion for participants to learn from each other.

1. Incident Analysis Learning Program - Module Seven
Recommendations Management
March 7, 2013

2. Welcome
Tina Cullimore Sandi Kossey Erin Pollock Nadine Glenn Ioana Popescu

3. Learning Program
What was learned?
What can be done?
How and why?
What happened?
Multi-incident
Concise Comprehensive

4. 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

5. Agenda
3-parts
• Knowledge expert + Q&A
• Practice leader + Q&A
• Facilitated discussion (learn from each other)

6. Introducing: WebEx
We will use:
- Raise Hand & Checkmark
- Chat
- Pointer & Text
6
9-Apr-13 6

7. About You
0 How many RA are sitting on your organization’s shelf 600
collecting dust?

8. Presentation
Amir Ginzburg, Faculty

9. 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

10. 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

11. 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

12. Hierarchy of Effectiveness

13. 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

14. 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

15. Example
Table to summarize and prioritize RA

16. 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

17. Example Tracking Tool
Larsen Scale

18. 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

19. 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

20. 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

21. Questions?

22. Real-life Experience
Tamara Kennedy-MacDonald, Faculty

23. Managing Recommendations
to Improve Quality & Safety
The Fraser Health Experience
Tamara Kennedy-MacDonald, MSc
Special thanks to Jane Mann
23

24. Introduction
“We’ve received a report…”
Patient Safety Review
Patient Care Quality Review
Board
Coroner’s Report
Accreditation Canada Report
External Review
24

25. “…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!
25

26. 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?
26

27. Fraser Health’s Journey
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

28. 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
28

29. 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?
29

30. 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

31. 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

32. 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
32

33. Workflow
Accountable
Leader
File Handler
Board Committees
Recommendation
Owners
Action Owners
33

34. Recommendations Module
List all review reports

35. Contributing Factor/Recommendation

36. 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?)
36

37. 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
37

38. Scoring Tool

39. Scoring tool – Hierarchy of Effectiveness

40. Scoring tool – Organizational Support

41. Support Scoring tool – Resources

42. 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&reco
rdid=218 to view it.

43. Completed Recommendation

44. Recommendations Module:
Post-implementation assessment guide
• Measurement used (type of evidence)
• Impact of change on risk or hazard

45. Recommendations Module:
Recommendations Report

46. 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
46

47. Questions?

48. Learn from Each Other

49. 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

50. Breakout Session
Some participants will Some participants will
stay in the main “move” to breakout
room rooms
- No phone next to
your name
- Say no when
invited to breakout

51. Large Group De-Briefing
Highlights from small group discussion
Nuggets from the Q&A

52. Recap and Next Steps
End of session evaluation
Follow up survey
The last webinar: March 28th
Follow-through and share
what was learned

53. Resources
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/Inci
dentAnalysisLearningProgram/Pages/Session-
Recordings-and-Documents.aspx
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsReso
urces/IncidentAnalysis/Pages/Tools.aspx

54. Mulţumesc
Thank You