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:

Warren Hill
Consultant, Quality Improvement and Patient Safety
Fraser Health

Published in: Health & Medicine
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Developing an Effective Serious Harm Event Review Process for Residential Care

  1. 1. 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 1 1
  2. 2. The Issue  Avalanche of safety reports  Event follow-up isolated & inconsistent  Siloed learnings  Review processes are fragmentary 2
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. Review Process: Serious Harm Events 6
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. The PSLS Review Tool 10
  11. 11. 11
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Questions? 16