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Module 3: Incident Analysis as part of the Incident Management Continuum

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Canadian Patient Safety Institute
Canadian Patient Safety Institute

To increase the effectiveness of the incident analysis in improving care, analysis can’t be addressed in isolation from incident management (the multitude of activities that take place before and after an incident). Three main topics will be covered in this module: the main steps in the incident management continuum; differentiating between incident analysis (focused on system improvement) and accountability reviews (focused on individual performance), and selecting an incident analysis method.

Health & Medicine
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Incident Analysis Learning Program - Module Three Incident Analysis as part of the Incident Management Continuum Dec. 13, 2012
Welcome Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore
Learning Objectives The knowledge elements include an understanding of: • The incident management continuum • How incident analysis is an integral part of the continuum • How disclosure fits with the continuum The performance elements include the ability to: • Determine if incident analysis is appropriate using the incident decision tree • Select an incident analysis method
Agenda 3-parts • Practice leader • Knowledge expert • Facilitated discussion
Introducing: WebEx Be prepared to use: - Annotation tools - Chat/ Q&A - Interactive tools 5 13-Dec-12 5
Where are you from? International: (type here) _______________ _______________
About You
Presentation Nadine Glenn Gail Wells
Analysis Process— Incident Decision Tree
BEFORE THE INCIDENT Learning from Leadership Previous Incidents Support Or those Shared Culture And Attributes http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ RespectfulManagementSeriousClinicalAEsWhitePaper.aspx
IMMEDIATE RESPONSE • Care for Patient/Family/Provider • Report (Safety and Learning Report/Occurrence report/Documentation) • Secure Items Related • Begin Disclosure • Decrease the Risk of Imminent Recurrence
Disclosure Something happened. Now what? Why disclose effectively and compassionately? How to disclose effectively and compassionately What happens if we do not disclose at all?
Disclosure WHY: Disclosure is not a process of patient/family placation Key guiding principles • Patient-Centered Healthcare • Patient Autonomy • Healthcare that is Safe • Leadership Support • Disclosure is the right thing to do • Honesty and transparency What is a disclosure culture?
Disclosure HOW • What do patients want to hear? • What do providers need to say? • Clinical Needs • Emotional Needs • Information Needs
Disclosure WHAT IF WE DON’T ―Long after we have forgotten what you told us, we remember how you made us feel‖
PREPARE FOR ANALYSIS • Select an Analysis Method • Preliminary Investigation: Fact Finding • Identify the Team and Team Approach • Coordinate Meetings • Plan and Conduct Interviews
Analysis Process--Timeline Date and Description Source Time Oct 1 @ Pt rings call bell. Asks provider Interview/Patient 1505 for analgesic for post op pain Chart 1510 Analgesic given Medication Administration Record 1530 Provider checks on patient. Patient Chart Finds patient on floor 1531 Provider calls for help. Patient Interview assessed. No apparent injury 1535 Patient returned to bed using Patient Chart lift
ANALYSIS PROCESS Methods Include: • Comprehensive • Concise • Multi-Incident Each method will determine: • What happened • How and why it happened • What can be done to reduce the risk of recurrence and make care safer • What was learned
Criteria to Consider in Selecting an Analysis Method
3.6.3 Comprehensive Analysis Page 39 Canadian Incident Analysis Framework
Page 46 Canadian Incident Analysis Framework Agreed upon Actions for facts improvement (if any) Key contributing Factors and Evaluation findings
Page 48 Canadian Incident Analysis Framework
Figure 3.6.5. Multi-Incident Analysis Page 51 Canadian Incident Analysis Framework
Recommended Actions Develop Recommended Actions • Key features of effective recommended actions • Hierarchy of effectiveness • Order of priority for recommended actions • Consult on the draft recommended actions Page 57 • Prepare and hand-off report
Recommended Actions Manage Recommended Actions • Validate actions from strategic and operational perspectives • Delegate recommended actions for implementation and empower implementation
FOLLOW-THROUGH • Implement Recommended Actions • Monitor and Assess Effectiveness of Recommended Actions • Boston Consulting Group Tool http://dice.bcg.com/dice.html
CLOSE THE LOOP • Sharing the Learning (Within and outside org.) • Feedback (those involved in the process/patients • Feed-forward (Sharing learning externally—Alerts, advisories or memos) • Review and evaluate the Incident Management Process
Case Study– Virtual Group Exercise
CASE STUDY—Part 1 Background In a Rural Hospital with 1 Obstretical/Gynecologist, the OB/Gyne physician takes a week vacation. The traditional process is that all patients close to delivery date are notified and told to travel to the city (1 and a half hrs away) if labour begins. The Ob/Gyne physician in the city is notified and memos sent. If a patient presents to the ER of the Rural Hospital, the nurse and physician are to send the patient immediately to the city.
Case Study –Part 2 A patient in labor arrives at the ER The Registration Clerk sends the patient to the nurse on the OBS Unit for Assessment The nurse and physician assess and call the Manager-on Call to inform that the patient is 8 cm dilated and the patient should not be transferred via ambulance. Outcome: Patient requires a C-Section which is performed by the General Surgeon
Breakout Session Most participants will ―move‖ to breakout rooms Some participants will stay in the main room Those prompted: click YES to both pop-up screens to ―move‖
Facilitation Questions Would there be benefit in conducting an incident analysis? Look at this occurrence and decide what method of analysis you would use. How would you manage this incident?
Analysis Process— Incident Decision Tree
Large Group De-Brief 5 minutes
Goal Setting: Next Steps Tomorrow I/We will….
Wrap-up
Next Steps • End of session evaluation  certificate • Follow up survey  we learn from you Incident Analysis Learning Program • Comprehensive analysis – January 10, 2013 • Concise analysis – January 31, 2013 • Multi-incident analysis – February 21, 2013 • Recommendations management – March 7, 2013 • Follow-through and share what was learned – March 28, 2013
Resource slide Module 1 Recording: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP rogram/Pages/Session-Recordings-and-Documents.aspx Module 2 Recording: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningProgr am/Pages/Session-Recordings-and-Documents.aspx Disclosure guidelines http://www.patientsafetyinstitute.ca/English/toolsResources/disclosure/Pages/def ault.aspx Guidelines for informing the media after an event: http://www.patientsafetyinstitute.ca/English/news/Documents/CPSI%20Best%20 Practice%20Guide.pdf IHI document: Respectful Management of Serious Clinical Adverse Events http://www.ihi.org/knowledge/Pages/IHIWhitePapers/RespectfulManagement SeriousClinicalAEsWhitePaper.aspx CMPA Good Practices Guide: www.cmpa-acpm.ca/gpg HQCA Document (as another way to conduct incident analysis) http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi ews%20FINAL%20June%202012.pdf
Mulţumesc Thank You

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Module 3: Incident Analysis as part of the Incident Management Continuum

  • 1. Incident Analysis Learning Program - Module Three Incident Analysis as part of the Incident Management Continuum Dec. 13, 2012
  • 2. Welcome Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore
  • 3. Learning Objectives The knowledge elements include an understanding of: • The incident management continuum • How incident analysis is an integral part of the continuum • How disclosure fits with the continuum The performance elements include the ability to: • Determine if incident analysis is appropriate using the incident decision tree • Select an incident analysis method
  • 4. Agenda 3-parts • Practice leader • Knowledge expert • Facilitated discussion
  • 5. Introducing: WebEx Be prepared to use: - Annotation tools - Chat/ Q&A - Interactive tools 5 13-Dec-12 5
  • 6. Where are you from? International: (type here) _______________ _______________
  • 9.
  • 11. BEFORE THE INCIDENT Learning from Leadership Previous Incidents Support Or those Shared Culture And Attributes http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ RespectfulManagementSeriousClinicalAEsWhitePaper.aspx
  • 12. IMMEDIATE RESPONSE • Care for Patient/Family/Provider • Report (Safety and Learning Report/Occurrence report/Documentation) • Secure Items Related • Begin Disclosure • Decrease the Risk of Imminent Recurrence
  • 13. Disclosure Something happened. Now what? Why disclose effectively and compassionately? How to disclose effectively and compassionately What happens if we do not disclose at all?
  • 14. Disclosure WHY: Disclosure is not a process of patient/family placation Key guiding principles • Patient-Centered Healthcare • Patient Autonomy • Healthcare that is Safe • Leadership Support • Disclosure is the right thing to do • Honesty and transparency What is a disclosure culture?
  • 15. Disclosure HOW • What do patients want to hear? • What do providers need to say? • Clinical Needs • Emotional Needs • Information Needs
  • 16. Disclosure WHAT IF WE DON’T ―Long after we have forgotten what you told us, we remember how you made us feel‖
  • 17. PREPARE FOR ANALYSIS • Select an Analysis Method • Preliminary Investigation: Fact Finding • Identify the Team and Team Approach • Coordinate Meetings • Plan and Conduct Interviews
  • 18. Analysis Process--Timeline Date and Description Source Time Oct 1 @ Pt rings call bell. Asks provider Interview/Patient 1505 for analgesic for post op pain Chart 1510 Analgesic given Medication Administration Record 1530 Provider checks on patient. Patient Chart Finds patient on floor 1531 Provider calls for help. Patient Interview assessed. No apparent injury 1535 Patient returned to bed using Patient Chart lift
  • 19. ANALYSIS PROCESS Methods Include: • Comprehensive • Concise • Multi-Incident Each method will determine: • What happened • How and why it happened • What can be done to reduce the risk of recurrence and make care safer • What was learned
  • 20. Criteria to Consider in Selecting an Analysis Method
  • 21. 3.6.3 Comprehensive Analysis Page 39 Canadian Incident Analysis Framework
  • 22. Page 46 Canadian Incident Analysis Framework Agreed upon Actions for facts improvement (if any) Key contributing Factors and Evaluation findings
  • 24. Figure 3.6.5. Multi-Incident Analysis Page 51 Canadian Incident Analysis Framework
  • 25. Recommended Actions Develop Recommended Actions • Key features of effective recommended actions • Hierarchy of effectiveness • Order of priority for recommended actions • Consult on the draft recommended actions Page 57 • Prepare and hand-off report
  • 26. Recommended Actions Manage Recommended Actions • Validate actions from strategic and operational perspectives • Delegate recommended actions for implementation and empower implementation
  • 27. FOLLOW-THROUGH • Implement Recommended Actions • Monitor and Assess Effectiveness of Recommended Actions • Boston Consulting Group Tool http://dice.bcg.com/dice.html
  • 28. CLOSE THE LOOP • Sharing the Learning (Within and outside org.) • Feedback (those involved in the process/patients • Feed-forward (Sharing learning externally—Alerts, advisories or memos) • Review and evaluate the Incident Management Process
  • 29. Case Study– Virtual Group Exercise
  • 30. CASE STUDY—Part 1 Background In a Rural Hospital with 1 Obstretical/Gynecologist, the OB/Gyne physician takes a week vacation. The traditional process is that all patients close to delivery date are notified and told to travel to the city (1 and a half hrs away) if labour begins. The Ob/Gyne physician in the city is notified and memos sent. If a patient presents to the ER of the Rural Hospital, the nurse and physician are to send the patient immediately to the city.
  • 31. Case Study –Part 2 A patient in labor arrives at the ER The Registration Clerk sends the patient to the nurse on the OBS Unit for Assessment The nurse and physician assess and call the Manager-on Call to inform that the patient is 8 cm dilated and the patient should not be transferred via ambulance. Outcome: Patient requires a C-Section which is performed by the General Surgeon
  • 32. Breakout Session Most participants will ―move‖ to breakout rooms Some participants will stay in the main room Those prompted: click YES to both pop-up screens to ―move‖
  • 33. Facilitation Questions Would there be benefit in conducting an incident analysis? Look at this occurrence and decide what method of analysis you would use. How would you manage this incident?
  • 36.
  • 37. Goal Setting: Next Steps Tomorrow I/We will….
  • 39. Next Steps • End of session evaluation  certificate • Follow up survey  we learn from you Incident Analysis Learning Program • Comprehensive analysis – January 10, 2013 • Concise analysis – January 31, 2013 • Multi-incident analysis – February 21, 2013 • Recommendations management – March 7, 2013 • Follow-through and share what was learned – March 28, 2013
  • 40. Resource slide Module 1 Recording: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP rogram/Pages/Session-Recordings-and-Documents.aspx Module 2 Recording: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningProgr am/Pages/Session-Recordings-and-Documents.aspx Disclosure guidelines http://www.patientsafetyinstitute.ca/English/toolsResources/disclosure/Pages/def ault.aspx Guidelines for informing the media after an event: http://www.patientsafetyinstitute.ca/English/news/Documents/CPSI%20Best%20 Practice%20Guide.pdf IHI document: Respectful Management of Serious Clinical Adverse Events http://www.ihi.org/knowledge/Pages/IHIWhitePapers/RespectfulManagement SeriousClinicalAEsWhitePaper.aspx CMPA Good Practices Guide: www.cmpa-acpm.ca/gpg HQCA Document (as another way to conduct incident analysis) http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi ews%20FINAL%20June%202012.pdf