Follow Through and Sharing Learning · Incident Analysis Learning Program - Module Eight Follow Through and Sharing Learning March 28, 2013

Incident Analysis Learning Program - Module Eight

Follow Through and Sharing LearningLearningMarch 28, 2013

Welcome

Sandi Kossey Ioana PopescuErin PollockTina Cullimore Nadine Glenn

Learning Program

What can be done?

What was learned?

What happened?How and why?

Multi‐incident

ComprehensiveConcise

Learning Objectives

• Describe tools for more effectively implementing, measuring and monitoring recommended actions. g g

• Explain the importance of sharing learning from the i id l i i ll d ll h i k f incident analysis internally and externally so that risk of recurrence is reduced across multiple organizations and jurisdictionsj

• List characteristics of a good patient safety alert or d i h l i f f db k d f d f dadvisory to share learning for feedback and feed-forward

purposes.

Agenda

3 parts3-parts• Knowledge expert + Q&A (x2!)

• Practice leader + Q&A (x3!)

• Facilitated discussion (learn from each other)

Introducing: WebEx

Be prepared to use:‐ Raise Hand & Checkmark

‐ Chat & Q&A

‐ Pointer & Text

628‐Mar‐13 6

About You

What percentage of recommended actions actually result0 100What percentage of recommended actions actually result in safer care within your organization?0 100

Follow-ThroughFollow ThroughImplement, Measure, Assess

Ioana Popescu

Implement

Recommended Actions:• Not focused on contributing factors• Doesn’t have clear objectivesj• Not clearly communicated • Not visibly supported by senior leaders• Not visibly supported by senior leaders• ….

Tools

How?• Kotter’s 8 step process Kotter s 8 step process • Model for Improvement• DICE (Duration, Team, Commitment, Effort)( , , , )

Monitor and Assess Effectiveness

- Did the RA have the desired impact? Is care safer?If no revisit the RA identify alternative solutions- If no, revisit the RA, identify alternative solutions

- Monitoring requires measurement- Ask staff: how would you know if an action was Ask staff: how would you know if an action was

effective?- Outcome and process- “just enough” data - small sequential samples

S li i - Set realistic targets- Pg. 67 questions to

help design data collectionhelp design data collection

Deep Dive – Improvement Methodology and MeasurementMethodology and Measurement

Bruce Harries, Improvement Associates

ObjectivesObjectives

• Introduce the Improvement FrameworksIntroduce the Improvement Frameworks Getting Started Kit

• Better understand the Model forBetter understand the Model for Improvement

• Understand how the model can be applied toUnderstand how the model can be applied to design, test and implement actions to reduce the risk of harm

• Better understand measures for learning and monitoring actions

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Model for ImprovementModel for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Act Plan

Study Do

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Source: Associates in Process Improvement

When to Use the Model for Improvement

Improve a Family’s shopping

Improve a processIn an organization

Design a newproduct

Re‐design a nationalSystem (e.g. Medicare)

Improve ones Improve service Reengineer Reengineer anImprove onesgolf game

Improve serviceat a diner

Reengineer a subsystem

Reengineer anorganization

LeastFormal and

MostFormal and

less moredocumentation, tools, time,

Complex Complexrequired requiredgroup interaction, measurement, and so on

Source: Langley, et al. The Improvement Guide

ImprovementImprovement

All improvements require change but not all p q gchanges result in improvement.

Associates in Process Improvement (API)

Where do ideas for change come from? They must be developed Some ideas may be successful somebe developed. Some ideas may be successful, some will not. Testing is required. Which ideas should be implemented? Only the ideas where there is a high d f b li f h h h hdegree of belief that the changes when implemented will result in improvement.

Ron Moen (API)Ron Moen (API)

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Increasing Degree of Belief

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Common MethodsCommon Methods

• Critical thinking – 5 why’s flowchartsCritical thinking 5 why s, flowcharts, • Creative thinkingCh• Change concepts

• Applying technology • Benchmarking and learning from others

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Change ConceptsChange Concepts

Examples:p12. Synchronize steps14. Minimize Handoffs49. Extend time of specialists52. Stop tampering61. Use constraints72. Manage uncertainty

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Moving to Action…Moving to Action…

Plan:•State objectives. •Make predictions•Make conditions explicit.•Develop plan (5 W’s, How)

Act:•Adopt, adapt or abandon based on what was learned.•Build knowledge into next PDSA , )

Do:•Carry out the test•Document problems, surprises and

Study:•Complete analysis & synthesis•Compare data to predictions

into next PDSA Cycle

surprises, and observations.•Begin analysis.

Compare data to predictions •Record under what conditions results could be different.

•Summarize what was learned.

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MeasurementMeasurement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Act Plan

Study Do

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Source: Associates in Process Improvement

Collect Data Over TimeCollect Data Over TimeDo you think this change resulted in an

improvement?Before & After Tests

8

9

8

improvement? or

6

7

63% Improvement

3

4

5

Cyc

le T

ime

3

1

2

Make Change

0Week 4 Week 11

Source: Moen et. al. Improving Quality Through Planned Experimentation

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Do you think this change resulted in an y gimprovement?

Case 1

8

10or

6

8

Tim

e

4

Cyc

le T

Make Change

0

2

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week

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Case 210

or

6

8

me

4

Cyc

le T

im

Make Change

0

2

Make Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week

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Case 310

or

6

8

me

4

Cyc

le T

im

Make Change

0

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g

01 2 3 4 5 6 7 8 9 10 11 12 13 14

Weeek

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Case 4

8

10

2

4

6

Cyc

le T

ime

Make Change

01 2 3 4 5 6 7 8 9 10 11 12 13 14

Week

Case 5

8

10

4

6

Cyc

le T

ime

Make Change

0

2

1 2 3 4 5 6 7 8 9 10 11 12 13 14

WeekCase 610

4

6

8

Cyc

le T

ime

Make Change

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0

2

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Week

Make Change

Annotated Run Chart ‐ ExampleAnnotated Run Chart Example

Source: A Saskatchewan Falls Collaborative Team

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ReferencesReferences

• Improvement Frameworks Getting Started Kit p ghttp://www.patientsafetyinstitute.ca/English/toolsResources/ImprovementFramework/Documents/Improvement%20Frameworks%20GSK%20EN.PDF

• Langley, G. et al. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (Second Editi ) S F i J BEdition). San Francisco: Jossey‐Bass

Contact Info:Contact Info:Bruce [email protected] 437 5861780.437.5861

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ll h h l i hFollow Through, Closing the Loop and Sharing Learnings:St Michael’s Hospital experienceSt. Michael’s Hospital experience

Dr. Chris Hayesh i Q li f iChair, Quality of Care Committee,

Medical Director, Quality & Patient Safety,St. Michael’s Hospital

Medical Officer, CPSI

Follow Through, Closing the Loop and Sharing the Learnings

Overview

• Brief description of the process at St. Michael’s• Discussion of our challenges• Look into the “future”

QCC Process OverviewQuality of Care Committee Overview

QCC Process Overview

Quality of Care Committee Overview


Role of the QCC/ LQCCs

• Prepare for analysis• Conduct the analysis• Prepare recommendations for

approval

• The department/ program/ senior management team is responsible for approvingresponsible for approving, assigning and “ensuring” the implementation of the recommendationsrecommendations

• The assigned groups report back on the status of the recommendation

Quality of Care Committee Overview

2012201114QCC/LQCC

250%4QCC/LQCC

HVOB

MHDCCP

GYN

HV115QCC/LQCCMembership

161%44QCC/LQCCMembership

Corporate QCC

Lab

SCCP i O

FCMCorporate QCC OBLab

29+Reported Critical Events

16%25Reported Critical Events

SCC

GIM

EDTNS

Mobility

Peri‐Op

MH99Avg. Review Time(Working Days)

16%119Avg. Review Time(Working Days)

31+QCC/LQCCRecommendations

417%6QCC/LQCCRecommendations


Recent changes

• Expanded the number of LQCCs• Held a retreat to:

• Educate on the Canadian Incident Analysis Framework• Orient members to the revised tools and templates

H l th t i f l i t d SMART• Help them create meaningful, appropriate and SMART recommendations

2 Template for LQCC Recommendations to QCC

Clinical Issue/Context:

Case # / 2012,

Rec # Suggested Action Responsible Date of Completion

For each recommendation, provide a brief description of the clinical event/issue.

# /12 Specify recommendation. Identify the most responsible individual/ council that would be t k d ith th

Specify desired date of development/ implementation (M th/Y )tasked with the

development/ implementation of recommendation.

(Month/Year)

3 Template for Recommendation Approval

4 Template for Communication of Recommendation


So how’s it all working?

• Increasingly better recommendations• Greater appreciation for and understanding of the

recommendations by programmatic or senior leadership• Greater accountability over recommendation implementation and

“ l ti ”“completion”

• But…• Are the recommendations actually being implemented?• Are the recommendations actually being implemented?• Is there real associated practice change?• Have we “solved” the problem?• Are patient safer?Are patient safer?


We don’t really know!

• Programs report back subjectively on implementation status• Don’t require data on process and outcome indicators• Implementation may or may not use true quality improvement• Implementation occurs through a different process than other

t QI j tcorporate QI projects

• Is there really the buy-in and commitment to safety improvement?• Do people really believe that the recommendations will lead to• Do people really believe that the recommendations will lead to

improved safety?• Do we have the right support and resources to achieve success• Is it possible to measure outcome improvement for relatively rareIs it possible to measure outcome improvement for relatively rare

events


How do you get better?

• Looking to combine the QI and QCC implementation processes• Creating Quality Councils in each department/ program that will

• Have the LQCC Chair as a member• More openly discuss PSI reviews and work to create more

f ibl t bl d i t l dfeasible, acceptable and appropriately resourced recommendations

• Working to attach data requirements to evaluate recommendation implementation and outcomeimplementation and outcome

• Incorporating our Simulation Centre as means to augment root cause analysis, recommendation design, implementation andcause analysis, recommendation design, implementation and evaluation

• Keep at it…keep looking for opportunities to improve


Summary

• Our process for analyzing and learning from patient safety incidents is not perfect but is improving

• Following through and fixing safety issues is the hardest part• True improvement is based on finding the “right” solutions and

i l ti it i th “ i ht”implementing it in the “right” way

• This takes time….• But it’s worth it!!• But it s worth it!!

• Thank you

Learn from Each Other – Follow-through

S k Q d A G Di iSpeaker Q and A, Group Discussion

Theory Burst – Sharing Learning

Sandi Kossey, Senior Director

Closing the Loop – Sharing Learningg

Feedback: WHY?• Patients want to know:• Patients want to know:

1. The facts2. What is being done to minimize harm NOW3. An apology4. What will be done to prevent similar harm in the

future

• Staff want to know:1. Their reporting of incidents have led to change2. Their patient care can be as safe as possible3. That the changes that were implemented have had an

impactp4. The organization has a true learning and sharing

culture

Closing the Loop – Sharing Learning

Feedback: WHAT?• The story of what happened (the facts)• The story of what happened (the facts)• What contributing factors were found• The recommended actionse eco e ded act o s• Implementation plan• Timelines for implementation and follow-up• Results or impact• Feed-forward plan (how will this get shared outside the

i ti )organization)

Closing the Loop – Sharing Learningg

Feedback: HOW? • What does your organization do?• What does your organization do?

• Newsletters• Internal patient safety alerts/advisories• Ground Rounds• M&M sessions

• How far through the organization do learnings get How far through the organization do learnings get shared?

• UnitD• Department

• Sites

Close the Loop – Sharing Learningg

Feed-Forward: WHY?• The same incidents are occurring across Canada and

around the worldaround the world• No one should be stuck without a solution to a

problem that you have already solved

Feed-Forward: WHAT?• What happened and why it may have happenedpp y y pp• What was the organization’s response• What actions were implemented and what were the

resultsresults• What is recommended that others do to prevent

similar harm


Feed-Forward: HOW?• De identified learning in the form of patient safety • De-identified learning in the form of patient safety

alerts, advisories or notices on a public website• Inclusion in Global Patient Safety Alerts

www.globalpatientsafetyalerts.com


Informing the Public: WHY? WHAT? HOW? • Timely communication after a patient safety incident y p y

will:• Enhance public trust• Protect public safety• Protect public safety• Educate the public

Be sure to involve the patient and their family in the decision of what information to share

B k d t t d d ti • Background, context, recommended actions implemented, results

Patient Safety Alerts –Giving and Getting the Message

Linda Poloway, BScPharm, FCSHPLinda Poloway, BScPharm, FCSHPExpert Reviewer Global Patient Safety Alerts

What is a patient safety alert?

• Description • Purpose• Types of incidents

di i• Medication• Equipment and supplies / devices• Surgical proceduresSurgical procedures• Care management• Patient identification• Falls

• Source

PENNSYLVANIAPATIENTSAFETYADVISORY

SafeMedicationUse.caS d b H l h

ADVISORY

The Joint CommissionSupported by Health Canada

RISK ALERTSOregon

RISK ALERTSSENTINEL EVENTS Patient Safety

Commission

Quality of the Patient Safety Alert

• Clear title reflecting actual content

• Alert—KimVent® Closed Suction System (Adults) T-Piece( )

• 4 CASES OF RETAINED GAUZE IN VAGINA AFTER EPISIOTOMY REPAIR


• Clear title reflecting actual content

• Newer Oral Anticoagulants

• Risks Associated with Unfractionated Heparin to Maintain Patency of Intravascular DevicesMaintain Patency of Intravascular Devices


• Purpose of alertp

• Directive• Consumer advice• Warning• Opportunity for shared learning from adverse event


• Clear, concise description of the incidentClear, concise description of the incident

• What, who, when, how• Include incident report if possible• Pictures


• Pictures• Pictures

1 mL Epinephrine Ampoule1 mL Epinephrine AmpouleSnap-point indicatorActive ingredient name in colourTALLman letteringMachine readable bar code


• Pictures


• PicturesPictures


• Investigation and findings

• How was the investigation done?• What happened in what environment involving

whom?whom?• List specific drugs, devices, equipment and

supplies involved• What was the patient outcome?What was the patient outcome?• Had this incident happened before?

• How often?• What was done about it?• What was done about it?

• Are the findings directly linked to the incident?


• Recommendations for improvement with strong likelihood for implementation and optimal resultslikelihood for implementation and optimal results• Specific – clear statement of what is to be improved• Measurable – ability to measure if the y

recommendation has been implemented and has achieved the desired outcomeAccountable responsibility and timelines assigned• Accountable – responsibility and timelines assigned

• Realistic / Reasonable – considerate of local, regional, cultural, financial implicationsg , , p

• Timely – recommendations can be reasonably achieved in identified time frame

Hierarchy of ActionsHierarchy of Actions

Forcing functionsAutomation

WE

ST Automation

Simplification / standardizationReminders, checklists

AKER

TRON Reminders, checklists

Rules and policiesEducation

RGER

Information

Recommendations – Good and Not so Good

• “Remind staff to be vigilant when performing post-wound repair vaginal examination to exclude the possibilitywound repair vaginal examination to exclude the possibility of retained foreign objects.”

• “Enhance training of staff on suicidal risk identification d t ”and assessment.”

• “Consider requiring prescribers to undergo a privileging process to verify proficiency with PCA pain management.”p y p y p g

• “Ensure that buccal midazolam is only administered using oral syringes that are not compatible with intravenous or other parenteral devices ”or other parenteral devices.

• “Develop a standardized handoff process, including checklists, for all patients transferred between facilities.”

Key messages to communicate in an alert

• What happened in what environment involving whom?

• List specific drugs, devices, equipment and supplies involved using both brand and generic names where feasiblewhere feasible

• What was the patient outcome?• What did the facility do to improve things What did the facility do to improve things

immediately?• What are the recommendations that will improve

f t i th f t ?safety in the future?• What follow up will be done to ensure continued

improvement?improvement?

Why do we need good alerts?

• Enhanced database of patient safety incidents which can be used to learn from and:which can be used to learn from and:• Prevent similar patient safety incidents from

occurring• Build safety nets and quality controls

• Respond effectively to similar patient safety incidents which have occurredwhich have occurred• Implement similar recommendations• Build on recommendations published

• Develop a communication network for continuing quality and safety as well as source of reference in specific casesspecific cases

Learn from Each Other – Sharing for LearningLearning

Speaker Q and AGroup Discussion

Recap and Next Steps

End of session evaluation;

Follow up surveyFollow up survey

Learning Program De-Briefing

We learned from the end of session evaluations:• Enjoyed the learning program• Enjoyed the learning program• Don’t need deep dives in any of the topics• Need more: constellation diagram and disclosureeed o e co ste at o d ag a a d d sc osu e• More interested to connect with peers than faculty

Next:• Module on constellation diagram and disclosure• 3 month follow-up (90% of you allowed us to connect

i h i i h i i f )with you again in the registration form)• Trainers: PSEP-Canada

Please stay in touch! Please stay in touch!

Resources

Learning Program – previous modules

Incident Analysis Tools

Global Patient Safety Alerts

Canadian Disclosure Guidelines

Guidelines for Informing the Media

Mulţumesc

Thank You

ShukriaShukria