Life Cycle of a Critical IncidentCanadian Patient Safety Officer Course

Cecilia Bloxom, Director of Communications

Paula Beard, Senior Director (Western Region)

What’s going to happen…

Part A: In the Beginning…

Part B: Who’s Asking?

Part C: Can we Talk?

15 minutes Drink coffee and take a deep breath

Part D: What Happened?

Part E: What are we Going to Do About It?

Part F: Are we Sure we Did Something About It?

Part G: Can we Talk Some More?

Part A

In the beginning there was a patient safety incident report…

What do we do now?

Assumptions:

– Within your team individuals will play the role of:• CEO• Attending Physician• Charge Nurse• Patient Safety Officer• Other assignments will be determined based on the

exercise and the group’s decision to add roles

Assumptions

Staff have made the situation safe for others

An imminent recurrence has been prevented

Support has been provided for the family including the identification of a key family contact which is the resident’s daughter

Part A: In the Beginning

You have 15 minutes to build a plan with

your team on how to address the critical

incident

1. Build your plan & let those within your organization know what role they will play

2. Report back to your coach

3. Large team discussion on what went well and any challenges

Did you?

Notify the…

– Attending Physician– Chief Executive Officer– Nursing Manager– Social Worker– Health Information– Chief of Staff/Medical Managers– Risk Management/Legal Counsel/Insurer– Communications– Other staff as required. If so who?

…about the critical incident

Part B: Who’s Asking?

Effectively communicating after a patient safety incident

The Media calls…

DAUGHTER OF THE RESIDENT CALLS THE LOCAL TELEVISION STATION AFTER BEING NOTIFIED ABOUT HER MOTHER.

YOU NOW NEED TO RESPOND TO THE MEDIA AND THE PUBLIC.

Informing the Media

Assumptions:

– The resident’s daughter has not consented to waive her or her mother’s privacy

– You have asked for and been given 15 minutes to get back to the requesting media outlet (local news at noon are on their way)

– It is 2 days since the critical incident and the investigation is underway

Informing the Media

In your team –

1. Select a spokesperson and ensure that the person plays the organizational role (e.g., Communications, physician, CEO) as decided by the group

2. Identify who should assist with developing the messaging

3. Assist spokesperson to prepare the statement for the media

4. Your coach will act as the reporter

The Media calls…

POTENTIAL HEADLINES:

SENIOR WITH DEMENTIA FOUND FROZEN AFTER WALKING OUT OF SECURE FACILITY

DAUGHTER WANTS TO KNOW WHY HEALTH SYSTEM KILLED HER MOTHER.

Responding to the Media…

We know that:

Organizations that appear to be slow in responding

to patient safety incidents and/or perceived to be

consciously “covering them up” are often subject to

intense scrutiny, not only by the public and media,

but also by regulatory bodies or government.

Responding to the Media…

Expectation:

The culture around the disclosure of information on

patient safety incidents is changing.

It is now the expectation, not the exception that

organizations share this information with key

stakeholders and audiences.

Crisis Communications Plan

Context: What’s the main issue that needs to be addressed through communications? What/whose approvals do you need to proceed with communications?

Crisis Communications Plan

Environmental Scan:

What is the current situation, the key issue, the urgency, seriousness or pressing nature of these issue.

What’s been done to date to address them or identify what operational response has been approved?What information are you missing that you need to proceed?

Who do you need to contact and get involved?

Crisis Communications Plan

Timing: How much time do you have?

Clarify if more research and investigation are required and how long will that take.

Could/should the information-sharing be part of a larger announcement on broader patient-safety initiatives being launched by your organization? In other words, consider the broader patient-safety initiatives of the organization and how, or if, this event might reflect or advance them.

Crisis Communications Plan

Objectives: What do you want to achieve – i.e. raise awareness, share information, defuse controversy, change behaviour? Are your objectives actionable and measurable?

Crisis Communications Plan

Stakeholders/Audiences: Who are the stakeholders, both internal and external, who are directly affected by this; who are the key audiences (internal and external) that can influence outcomes, and/or are involved and interested in the issue.

Crisis Communications Plan

Messages: What are you going to say? Address the 5Ws, with the main focus on “why we are doing this”, supported by what actions we are taking/proposing; who will they affect; when will they occur; where will it take place; and how will it roll out, change/improve things, etc. When developing messages, ensure you always consider your audience. Tailor your messages so the language is clearly understood by the audience. Avoid using healthcare jargon or industry-specific language.

Developing Key Messages

Keep it short Make them memorable Write them towards your target audience Don’t use acronyms

What’s the what for your target audience

Caregivers

“Is someone going to get fired?”

What’s the what for your target audience

Other Patients and their families…

“Is this facility safe?”

What’s the what for your target audience

Policy makers

“What are you doing to ensure every patient is safe and this does not happen again?”

What’s the what for your target audience

Media

“What’s the story?”

What’s the what for your target audience

Media

“Who, what, when, where, why and how?”

Crisis Communications Plan

Issues Scan: What are the key issues that need to be addressed? What issues might create barriers or controversy; which ones provide opportunity? How do those issues align by stakeholder/audience? How are they likely to be perceived/presented by the public and/or media – i.e. positive, negative or neutral?

Crisis Communications Plan

Strategy: How high or low-profile do you want your “notification” to be? How wide a circle of audiences/stakeholders should it include? Should public outreach and communication be proactive or reactive? Consider the need to notify audiences in stages as the notification group is broadened, depending on the issue..

Crisis Communications Plan

Tactics: Your strategy will help define the scope of your tactics – e.g. a high-profile and proactive strategy obviously dictates more outreach, a wider range of information channels and communication products, and potentially a greater involvement by more members of your organization.

Crisis Communications Plan

Key considerations include:

What is your pre-announcement plan to talk to and/or precondition key stakeholders and audiences?

What is your plan surrounding the actual announcement? How do you propose to follow up, sustain and adjust your

messaging over time? What communications vehicles/channels are you proposing to

distribute the information – i.e. face-to-face, print, web-based, digital, etc.?

How do you propose to target specific key stakeholders and audiences?

Crisis Communications Plan

Roles and Responsibilities: Who needs to develop and deliver the tactical outputs – be specific. For example:

What’s the role for your CEO, if any? Who are your other key spokespeople? Who else besides communications needs to be

involved – e.g. board members, professional staff, Legal, HR, Finance, partners, volunteers, etc.?

Part C: Can we Talk?

In your team –

1. Identify a key contact for the family

2. Discuss if, when and how you would like to meet with the family

3. Decide what you will discuss with the family

4. Invite the resident’s daughter in to have the discussion (your coach)

Did you?

Utilize a process agreed upon by your team

Provide as many known facts as possible

Not speculate about the cause

Consider providing information regarding the organizational response

Identify a process for staying in contact and following up

Take a Deep Breath…

It’s coffee time!

Please be back in your teams in 15 minutes

Part D: What Happened?

In your team:

1. Decide how you are going to investigate what happened

2. List the steps you will take

3. Have a discussion based on the time line you will be provided by your coach about what your team believes is the contributing factors to the critical incident

Did you?

Quarantine and review articles related to the event

– Devices • To ensure defective devices are removed from service• Repair/return to manufacturer (serial numbers may be needed)

– Tour the Location– Drugs/solutions and associated packaging

• For analysis

– Physically examine drugs/devices involved in an event

– Health record

Did you?

Interview staff and others as appropriate (including

the family)– As soon as possible after the event

– One person at a time

– Interview all staff involved in the event as well as the family as appropriate.

– Use a cooperative approach

When interviewing did you?

• Ask individuals to “tell their story” and “re-enact” event. If possible, do not interrupt.

• Use open-ended questions

• Stay on track

• Record interview in a comfortable way

• Thank people for helping to provide understanding of event

Did you?

Conduct a literature review to:• Determine leading practices and relevant evidence

based guidelines

• Review standards of practice

• Any intervention, elimination or prevention strategies that has been previously tried for this type of incident

Did you?

Review the incident as a team:

– Multi-disciplinary

– Those with direct knowledge of the event processes

– Those responsible for change

Use a different method?

How did you arrive at the root causes

Use diagramming?

Are you sure your findings contributed to the critical incident?

How will you ensure there is an organizational memory of the critical incident?

Part E – What are we going to do about it?

Using your contributing factors from Part D, develop an action plan for the organization

Hint: Ensure they encourage system level changes which, if implemented, will have lasting effects on safety

Did your changes…

Receive leadership endorsement?

Consider a hierarchy of effectiveness?1. Forcing functions and constraints

2. Automation / computerization

3. Simplification / standardization

4. Reminders, checklists, double checks

5. Rules and policies

6. Education

7. Information

Part F: Are we Sure we Did Something About it? 30 minutes

The team will need to:

1. Develop a measurement plan.

2. Provide a 5 minute report to the Board Quality Committee (your coach)

Did you?

Assign actions to specific individuals Specify timelines Consider:

– Potential impact on individual units/staff– Barriers to implementation– Cost of implementation– Likelihood of causing additional adverse events– “Pilot-testing”

Did you?

Assess current status to determine if actions were effective

Monitor to ensure changes are maintained

Provide feedback to staff about impact of patient safety efforts

Did you?

Measure effectiveness of the action not [just] completion of the action – e.g. measure that falls assessment occurs for x% of new

patients admitted, NOT the number of staff trained to do falls assessment

Ensure the measures were quantifiable with defined numerator and denominator (if appropriate)

How do you know when you are done?

When is measurement complete?

How will you know if the improvement is successful?

1. Repeated measurement (e.g. audit) demonstrates sustained change

2. When the new process is routine

3. When new employees demonstrate proper procedure after orientation

Who else needs to know?

Consider communicating the information learned to those who could also benefit from the information

1. Within the organization

2. Outside the organization

3. “Incidental findings”

Click icon to add picture

Part G – Let’s talk some more 15 minutes

As a team consider what you can tell the resident’s daughter about what you know now.

When you are clear about what information and who will provide it to the resident’s daughter ask her to have another conversation with you.

Team Debrief

1. How much can you plan for and how much flexibility do you need when designing an organizational plan for addressing critical incidents?

2. If the original close call was reported to the organization how would the plan and the organizational response change?

3. What is the most important action or decision you will change or adapt after today’s exercise?