Developing an Effective Serious Harm Event Review Process for Residential Care

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warren.hill@fraserhealth.ca

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

Developing an effective serious harm event review process for Residential Care

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The Issue

Avalanche of safety reports Event follow-up isolated & inconsistent Siloed learnings Review processes are fragmentary

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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

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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

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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

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Review Process: Serious Harm Events

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Monthly Review

Moderate & Serious Harm

Events

Secondary

Review/ Actions

Tertiary Critical Patient Safety Review

Follow-up with Review Committee

Results to Review Committee & Leadership Group

Organization-wide Learning

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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

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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?

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The PSLS Review Tool

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Results

RCAL average number of events reviewed increased by 64%: Mar thru Sept meetings (1st meeting): 21 events Sept(2nd meeting) thru Nov meetings: 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

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Events Presented at RCAL QRC

0

5

10

15

20

25

30

35

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MARCH APRIL MAY JUNE SEPT (1ST) SEPT (2ND) OCT NOV

ONGOING

CLOSED

New review tool implemented

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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

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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

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Questions?