Clinical Learning Action Plan Ay 2015-2016 Priority CLER Focus Area Pathway Action Plan Progress Owner Reporting of adverse events, Patient Safety 1 close calls (near misses). Implement Quality Facilitator Patient Safety Rounding w ith each residency program/resident team Tamela Morgan
Educate Residents on Patient Safety and Reporting of Safety Events PD/Faculty
Continue event reporting as a scorecard item in AY 2015-16 GME Office Simulation and Patient Safety Education Sub- Committee Develop Patient Safety Simulation Training Curriculum (SPSESC) Develop Education Module about the science of patient safety & Reporting of Safety events (SPSESC) Educate Residents using Science of Safety Module (SPSESC) Provide monthly feedback to Resident/Fellow reporters related to patient safety event Tamela Morgan Clinical Site Monitoring of resident/fellow engagement Provide quarterly report for patient safety events by in patient safety residents/Fellow s and Faculty to GMEC Tamela Morgan Resident/Fellow experience in patient safety investigations Provide quarterly report for RCA attendance by residents and and follow -up faculty to GMEC. Tamela Morgan
2 Healthcare Quality Education on Quality Improvement Development of Basic QI curriculum QPS/SPSESC Internal Medicine Internal Medicine Pilot Residency Program
Develop training module for basic QI w ith experiential learning QPS/SPSESC Provide basic QI education to residents and faculty QPS/SPSESC Internal Medicine IM basic QI Education Residency Program
Education to include Carilion quality and patient safety priorities. QPS/SPSESC
3 Care Transitions Education on Care Transitions Implement transitions of care education for faculty QPS/SPSESC Residents/Fellow engagement Implement a common approach for managing resident hand- Program in change of duty hand-offs. offs. (IPASS) Directors/DIO Create a process and observation tool for faculty to monitor handoffs. QPS Subcommittee
Evaluate through direct observation of residents/fellow by faculty member is required to ensure residents/fellow abailities to perform standardizated, Review transitions of care policies and identify w eak areas and efective, efficient handoffs. faculty spervision of handoffs. Directors/DIO DIO to assure handoff tool monitored by each program Directors/DIO
Roles of clinical staff members other than physicians in resident/fellow 4 Supervision supervision Assure that clinical staff are aw are of the objective method for identifying that residents/fellows are qualified for independent procedures. Tamela Morgan Track MSPROC complaints regarding supervision. Tamela Morgan Quality Rounding w ith Chief Quality Officer Tamela Morgan
Periodic monitoring of physician fatigue and burnout is essential to identifying vulnerabilities and designing Duty Hours/Fatigue and implementing actions to 5 Management enhance patient safety. Physician Wellness subcommittee Dr. Greenw ald Development of Wellness plan for residents
Resident/fellow and faculty member education on Educate new residents during orientation about appropriate and 6 Professionalism professionalism inappropriate uses of Copy & paste. GME Office Clinical Learning Environment Review Six Areas of Focus • Patient Safety
• Quality Improvement
• Transitions in Care
• Supervision
• Duty Hours Oversight, Fatigue Management and Mitigation
• Professionalism GME Resident/Fellow Scorecard AY2016-2017 1. Hand hygiene compliance
2. Patient Safety Event Reporting
3. CLABSI
4. CAUTI
5. PSI 06
6. PSI 12
7. VTE2
8. Duty Hour Violations
9. Flu Vaccine Compliance
10.Ready to Move from the Emergency Department How to Report a Patient Safety Event
•Call 7 Safe (77233) and Leave a message
OR
•Use the event reporting system icon on your computer.
•http://insidecarilion.org/hubs/event-reporting
WHAT SHOULD BE REPORTED?
Report Events that caused harm or have potential to cause harm!
1. Delay in Care • Xray completion delayed
2. Failure to Rescue • Patient deteriorating and there was a delay in identification of the need to treat.
3. Patient Falls • Patient/visitor falls
4. Laboratory Events • Missed labs WHAT SHOULD BE REPORTED?
5. Medication Errors •Medication dosing not correct
6. Communication Breakdowns •Failure to handoff 7. Unplanned Extubation •Patient pulling ETT out •ETT becoming dislodged
8. Unprofessional Behavior •Nurse yelling at the physician WHAT SHOULD BE REPORTED? 9. Equipment Failure or Malfunction •Exam gloves used in the ED were easily torn.
10. Unscheduled Re-Admissions within 30 days
11. Quality of Care Concerns •Wrong medicine ordered for patient treatment
12. Deviance from Policy and Best Practice •Failure to follow the specimen policy.
13. Unplanned upgrade in Level of Care •Rapid Response/Code Blue CMC AY 2015-2016 Event Reporting Data
Total Events Reported for CMC 14,462
Events Reported by Residents 187
Events Reported by Faculty 67
Total RCAs Completed 33
RCAs attended by Residents 14
Number of Residents that attended RCAs 31
RCAs attended by Faculty 26 Patient Safety Events Reported by Residents & Faculty AY2015-2016 30 25 25 24 25 20 15 17 15 12 14 13 12 14 13 13 10 9 10 9 10 Event Volumes Report Event 7 7 8 5 3 4 3 5 0 2 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Faculty 3 8 7 2 10 5 6 3 3 8 7 5 Resident 2 14 25 24 13 17 12 14 25 13 13 15 Faculty 2014-15 6 11 4 5 7 4 5 7 2 1 5 3 Resident 2014-15 12 9 10 9 3 7 7 4 3 10 5 8 Quality and Patient Safety Improvements AY 2015-16
1. Implemented standardized central line tracking and quality reporting
2. Increased reporting of patient safety events by 98% since AY 2014-15
3. Reported 3 events that resulted in Root Cause Analysis
4. Developed through a partnership between Internal Medicine and Continuing Professional Development a pilot Quality Improvement Curriculum resulting in 8 QI Projects for IM residents.
5. Implemented the Treatment Team use in EPIC to decrease confusion with nursing staff about whom to call.
6. Addition of new timeout element added to OB procedures Root Cause Analysis Evaluation Tool • RCA Plan • Step 1: Determine that an adverse event occurred
• Step 2: Define Composition of RCA Team
• Step 3: Review Literature
• Step 4: Conduct RCA
• Step 5: Develop an Action Plan
• Step 6: Measure Effectiveness of Plan The Swiss Cheese Model of Accident Causation
Some holes due to active failures HAZARDS
ADVERSE EVENT Other holes due to latent failures
Successive layers of defenses, barriers and safeguards CMC Process for Serious Event Review
•Event occurs, reported via referral, on-line report or 7 Safe •Reviewed by quality teams Event •Events with harm > level 4 (temporary major) occurs
•Review of event with those most aware of circumstances Meets definition for •Review of event compared to standard clinical practice, processes, policies/procedures further •Is it a sentinel event? Meets review criteria for RCA or IA? review
•Team formed, team leader from area involved in event •Review scheduled, focuses on process, action plan developed and implemented RCA or IA scheduled •If necessary, clinical practice or behavior reviews completed
•Serious & Sentinel event reduction committee( SSERC) reviews event, action plan and timelines Serious & •SSERC recommends other resources to support action plan (TSG, Epic team, etc) Sentinel Event •SSERC approves final action plan and timelines for follow-up Reduction Committee
15 DMAIC, Process Mapping, Fishbone A Framework for Improvement DMAIC
Define Measure
Control Analyze
Improve D (Define)
Define the Problem – Verify that it exists – Verify that it is important to customers – Verify that improvement is reasonable
Define the Customer(s) – Internal and external
Define Project Scope – Start and end point of process you hope to improve
Define Team Roles/Expectations – Team leader – Team facilitator M (Measure)
Document the Design of Current Process – Create a detailed process or value stream map – Identify process inputs, outputs, and sources of variation
Measure Current Performance (establish baseline) – Create a detailed process or value stream map – Collect data and establish baseline performance – Analyze current process capability
Make Quick Hit Improvements – If there is low hanging fruit – fix it right away! A (Analyze) Perform Value Analysis – Value adding steps – Non-value adding steps – Non-value adding but necessary steps
Identify bottlenecks, constraints, and “rework” points – Generate theories to explain causes – Prioritize focus areas for improvement I (Improve) Develop potential solutions – Create “future state” process maps – Evaluate, select, and finalize best options
Develop and implement process trials – Test new processes on a smaller scale before broader implementation – Measure for success as defined by project goals
Create plan for larger scale implementation of new process(es) C (Control) Make new processes permanent – don’t revert back to the “old way”! – Pre and post project success metrics – Documented standard operating procedures • Process maps and instructions • Documentation of training • Visual process controls – System for monitoring and auditing process – Final documentation including lessons learned and recommendations for additional opportunities Investigative QI Tools
• Process Mapping • Cause and Effect analysis Process mapping
Visually captures how various activities relate to one another in a healthcare process.
Can be used to define an existing process or develop a new one. Constructing a Process Map
1. Establish the start and the end of the process and use an oval terminal symbol to depict these.
Prescribe Patient Lasix diuresing Constructing a Process Map
2. Start with major “high-level” steps in the process. Use rectangles to represent actions and diamonds to represent decisions.
Prescribe CPOE or CPOE Pharmacy RN Paper dispenses administers Patient orders? Lasix Lasix to Lasix patient diuresing
Paper
Pharmacy transcribes order Constructing a Process Map
3. Add more detail about each major step of the process – can be mapped further to better understand specific step in a process.
Prescribe CPOE or CPOE Pharmacy RN Paper dispenses administers Patient orders? Lasix Lasix to Lasix patient diuresing
Paper - Bring Lasix to patient - Double check patient’s name Pharmacy - Watch patient take Lasix - Document on MAR transcribes order Constructing a Process Map
4. If you are unclear about a specific step, you can use a cloud as a placeholder and re-visit when more information is available.
Prescribe CPOE or CPOE Pharmacy RN Paper dispenses administers Patient orders? Lasix Lasix to Lasix patient diuresing
Paper - Bring Lasix to patient - Double check patient’s name Pharmacy - Watch patient take Lasix - Document on MAR transcribes order High Level Process Map
ED See See See Get See Registration Triage ED Nurse Physician Diagnostics Physician Nurse again Detailed Process Map High-Low Process Map
ED See See See Get See Registration Triage ED Nurse Physician Diagnostics Physician Nurse again
• Enter personal • Brief history • History • History or • Get lab or X- • Final information • Check vitals • Send for lab Physical exam ray Diagnosis • Verify OHIP • Send patient or X-ray if • Order tests • Prescribe Status to waiting obvious treatment • Send to triage room • Etc. Swim Lane Process Map Process mapping
Ways to make use of the information from a process map: • Where are the bottlenecks? • Where is there variation in practice? • Are there opportunities to standardize? • Can steps or handoff be eliminated? • Where are the rework points? Ishikawa (fishbone) diagram
Brainstorming tool used to organize the potential causes of a specific quality problem.
Also known as a cause and effect diagram. Ishikawa diagram
1. Write the quality problem in a box at the right of the diagram (the “effect”).
Effect (Quality Problem) Ishikawa diagram
2. Draw a central line, and from this line, diagonal lines that represent the different categories of causes or contributing factors.
Organizational Equipment
Effect (Quality Problem)
Providers Patient Ishikawa diagram
3. Identify different causes and categorize them under the most appropriate grouping.
Organizational Equipment
Cause Cause Cause Effect (Quality Problem) Cause
Providers Patient