Event Based Nursing Peer Review: Knowing Harm to No Harm

Transcription

1 Event Based Nursing Peer Review: Knowing Harm to No Harm Arkansas Children s Hospital Mitch Highfill, BSN, RN Debra Jeffs, PhD, RN-BC Stephanie Benning, MSN, APRN, PCNS-BC, CPN Ellen Mallard, MSN, APRN, ACCNS-N, RNC-NIC

2 Learning Outcomes At the end of our presentation, attendees will be able to: Discuss implementation, outcomes, and future goals of Event Based Nursing Peer Review at ACH Apply relevant aspects of Event Based Nursing Peer Review to an organization s safety improvement strategies

3 Arkansas Children s Hospital Only children s hospital in Arkansas State's only Pediatric Level I Trauma Center Regional Burn Center for children and adults Adult Congenital Heart Disease Program 359 beds Inpatient Admissions: 15,000 Outpatient Visits: 355,600 ED Visits: 58,700 Transports: 2,200 Medical Staff/Mid-levels/Residents: 650 Employees: 4,100 Strategic Plan: Expansion in the northwest corner of the state with new 24 bed hospital Emergency Department/Urgent Care/Clinic 5 operating rooms Imaging and Diagnostic Services Helipad with refueling station

4 BACKGROUND SAFETY = Core Organizational Value Error Prevention for High Reliability Organizations: STAR - Stop / Think / Act / Review ARCC method - (Ask a question, Request a change, Voice a concern, and Chain of command) QVV Qualify the source (do I trust this source), Validate the content (does it make sense to me), Verify your action (check with an expert) Organizational Safety Initiatives: Make Zero Happen Know Harm No Harm Preliminary meetings between Chief Quality Officer and Chief Nursing Officer about Nursing Peer Review Nursing Leadership set Nursing Peer Review as a Strategic Goal

5 BACKGROUND Professional Excellence (PE) Organizational Council became the Driver Professional Excellence/Recruitment & Retention (PERR) Organizational Council

6 BACKGROUND Nursing peer review introduced conceptually in PE Council in 2011 Unfreezing, informing and brainstorming through 2012 PE Council chair instability within a short period in 2013 New chair later in mid-2013 offered stability through development process and uniting of two councils into the combined PERR Council

7 BACKGROUND Literature on peer review and consultation with another hospital informed the PE Council about nursing peer review Clarity gained about two separate peer review processes: Annual performance review Error incidents PE Council chose to name the process, Event Based Nursing Peer Review (EBNPR), to avoid any negative connotations associated with errors or incidents

8 BACKGROUND EBNPR developed in earnest: Clear timeline updated/presented at each PE Council meeting EBNPR initiated in August 2014 Nurse-led development process all elements! Premise: Nursing peer review is based on organizational goals of safety and improving quality care and reducing error through emphasis on system improvement and avoidance of blame.

9 QUALITY NURSING PEER REVIEW HIRING: Behavioral interviewing Peer interviews Communicate clear performance expectations EVALUATION: ACHieve Promotions Annual Performance Review EVENT-BASED NURSING PEER REVIEW

10 FRAMEWORK: Donabedian Model Structure Process Outcome References: Agency for Healthcare Research and Quality January Donabedian, A. The quality of care. How can it be assessed? JAMA, 1988, 260(12):

11 STRUCTURE: Policy Collaboration with Human Resources Vice President Hospital attorney consultation offered legal implications including addition of a confidentiality agreement attestation required of all peer reviewers Organization Risk Management/Quality Improvement oversees all hospital peer review processes Kept policy broader without too much detail Addenda can be more easily and frequently updated and contain the details about procedure and forms

12 STRUCTURE: Policy

13 STRUCTURE: Templates

14 STRUCTURE: Screening and Review Tools

15 STRUCTURE: Great Catch Monthly Award Near miss events are celebrated to recognize nursing s role in preventing harm and to promote future safe practices. 15

16 STRUCTURE: Facilitators Two new MSN Clinical Nurse Specialists were assuming their new roles from clinical nurse positions An organization-wide leadership role would assist with transitioning to the CNS role by widening the sphere of influence Stephanie Benning, MSN, APRN, PCNS-BC, CPN Ellen Mallard, MSN, APRN, ACCNS-N, RNC-NIC Each has responsibility for 2 EBNPR Subcommittees Provide coverage for each other

17 Facilitators Ellen Mallard and Stephanie Benning

18 STRUCTURE: Committee Members Peer Reviewer Interest Form Selection process for members Criteria for members: RN or LPN Minimum 2 years nursing experience No current disciplinary action

19 STRUCTURE: Subcommittees 8 clinical nurse members per subcommittee Structured as 4 Subcommittees in similar care areas: Medical-Surgical In-patient Intensive Care In-patient Surgical Services/Ancillary Services Ambulatory Clinics 19

20 STRUCTURE: Meeting Schedule Members of the Subcommittee rotate with 3 members participating in each EBNPR meeting with an alternate selected Each Subcommittee meets twice each month on an established schedule. A committee member schedules the EBNPR members for each quarter.

21 Example schedule 21

22 PROCESS: Roll-Out Communication! Council Meetings Directors forums Posters on clinical areas Education of all nurses: Intranet learning module for all nurses EBNPR Skit recorded Nursing Peer Review FAQs EBNPR Nursing Grand Rounds presented by clinical nurses Recruitment, Selection and Orientation of Committee Members Online Just Culture Classroom Signed Confidentiality Attestations

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24 PROCESS: Generating Events All error and near miss events are entered into Safety Tracker (ACH electronic error reporting system) Safety Tracker is the trigger for events

25 PROCESS: Event Entry to Review Clinical Nurse Specialist Facilitator: Receives notice of events from Safety Tracker daily report Determines which events meet criteria for EBNPR Selects qualifying events Communicates via with nurse(s) involved in the event and their director(s) and the Subcommittee members about the scheduled EBNPR meeting Facilitates review of event by 3 nurse peers and nurse(s) involved in the event during the EBNPR meetings Follows-up with recommendations made during reviews

26 PROCESS: Conducting the Review

27 EBNPR Session

28 PROCESS: Documentation Secure database built by Facilitator All data for each event for EBNPR entered Aggregate reports and individual event reports generated

29 PROCESS: PERR Council Role Oversight of EBNPR Review of EBNPR previous month s aggregate data Select monthly Great Catch award from the previous month s near-miss events Nurses from the PERR organizational council present the clinical nurse with the Great Catch award at a clinical area-based meeting.

30 RESPONSIVENESS: Year 2 in Progress Widened criteria for EBNPR to review more diverse events Reviews of Clustered Events with common themes to increase impact of EBNPR Near Miss focus group reviews to contribute toward an organizational goal of increased near miss reporting Discuss events and associated critical thinking skills and strategies used by nurses to prevent harm Revisions to forms and templates Replacement of Committee Members and Orientation

31 PROCESS: 360 Evaluation Quality Improvement organizational strategies Facilitator reflection Separate anonymous evaluation surveys to: Participants Committee Members Directors All Nurses IRB exempt / Consent determined by completion of survey

32 OUTCOMES: Year 1 Data 819 nurse-related events from Safety Tracker met criteria for EBNPR 99 events were reviewed by clinical nurse peers in EBNPR Almost 80% of EBNPRs from Intensive Care & Medical-Surgical units 269 near-misses intercepted by nurses before reaching patients

33 Recent Great Catch Award Recipient Cindy Davis, LPN in the General Pediatric Clinic with her Director, Lori Batchelor, BSN, MHA, RN, CPN, NEA-BC and EBNPR Facilitator, Ellen Mallard, MSN, APRN, ACCNS-N, RNC-NIC

34 OUTCOMES: Dissemination Events focus on system-wide improvements that could reduce future errors and improve patient safety Submissions to Councils or Committees Example: Submission to the Ambulatory Council regarding fall prevention practices. from a clinical nurse in the ENT Clinic to ambulatory care clinic nurses recommending implementation of specific fall prevention interventions discussed during peer review and council meetings. SBAR s Quarterly Nursing Matters column articles Education Rounds on clinical areas Pediatric Nurses Week: EBNPR information table

35 Nursing Matters Articles 35

36 Education Rounds Reports

37 OUTCOMES: Dissemination Meetings with Quality Improvement to discuss trends, recommendations, and redundant quality review processes Following-up and who does what are topics for discussion.

38 Outcome: QI Oversight Table

39 EXPECTED OUTCOMES for Nursing Increase clinical knowledge and skills Develop changes in education and administration to ensure quality care Reveal opportunities for research and evidence-based practice Promote nurses adherence to established standards Allow frontline nurses to actively participate in areas for improvement Represent a non-blame culture of accountability where teams review individual processes and events instead of focusing on the individual

40 OUTCOMES: What Do Nurses Report? Information/Data from EBNPR Evaluation Surveys: Participants: 25% Committee Members: 35% Directors: 40% All Nurses: 12%

41 Participants Perceptions: Required to attend Benefit: Raised awareness of safety Opportunities: Discuss safety issues with peers Professional development Change/improve practice More satisfied with Near Miss reviews (newer) SBAR s but want other means of dissemination 41

42 Committee Members Perceptions: Opportunities: Increased awareness of safety issues Discuss safety issues with peers Professional development Change/improve practice Highly satisfied with the process All agreed: Orientation prepared them for the role 42

43 Directors Perceptions: Contacted nurse to attend via , in-person, calls Made staffing schedule changes All addressed the event with the nurse prior to EBNPR Staffing and fear are limiting attendance Follow-up: Staff meetings / Individual nurse meetings Mostly satisfied with the process Potential value Punitive perception dissipates with participation 43

44 Nurses Perceptions: Most aware of EBNPR and its purpose Most aware EBNPR aligns with organization safety goals Split 50/50: Awareness of outcomes SBAR s and Nursing Matters articles Not aware at all / Want to see practice changes Others: Discussion in staff meetings, council meetings, bulletin boards, participated Equally split on likelihood to attend EBNPR sessions 44

45 Overall Survey Conclusions Attendance: Staffing / Time / Convenience Leadership buy-in Mixed positive and negative perceptions Valuable Punitive / Fearful Follow-up dissemination / Raise awareness Results / Changes in practice Culture change / Balance 45

46 Encouraging Nurses Quotes: very, very important...it is one of the hallmarks of a true profession...to monitor ourselves. Long overdue and it is showing us the problems and the good nursing. keep up the good work I think it is helpful to discuss safety events in order to prevent them in the future. This is a good program. I admit I was skeptic of this at first. It has been a great thing for our hospital. I know the staff that have worked hard to get it going are seeing some trends in occurrences and good things are coming from it to keep our patients safer. Nice job! 46

47 LESSONS LEARNED Positive Impact: Peer-to-peer interactions and recommendations are powerful. Challenges: Minimal participation in reviews by nurses involved in the event Anticipatory intimidation about participating, but after participating, initial concerns are often allayed Be Nimble: Needed in selecting events for EBNPR due to organizational RCAs, ACAs, and CHA SPS work groups. Resulted in early decision to review only medication occurrences and PIV infiltrates for Year 1. Review forms needed editing to facilitate documentation during reviews.

48 RESPONSIVENESS Communication! Transparency Make value evident Disseminate in clear, meaningful ways Identify and raise awareness about practice changes resulting from EBNPR Consider multidisciplinary reviews 48

49 Questions? Comments?

50 Thank you for attending! Presentations: Presenter contact information: Debra Jeffs Arkansas Children s Hospital jeffsda@archildrens.org 50