Increasing resident incident reporting. Michelle Brooks VCU Health Ashley Duckett MUSC Winter Williams UAB Starr Steinhilber - UAB

Transcription

1 Increasing resident incident reporting Michelle Brooks VCU Health Ashley Duckett MUSC Winter Williams UAB Starr Steinhilber - UAB

2 What can we help you with?

3 An Incident...

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5 Background - Incident Reporting IOM report - To Err is Human - 98,000 deaths/year due to medical error1 New studies - 200, ,000 deaths/year2 Underreporting is common3 Recommendation from IOM - establish reporting system4 Patient Safety and Quality Improvement Act of 2005

6 Background - Incident Reporting Identify safety hazards, prioritize where to focus resources, develop interventions, evaluate5 Anonymous web-based incident reporting tool6 Tradeoff between number & quality of reports7 Trend toward baseline - lack of sustainable QI efforts to improve incident reporting in literature8 Barriers

7 Background - CLER In general, residents and fellows lacked clarity and awareness of the range of conditions that define patient safety events and were unaware of how CLEs use the reporting of adverse events and near misses/close calls to improve systems of care, both broadly and at the individual departmental level. 9 Though most residents and fellows were aware of their CLE s process for reporting patient safety events, fewer of them appeared to have used it themselves to report events. When trainees did file a report, or have others file it for them, many received little or no feedback from the CLE. 9

8 Barriers to Incident Reporting?

9 Incident Reporting Barriers & Challenges Individual Reporting Hutchinson et al. Qual Saf Health Care 18:5; Data Handling & Analysis

10 Data Handling & Analysis Barriers Report Volume Sampling error Input Process Lack of feedback Punitive use of information Output Lack of standardized process Lack of transparency Staffing needs

11 Individual Reporting Barriers Attitude Problem deference Shame Fear of retaliation, liability Skills Time-consuming Cumbersome Knowledge What to report How to report Who reports

12 Local Barriers

13 Different approaches

14 Experience 850 residents and fellows ACGME CLER visit < 1% of incident reports placed by trainees 129 medicine/medpeds residents QI / PS Curriculum with M&M, longitudinal projects, monthly lectures Needs Assessment

15 Experience Anecdotal: Past 4 months, 3 incidents reported into STARS

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18 VA slide

19 Improvement strategies Got access to resident reports Town Hall in-service on how to put one in Patient Safety Rounds The life of a trend tracker Thank you s sent to residents Working with Incident Reporting Administration to decrease the number of fields

20 Different approaches

21 Experience 700 residents/fellows 190 residents/fellows in Dept of Medicine 90 residents (IM, Med-Peds, Med-Psych) Institutional QI/patient safety training during GME orientation Rapid cycle QI, team meetings in UIM MM and I conference

22 Incident Reporting CLER visit 2014 Baseline reporting -<2/month from physicians Pay for performance -- Resident Improvement Projects January phone hotline added July 2015 GME promotion of reporting project Access to reporting dashboard Inter-professional collaboration October 2016 EPIC button

23 Implementation Strategies Educational efforts Opportunities for reporting Monthly review at housestaff conference Quarterly review sessions with risk manager & nurse managers Quarterly submission of data MM and I cases IMPROVE project

24 PSI reporting by the numbers

25 Future Directions Individual feedback E-Value VA Faculty Development

26 Different approaches

27 Experience 750 trainees (residents/fellows) 250 trainees Department of Internal Medicine 141 Residents IM + 16 Med-Peds + 10 EM-IM Institutional QI/patient safety training during GME orientation (Walk the Walk) Institutional QI processes/initiatives; requirement for IHI modules Departmental QI curricula

28 VCU Health Incident Reporting Timeline 2013 Survey Previous APD and PD work toward encouraging patient safety reporting Gap Years Difficulties obtaining access to reports filed by residents Issues with the reporting process Reluctance to train learners in a process that was not ideal

29 CLER Report 2015 Feedback Number of reports filed by physicians = 217/10413 (2%) No feedback given to residents Feb CLER Do your residents file reports? How many? What kind of feedback do they receive? Mar Apr Residents start to receive feedback on reports via standardized . Sep Access to Reports Reports filed by residents filtered through performance improvement representative to the APD Dec

30 Intern Orientation 2016 Just-in-Time Teaching Associate Chair for QI for the department available to encourage residents to report. Jan Mar Targeted teaching on reporting during a didactic session. No practice/simulation June July Good Catch Award Requirement to Report Monthly award given at Morbidity, Mortality, & Improvement conference. Institutional requirement for residents to report with numerical goals for each department.

31 2016 Patient Safety Rounds Proactive patient safety rounding by QI resident with encouragement to report, peer coaching. July QI Pager Introduced a QI resident consult pager, with flyers in team rooms to have residents call with any questions about reporting. Aug Sep Structured Feedback Patient safety report on-demand assessment developed for entry into New Innovations. Intern re-training Oct Nov Integration into MMI 5 potential incidents in one MMI

32 Results Patient Safety Rounds Proactive patient safety rounding by QI resident with encouragement to report, peer coaching.

33 Implementation Strategies Intern training session Routine reminders and website demonstration Structured feedback on every report entered Incorporation of feedback/assessment into milestones Institutional and departmental establishment of requirements to report Patient safety rounds with peer coaching*

34 Future Directions Faculty education and support with similar feedback methods VA - eper system - difficulties with access to resident reports Upcoming CLER site visit GME training

35 Reaction to approaches

36 Assessment Tool Event Description Summary of Event Type of Event 1. Timeliness 2. Clarity 3. Objectivity 4. Language/Professionalism Reviewed By Outcome Adverse reaction Behavioral event Care coordination/communication Complication of procedure Equipment/device problem Fall Healthcare-associated infection Lab test Medication-related Omission/error in assessment, diagnosis, monitoring Other Radiology/imaging test Quality of Report Within 24 hours of event > 24 hours of event Succinct/simple Complex/difficult to understand Facts only Subjective comments No direct blame placed on Finger pointing/blaming other parties language used in report Adapted from Boike et. al. 2013

37 Assessment in New Innovations

38 The Incident Oscar got it wrong, wrong, sooooo wrong. The presenters announced the wrong Best Picture; Moonlight was the winner, not La La Land. It was the biggest, most embarrassing, most awkward mistake in the history of the Academy Awards Warren Beatty and Faye Dunaway were presenting but looked lost. When he opened the envelope, he paused for a long few seconds. He looked at Dunaway, puzzled. She took the envelope, read it, paused, and said La La Land.

39 The Incident...the accountant from PriceWaterhouseCoopers jumped and said, He took the wrong envelope! and goes running onstage. No one knows how Beatty got the best actress envelope instead of the best picture envelope.

40 The Incident Award announcer opens envelope and paused. Announcer checks envelope. The audience laughs. The announcer states, And the Academy Award for best picture goes to, and again pauses. The announcer showed the contents of the envelope to the co-announcer, who reported La La Land. The recipients take the stage. Someone then locates another envelope with contents that state that Moonlight won best picture.

41 Small group cases

42 How was using the tool?

43 Today we have: Discussed barriers to incident reporting Shared differing approaches to the process Practiced with an assessment tool that can be used to overcome the barrier to feedback and help residents improve their reporting What is one Incident Reporting task you want to do when you get home?

44 Conclusion

45 References 1. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, D.C: National Academy Press. 2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9: Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction. J Patient Saf. 2010;6: Elkin PL, Johnson HC, Callahan MR, Classen DC. Improving Patient Safety Reporting with the Common Formats: Common Data Representation for Patient Safety Organizations. J Biomed Inform Pronovost PJ, Morlock LL, Sexton JB, et al. Improving the value of patient safety reporting systems. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): ; Conlon P, Havlisch R, Kini N, Porter C. Using an anonymous web-based incident reporting tool to embed the principles of a high-reliability organization. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): ; Clarke JR, Johnston J, Davis M, et al. Mapping a large patient safety database to the 2005 patient safety event taxonomy. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): ; Boike JR, Bortman JS, Radosta JM, et al. Patient safety event reporting expectation: does it influence residents' attitudes and reporting behaviors? J Patient Saf. 2013;9: Weiss KB, Bagian JP, CLER Evaluation Committee. Challenges and Opportunities in the Six Focus Areas: CLER National Report of Findings J Grad Med Educ. 2016;8:25-34.