A strong culture of safety needs tools that match
Safety has always been important at Partners Continuing Care. Employees know that the organization expects everyone to prioritize patient safety, and reporting safety events is encouraged and nurtured. However, PCC has multiple facilities, which at one time were all using different systems to capture events and different taxonomies to classify severity. This variability made it difficult for the quality staff and system leadership to identify actionable trends. Also, some facilities reported safety events on paper forms, some used homegrown electronic systems. They all needed technology that would support the preexisting culture—so they turned to RL6:Risk and RL6:Feedback.
Partners Continuing Care (PCC) includes the Spaulding Rehabilitation Network and Partners HealthCare at Home (PHH). Spaulding's network has two inpatient rehabilitation facilities, two long-term acute care hospitals, two skilled nursing facilities and 23 outpatient centers. PHH is one of the largest home health care providers in New England and provides homecare such as skilled nursing, occupational therapy, diabetes support and wound care.
Since PCC went live with RL6, there has been a significant increase in incident submission. In addition, now that staff can directly input feedback in RL6—instead of going through patient relations—complaints are tracked and resolved more quickly. In the four years since its facilities have gone live, PCC has customized RL6 to meet its needs in several areas.
For example, the rehabilitation population includes patients with disorders of consciousness who are at greater risk for falls. PCC implemented low beds to reduce risk of injury, yet the data in RL6 looked as if there was an increase in falls. PCC customized its fall form to capture additional harm information (i.e., Did the patient move from a higher surface to a lower surface?).
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"The rates of falls might have gone up but the falls with injuries went way down. Numbers don't paint the full picture: you need the complete story."
Director of Patient Safety & Risk Management
Spaulding Rehabilitation Network