So you've implemented a great tool and have big plans for the change it will affect in your organization. But how do you get your front-line users engaged and, perhaps more importantly, build strategies to measure that engagement and respond to any gaps?
We turned this discussion over to experts Sandy Dunn and Tua Palangyo from Lucile Packard Children's Hospital, Robert Maier from Kaiser Permanente Colorado and Tiffany Gruno and Linda Belkner from Massachusetts Eye and Ear.
In case you missed the live stream of our panel, here are their answers to our audiences' questions:
Q: How do you prepare reports for leadership and what is contained in them?
Tua Palangyo: For the daily report it's a simple list report. It doesn't have any PHI, so it has the event date, report date, the event type, specific event type, event description along with the unit. We do our preliminary classification of the event – so we have what we call patient safety level of harm. If it's an event that we realize we need to look into a little bit more then we'll mark it as "investigating" on the PDF that goes out to the leadership. Some leaders get everything and other leaders get information based on their scope.
Q: With the physician engagement improvements that you've seen, have you seen a corresponding improvement in quality outcomes?
Linda Belkner: I'm not sure that we've had enough from the physicians to begin to see improvement. But what we're seeing is that the physicians, the ones on the frontlines, are bringing issues to us that we were somewhat aware of but we were not 100% about.
Robert Maier: What we've done is identified our physician users, so whenever they report into the system I automatically get notified that they've entered an event. We then have one of our risk managers go and investigate that event; we sort of fast-track their entries to make sure they're getting the service that they are expecting. They're getting more and more comfortable with it; we've had about 300 of our physicians directly enter an event and then call us to let us know that they've done so. They're getting into the habit of self-reporting their mistakes which is wonderful – that culture is getting there.
Q: Are your organizations doing anything unique in terms of capturing diagnostic errors?
Palangyo: We work really closely with our physician peer review groups and we share events that they refer to us with diagnostic errors. But in terms of our classification for a serious safety event we have to say that there is a deviation and sometimes it's hard for them to call out that there was a deviation that led to the diagnostic error, as opposed to the patient being really complex – so we're still challenged. But we do review those cases and oftentimes we're able to identify opportunities.
Maier: Our member services uses a system that whenever a member calls in or complains about an issue, whether it's diagnostic or treatment or just social interaction with their physician, that data gets automatically fed into our RL environment. It comes in as an event record with a detailed description of what the members complaint might be. So any of those events that are identified as diagnostic, we have two physicians in our department that will review those to identify and research [whether] they were delayed diagnosis, was there a misread of the chart and if necessary those will actually get moved into a peer review environment.
Q: Have you been tracking trends with your reports?
Maier: We have a lot of standardized reports that are automatically send to our medical office directors which show trends in volume over time or by department. As an admin, you always have to have your own selected suitcase of reports. How many people are logging in? How many of those logins have failed? So typically as an admin, you're constantly monitoring the system to see whether there are trends in the events that are being reported and what departments or buildings those are being entered in to do proactive outreach. Going, "We're noticing this, what's going on?" And [asking] whether there has been a lot of staff turnover in that area or is their necessary training that has to be done. And then from a systems side, space utilization, systemic issues, changes in Internet browsers – so you always have to have a bacth of trending reports to do what you need to do.
Sandy Dunn: I think something that has helped us is, not only do we have the trending reports, but we have our subject matter experts who really are our super-users because they manage every form. So each one of our forms is going to the unit but also to the subject-matter-experts. Sometimes it's hard to notice a trend, sometimes it's more of a hunch – so a person being on top of that, one more pair of eyes is really benefitting us.
Maier: There's definitely a benefit it's the person who is a subject matter expert. They know their workflow, they know their job, they know their department better than anybody else. I'm an admin, non-clinical, I don't know how pharmacy works, I don’t know how x-ray works. Those are the people who really need to be looking at it and the data needs to get in their hands to help analyze those trends.
Q: Are you using the list of contributing factors that RL software provides, or creating your own?
Maier: The contributing factors list we use has completely been cuztomized. We've gone in with each department, re-reviewing what their data looks like and what is being used and what isn't, we have extensively customized that list to be specific to those departments. So it's not one master list showing up for each department.
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