Sue Corkill, RN has been a nurse for 39 years, working in the operating room and ambulatory testing for esophageal surgery patients. Ten years ago, she made the move into surgical quality and for the last three years has been managing risk events entered in the RL6:Risk module. In 2015, she was co-lead for the implementation team for the RCA and Peer review modules at Bryan Medical Center. Sue has a passion for teaching and sharing ways to get the most out of the RL modules.
Following her webinar presentation Managing Patient Safety Events, Sue answered the questions that we didn't have time to get to during the live webinar. Read her Q&A below and register to watch the on-demand webinar if you missed the live event!
Did Bryan Health already have a culture where leadership was committed to and involved in risk reporting & management? Or is that something that you had to really work on and develop over time?
This is something we’ve worked on over time, and it really gained momentum when we implemented the RL6:Risk and RL6:Feedback modules. We made the decision to strive for meaningful follow-up and increase managers’ and directors’ involvement in event follow-up. The RL system really helped with this, giving us the ability to have everything related to the event in one location. We are still working on building our culture and increasing the transparency of harm events. We share harm events with all of the senior leadership, the Board of Trustees and the safety story that is shared at the monthly leadership meeting.
In your presentation, you mentioned how you review your harm events. How do you trend the non-harm events and who is involved with this? How do you use your aggregate data?
We ‘track and trend’ all of our non-harm events and the data is pulled into reports, as requested. Trending is for those events where there was no deviation from the standard of care and the outcome may have been unexpected or expected, depending on the patient’s condition.
Does Bryan Health’s Quality department have access to the system, or does the Risk department refer those events that are quality concerns to Quality?
At our organization, the RL systems are managed out of what is collectively called ‘Organizational Quality’. Our Risk Manager and the Quality Analysts work very closely in evaluating the events and determining what should be done.
How does Bryan Health use RL6:Risk to alert you of those serious adverse preventable events?
We use alerts for any event that is given a MERP safety classification of F through I. We ask the person entering the event to make a determination of the safety classification. Then, the manager or whomever is adding follow-up makes their determination of the final safety classification prior to closing the event. We determined who would need to get these special alerts: Risk Managers, Quality Analysts who perform root cause analysis, department directors and designated senior leaders. These are extra alerts that fire along with the usual file entry alerts associated with location and type of event.
How many review manager users does Bryan Health have? How do you help define accountability for event review, especially those that involve multiple locations?
We have many review managers and I’m not sure I can place an actual number on the count. Accountability for the event is generally defined two ways: the actual location of the event and the staff involved. If an event happens on your unit/area, as the manager you are responsible for follow-up. If the event involves another unit, the manager of that unit is also responsible for determining what happened on that end that contributed to the event. We really encourage a collaborative approach to these kinds of events. If your employee is involved in an event that happens outside of his or her home unit, you are also responsible for follow-up with that individual.
Is it the responsibility of the front-line reporter or reviewing manager to document if a patient was notified of an event?
It is the responsibility of the manager to document if the patient was notified of the event. Most of the time the patient knows about the event. However, if the patient isn’t aware and it was an event with harm, we utilize the manager, or the administrative manager, and the physician to talk with the patient and/or family.
After managers add follow-up, do you look at the quality of this follow-up before the event is closed?
That’s a good question! We certainly advocate meaningful follow-up and that is what our senior leaders would like to see. In reality, we see a lot of different types of follow-up. We do actively discourage one word follow-ups such as ‘reviewed’ and will task those individuals to add more detail. We do work with everyone on best practices for follow-up, but in the end, the event is theirs to ‘own’.
Who's responsible for closing your incident files in the Risk system: the safety team or the managers?
In our organization, the analysts who are responsible for the system close the files. We make sure all requested follow-up is there and look for any ‘reassignments’ of the file to other individuals. Our lab makes extensive use of RL6:Risk and when it's satisfied with the follow-up on an event, they will mark it ‘closed by lab’ and then I will officially close it.
I think for people who are looking for other options when it comes to having managers and the like close files, this would be one way to go. Managers can ‘close’ the file when they are satisfied that all follow-up has been obtained and then safety team, analyst or whomever is responsible for managing the system has the final closure.