They say it takes a village to raise a child, and if that’s the case then the same holds true when it comes to keeping our hospitals safe. Safety is something we often take for granted. Because we expect it, we overlook what it takes to ensure every facet of a hospital is safe for its patients, the community and the staff who work there. Those in healthcare know all too well the work that goes in, and the importance of looking for improvement opportunities anywhere possible.
With this in mind, we at Memorial Health System recently uncovered an untapped opportunity to bring safety efforts at our organization to the next level. It all started when a few people on our team at the hospital noticed that some of the Feedback (grievances) that were being recorded also contained a risk component to them. This made it difficult for us to investigate, transfer, or protect these instances when reporting to a PSO. So, naturally, something had to be done.
We quickly assembled a team—made up of Customer Service, Quality and Safety and Patient Safety Organization departments—together to discuss how best to map out a new procedure for handling these types of events. We then determined where these events should live, necessary alerts, file mapping needs, required form updates and what criteria meets a Quality of Care complaint.
Once all key criteria were established and form updates completed, we were able to create the Quality of Care Grievance Process. Below are the finalized steps we created to improve reporting in RL6 Feedback and Risk:
- After a Grievance is filed by a Patient/Family Member, the Patient Advocate enters it into Feedback.
- If the Grievance meets the Quality of Care Criteria, the Patient Advocate chooses a newly created grievance type called "Clinical Quality of Care" from the Issues List.
- The Patient Advocate also selects "Resolution Summary = Referred to Quality and Safety" under Resolutions and Outcomes/Resolutions Summary.
- Patient Safety is notified by the Patient Advocate about the Quality of Care Grievance via e-mail.
- Patient Safety uses the Feedback to Risk import feature to create a Quality of Care event in Risk. Within the Provision of Care form, we added a new Specific Event Type called "Quality of Care Grievance," which will be chosen by Patient Safety in these grievance cases.
- The Quality of Care Grievance investigation commences and is documented in Risk under "Add Follow-up" and "Resolutions and Outcome". Within Feedback, the investigation summary is documented under "Add Follow-Up/Sign Off."
- Under the Outcomes/Resolution Summary in Feedback, we added "Quality and Safety Review Completed". Once the investigation is completed, Patient Safety is responsible for checking this off.
- Patient Advocates are notified of the concluded event by a newly created "Sign Off Notification Alert."
- The Quality of Care event is closed in Risk.
- Patient Safety then mails the Patient Advocate to inform them that the Quality and Safety Review is completed.
- After reviewing Patient Safety's investigation, the Patient Advocate writes and sends a 30 day letter (which is documented in SENSOR Feedback).
- Finally, the Patient Advocate closes the Feedback Grievance file.
By building a team of key users and administrators, utilizing the great minds from our own "village", we were able to build a solution that improved Feedback reporting and streamlined the process of converting Quality of Care events from Feedback to Risk for everyone involved.