Jeri Reinhardt RN Vice President of Clinical Services and Performance Excellence Benedictine Health System Creating Reporting and Learning Culture Jeri Reinhardt RN CMOE Vice President Clinical Services and Performance Excellence ID: 802395
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Slide1
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Establishing a Reporting & Learning Culture
Jeri Reinhardt, RNVice President of Clinical Services and Performance ExcellenceBenedictine Health System
Slide2Creating Reporting and Learning Culture
Jeri Reinhardt, RN, CMOEVice President, Clinical Services and Performance Excellence
Benedictine Health System
Slide3Reporting & Tracking of Adverse Events
Why?It the right thing to do
It is required by CMS in Nursing FacilitiesCurrent F868RoP 11/2019 F865, F866, F8673 categories – medication, care and infection relatedStaff EngagementResidents and Families
Slide4CMS Medication Related Adverse Events (
Not Inclusive and subject to change)
BleedingHypoglycemiaKetoacidosisBleedingThromboembolismProlong ConstipationElectrolyte ImbalancesDrug ToxicityAlter Cardiac Output
Slide5CMS Care Related Adverse Events (
Not Inclusive and subject to change)
Falls, Abrasions, Skin TearsElectrolyte ImbalanceRespiratory Distress due trach or vent careExacerbation of existing conditions dues lack of careTube feeding complicationsIn-house acquired or worsening pressure injuriesElopement
Slide6CMS Infection Related Adverse Events (
Not Inclusive and subject to change)
Respiratory InfectionsPneumoniaInfluenzaSkin and WoundSurgical siteSoft tissueUTIsInfectious diarrheaNorovirusC. Diff
Slide7Doing the Right Thing
Desired results are delivered by efficient and effective processes Cannot create a safe care environment by:
Educating or training staffThrough punishment or corrective actionYou can only improve results by improving your processes
Slide8What about near misses
They are the “canary in the mine”With serious errors when asked the question – has anything like this ever occurred before – most often staff will state yes
Slide9Tracking of occurrences
Required by CMSCan be completed
By handElectronically Specialized softwareUsed to identify trends and opportunities for improvement
Slide10Conduct a RCA on Serious Events
Root Cause Analysis on death or serious issuesConduct interview, focus on facts – no blame
StepsDevelop a timeline of eventsUse tools to identify cause5 WhysCause and Effect DiagramAHQR RCACreate action plan on Root Cause(s)
Slide11RCA Requires
Critical Thinking SkillsA non-judgmental attitude
A desire to understand whyA belief that we can always do betterTime to stop riding the bike and see if the bike can be fixed – to look beyond the “Quick Fix”
Slide12Create a Timeline of Events
Can use post it notes and line up in sequential orderCan create a timeline and place (with post it notes) - when events occurred
Can create a Word document
Slide13BHS Investigation Areas
PeopleProcess System
Resident RelatedEnvironmentEquipment
Slide14Slide15Cause and Effect Diagram
Machines
Manpower
Materials
Methods
Medication
Given after
D/C
.
Timing of Shift Change
Holes
Slide16Joint Commission's Framework for Root Cause Analysis
24 Analytical questions
What was the intended processes flow?Any steps in process missed?Did the equipment perform?Were staff qualified and competent?How do staffing level compare to ideal?Was communication accurate, complete or unambiguous?Does the culture support risk reduction?
Slide17Agency for Healthcare Investigation and Analysis Guide: Appendix D
Over 50 analytical questions
Did all caregivers have the access to information about the patients?Was the medical record up to date?Were the barriers to communication?Were staffing levels appropriate? Staff trained?Was the physical environment conducive to providing safe care?Was the equipment function properly?Where all the steps in the process followed?Could a similarly qualifies person do the same thing?
Does a policy exist? Was the policy followed?
Slide18Determine Root Causes
If this cause was eliminated - could the event still occur?Typically have multiple causes
Develop action plan What will be done? Who will complete the task? When will it be completed? How will you know the risk as been removed?
Slide19Human Factors in Error
Operator error is inevitable
Human error rates are highTo Err is HumanExhortations to “be professional” or “to be more careful” are generally ineffective, becauseMost errors are committed inadvertently by people who are already trying to do their job professionally and carefully. They did not intend to commit the errors
.
Slide20National Center for Patient Safety Hierarchy of Solutions
Three levelsWeak
IntermediateStrongEasily accessible onlineLocated in CMS QAPI At-A-Glance resource
Slide21Weak Actions
Actions that depend on staff to remember their training or what is written in the policy. Weak actions enforce the existing processes.
Examples of Weak ActionsDouble checks and auditsWarnings and labels New policies and procedures/ memosTraining/ educationAdditional study or re-training
Slide22Intermediate Actions
Actions are somewhat dependent on staff remembering to do the right thing, but they provide tools to help staff remember or promote clear communication. Intermediate action modifies existing processes
Examples of Intermediate ActionsReduce interruptions /alter work loadSoftware enhancements/modificationsEliminate/reduce distractions (the red circle)Checklist/cognitive aid
Eliminate look and sound a likes
Read back
Enhanced documentation/communication
Redundancy
Slide23Strong Actions
Strong action changes or redesign the process
Actions that do not depend on staff to remember to do the right thingThe action may not totally eliminate the vulnerability but provides strong controlThey help to detect or warn prior to an error occurringThey may include hard stops which won’t allow the process to go forward unless something is corrected
Slide24Examples of Strong Actions
Architectural/physical plant changes
New device with usability testing before purchasingEngineering control or interlock Simplify the process and remove unnecessary stepsStandardize an equipment or process Tangible involvement and action by leadership in support of patient safety
Slide25Questions?
Jeri.reinhardt@bhshealth.org
612-845-2833