More is Better: Engaging Staff to Improve Event Reporting in Ambulatory Care Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ Patient Safety & Quality RN Melissa Taylor, BS, RN-BC Director of Nursing for Primary Care Anna Holland, RN Resource Nurse ©2019 Elliot Hospital All Rights Reserved

Elliot Health System member of SolutioNHealth Is non-profit organization since 1890 Largest provider of comprehensive healthcare in southern NH 296-bed hospital including the Regional Trauma Center Home care services Ambulatory care serving 100K patients

Elliot Ambulatory Care 44 Practices: Located in Manchester & surrounding communities (~15 mi radius from Manchester) 19 primary care & pediatric offices 106 primary care providers (MD, DO, NP, PA) 25 specialty practices serving adults, elders, & children 122 specialty care providers (MD, DO, NP, PA, LICSW)

Recognizing “under-reporting” Approximately 250,000 encounters with primary care providers each year Approximately 3 additional encounters with staff for each provider-patient encounter Yet we had small number of reported events Nurse visits E-chart messaging/responses Triage calls Referrals Prescription refills Scheduling Transitions of care

Reporting prior to ‘campaign’ 3x # provider encounters Year # Encounters primary providers Approximate # other interactions Approx total # encounters # Reported events  2015 261,665 784,995 1,046,660 66  2016 248,352 745,056 993,408 92  2017 231,972 695,916 927,888  258  2018 249,721  749.163 998,884  399

Identifying barriers to reporting Observations Discussions with: “Front-line” staff Nurse leaders Practice managers Providers (MDs, DOs, NPs, PAs) Risk management Clinical educators Patient Safety Officer Medication Safety Officer

Identified barriers Staff identification of barriers: Difficult reporting system Unaware what should be reported Unaware of how to report Unaware of why to report Unaware how report would be used Received little, if any, feedback Fear of punishment

Establishing Just Culture To Err is Human Human Error “Console” Drift becomes At-Risk Behavior “Coach” Reckless Reckless behavior “Punish”

Event reporting system System designed for in-patient use Many ambulatory-related events didn’t “fit” Forced fields required entry of irrelevant info Example: For falls – height of bed Other fields prevented entry of relevant info Example: Vaccines names not available under “medications”

Changes to Event-Reporting System Most categories unchanged But many sub-categories changed

Category change: Medication Medication Immunization

Transfer to a Higher Level of Care Category change: New category: Transfer to a Higher Level of Care No data how often No data why Difficult to review quality of transition of care

Sub-Category change: Category: Medical Equipment & Supplies Previous: Current: 20 sub-categories 5 sub-categories

Sub-Category change: Category: Security Previous: Current: 13 sub-categories 10 sub-categories including hospital-specific “codes”

Education of Mgrs & Staff Just Culture Reporting system Changes for the better What to report Why to report How to report How information is used

Primary Care Patient Safety Team: EPN Patient Safety Team! Primary Care Patient Safety Team: Team: Resource Nurses Providers Pharmacist Patient Safety Officer Risk Management Leader from Lab Patient Liaison

Primary Care Patient Safety Team: Purposes: To provide collegial support through (1) questions (2) suggestions (3) shared learning (4) emotional support To evaluate & reduce risk in all practices To identify trends & opportunities for improvement To review & address policies, procedures, workflow

Follow ups: Thank you “Lessons Learned” Newsletter distributed to all ambulatory care colleagues Staff meetings Education

Monthly Amb Care Newsletter Each month in the EPN/EPS Newsletter, we present a “Lesson Learned” based on recently reported events! If you recognize the event(s) that prompted a particular lesson, be proud that the event was reported by colleagues in your office or by you! Thank you and your colleagues for all you do each day to keep our patients and co-workers safe!!

Practice Resource Nurse Champion: Help staff recognize “events” Encourage staff to report events Celebrate staff who’ve reported Investigate events Share opportunities for improvement with Patient Safety Team

New: Director of Primary Care Nsg All events go to DON for review Provide support to Resource Nurses Coach Resource Nurses to support staff

Staff Nurse Co-Champion: Help colleagues recognize “events” Contribute to investigation Share opportunities for improvement with colleagues within the practice

Staff Nurse Use events for discussion & process improvement For example, Several vaccine-related events Office workflow now includes double-checks

Resource/Staff Nurse Engaging staff: Discuss at daily huddles Discuss at monthly staff meetings

Impact on # events: Year Approx total # encounters # Reported events # Encounters primary providers Approximate # other interactions Approx total # encounters # Reported events  2015 261,665 784,995 1,046,660 66  2016 248,352 745,056 993,408 92  2017 231,972 695,916 927,888  258  2018 249,721  749.163 998,884  399 Education began summer ‘17; Reporting system changed Sept ‘17

Immediate impact: 35 40 72 111 2017 reported events Year Education began summer ‘17; Reporting system changed Sept ‘17 Year # Encounters primary providers Approximate # other interactions Approx total # encounters # REPORTED EVENTS  2017 231,972 695,916 927,888  258 2017 reported events 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Jan-Mar Apr-June July-Sept Oct-Dec 35 40 72 111

Next steps: Continue to support staff to recognize & report events Examine current barriers to reporting Help modify a new event reporting system to best capture the needs of the ambulatory practices Help launch the new system Act Plan Study Do Act Plan Study Do Act Plan Study Do

We’d love to hear from you! Contact us: Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ Patient Safety & Quality RN .maronson@elliot-hs.org 603-663-2472 Melissa Taylor, BS, RN-BC Director of Nursing for Primary Care .mtaylor@elliot-hs.org 603-663-3503 Anna Holland, RN Resource Nurse .aholland@elliot-hs.org 603-552-1448