Download presentation
Presentation is loading. Please wait.
1
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
2
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
3
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)
4
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
5
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 249,721 998,884 399
6
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
7
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
8
Establishing Just Culture
To Err is Human Human Error “Console” Drift becomes At-Risk Behavior “Coach” Reckless Reckless behavior “Punish”
9
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”
10
Changes to Event-Reporting System
Most categories unchanged But many sub-categories changed
11
Category change: Medication Medication Immunization
12
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
13
Sub-Category change: Category: Medical Equipment & Supplies Previous: Current: 20 sub-categories 5 sub-categories
14
Sub-Category change: Category: Security Previous: Current:
13 sub-categories sub-categories including hospital-specific “codes”
15
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
16
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
17
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
18
Follow ups: Thank you “Lessons Learned” Newsletter distributed to all ambulatory care colleagues Staff meetings Education
19
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!!
20
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
21
New: Director of Primary Care Nsg
All events go to DON for review Provide support to Resource Nurses Coach Resource Nurses to support staff
22
Staff Nurse Co-Champion: Help colleagues recognize “events”
Contribute to investigation Share opportunities for improvement with colleagues within the practice
23
Staff Nurse Use events for discussion & process improvement
For example, Several vaccine-related events Office workflow now includes double-checks
24
Resource/Staff Nurse Engaging staff: Discuss at daily huddles
Discuss at monthly staff meetings
25
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 249,721 998,884 399 Education began summer ‘17; Reporting system changed Sept ‘17
26
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
27
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
28
We’d love to hear from you!
Contact us: 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
Similar presentations
