Continuous Quality Improvement: Learning from Events

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1 September 8, 2016 Continuous Quality Improvement: Learning Planning Team QI coordinator (facilitator) Mary Beth Mitchell Electronic health record (EHR) manager Lee Patrick Practice educator Pat Stahura 2 Copyright ECRI Institute,

2 Learning Objectives Develop action plans that are linked to identified root causes Develop action plans that are effective and impactful Develop measures of effectiveness for action plans 3 Systems Thinking Root cause analysis seeks to identify systemic or individual problems that contribute to an event These causes go deep enough to reveal the system issues underneath Once root causes are identified, they point to vulnerabilities and fixes at a systems level The fixes at the systems level can prevent recurrences 4 Copyright ECRI Institute,

3 Plans A thorough system analysis is fruitless without effective improvement strategies plans should mitigate the risk and prevent a reoccurrence of similar events 5 s Should Be Tied Directly to Causal Factors and Underlying (Root) Cause Adverse Event Causal Factor Causal Factor Causal Factor Causal Factor Root Cause Root Cause Root Root Cause Cause Root Root Cause Cause 6 Adapted from Vanden Heuvel et al. Root cause analysis handbook. 3rd ed. Houston (TX): ABS Consulting; Copyright ECRI Institute,

Adverse Event Causal Factor Causal Factor Causal Factor Causal Factor Recognition of abnormal sinus CT scan report delayed Root Cause Radiology report sent Root to ordering Cause physician s inbox

trained that in her absence test results would default to assigned covering provider s inbox to follow up Sinus CT scan report did not automatically default to assigned covering provider Following

4 Adverse Event Causal Factor Causal Factor Causal Factor Causal Factor Recognition of abnormal sinus CT scan report delayed Root Cause Radiology report sent Root to ordering Cause physician s inbox but she was on vacation Root Root Cause Cause Root Root Cause Cause Dr. trained that in her absence test results would default to assigned covering provider s inbox to follow up Sinus CT scan report did not automatically default to assigned covering provider Following the last EHR upgrade, the automatic default malfunctioned 7 Developing an Plan: A Basic Three-Step Process Develop at least one action for each root cause Track action plans: who, what, when, where, how Follow-up to make sure action plans have been implemented completely, correctly, and in a timely manner 8 Copyright ECRI Institute,

5 Case Scenario Dr. Smith sees a female patient with complaints of nasal congestion and watery eyes. Dr. Smith prescribes Flonase nasal spray and orders a sinus CT scan When ordering the prescription in the EHR, she types FLO in the medication order screen and the EHR automatches Flomax, a medication for an enlarged prostate that is not approved by the Food and Drug Administration for women Without noticing the error, Dr. Smith selects the incorrect medication 9 Case Scenario (cont.) The patient fills the prescription and takes it as directed Flomax also has a side effect of hypotension. Several days after beginning the medication, the patient presents to the emergency department (ED) with dizziness and the error is discovered 10 Copyright ECRI Institute,

6 Case Scenario (cont.) The patient returns to the health center as directed by the emergency room Dr. Smith examines the patient Results of sinus CT scan are not available Dr. Smith leaves for vacation 11 Case Scenario (cont.) Radiology calls the health center with abnormal CT results Receptionist writes the telephone report down and places in Dr. Smith s inbox Results of abnormal sinus CT scan are also ed to Dr. Smith s portal. Assigned covering provider for Dr. Smith is unaware CT results are pending for the patient Delayed follow-up to the CT scan report for a sinus mass; rule-out squamous cell carcinoma 12 Copyright ECRI Institute,

7 Root Causes 1. Protocols or systems were not developed to require verification of prescriptions to intended medications before sending prescription to the pharmacy 2. Abnormal CT scan report did not automatically drop into the assigned covering provider s inbox during Dr. Smith s absence (automatic default malfunctioned) 13 Developing Plans: Using Evidence When looking to redesign your process to correct causes and mitigate hazards, look to best practices and established science from sources such as: Professional, regulatory, and accreditation bodies Recognized subject matter experts Peer-reviewed/refereed literature National/regional practice standards Copyright ECRI Institute,

8 Root Cause #1 Protocols or systems were not developed to require verification of prescriptions to intended medications before sending prescription to the pharmacy American Health Information Management Association. Best practices in electronic health records: American Academy of Family Physicians. Workflow & redesign for EHR: 15 Root Cause #1 (cont) Office of the National Coordinator for Health Information Technology, HHS. How to implement EHRs: professionals/ehr-implementation-steps/step-1- assess-your-practice-readiness American Medical Association. Error-proofing your office: rules and protocols to help reduce risk: ssion/ /4/ 16 Copyright ECRI Institute,

9 Root Cause #2 Following the last EHR upgrade, automatic default did not function as anticipated and was not reported SAFER Guides to Improve EHR System Massachusetts Coalition for the Prevention of Medical Errors (MA Coalition). Build reliability into the system [online]. [cited 2011 May 24]. Available from Internet: n3.shtml White B. Four principles for better test-tracking. Family Practice Management 2002 Jul/Aug: Creating Impactful Plans 18 Copyright ECRI Institute,

Hierarchy of Plan Strategies High/strong Best strategy for removing dependence on the human to get it right (these strategies are physical and permanent, rather than procedural and temporary) Medium/

10 Hierarchy of Plan Strategies High/strong Best strategy for removing dependence on the human to get it right (these strategies are physical and permanent, rather than procedural and temporary) Medium/ intermediate Reduces reliance on the human to get it right, but does not fully control for human error Low/weak Supports/clarifies the process, but relies solely on the human. These actions do not necessarily prevent the event/cause from occurring 19 Sources: VA National Center for Patient Safety, U.S. Department of Veterans Affairs. Root cause analysis tools Feb National Patient Safety Foundation. RCA 2 : Improving root cause analyses and actions to prevent harm. Version Jan. Strength of Strategy: Low-Impact Measures Low/ weak Document Education/information Rules and policies Be more careful Warnings and labels Double checks 20 Copyright ECRI Institute,

11 Strength of Strategy: Medium-Impact Measures Medium/ intermediate Use checklists/cognitive aids Standardize to reduce process variability Minimize choices Increase detectability Optimize redundancy Train with simulation Standardize communication tools 21 Strength of Strategy: High-Impact Measures High/strong Simplify the process Automate Incorporate forcing functions/engineering controls Incorporate fail-safe mechanisms Tangible involvement by leadership Architectural/physical plant changes 22 Copyright ECRI Institute,

12 Example: Incorrect Medication Prescribed in EHR Problem #1: The prescribing physician did not doublecheck the prescription she ordered for accuracy Root cause: Protocols and systems were not developed to require verification of prescriptions to intended medications before sending prescription to the pharmacy 23 Plan Example Problem #1: The prescribing physician did not doublecheck the prescription she ordered for accuracy s: High impact Hardwired pop-up requires the physician to verify that the prescription has been matched against the intended medications before sending the prescription to the pharmacy Medium impact Updated protocol requires the provider to verify and document that the prescribed medications are correct Low impact Office-wide education on updated protocols 24 Copyright ECRI Institute,

13 Example: Abnormal Sinus CT Report Delayed Problem # 2 Abnormal CT scan report did not automatically drop into the assigned covering provider s inbox during Dr. Smith s absence Root cause: Following the last EHR upgrade, automatic default did not function as anticipated and was not reported 25 Plan Example Problem #2: Abnormal CT scan report did not automatically drop into the assigned covering provider s inbox during Dr. Smith s absence s: High Schedule IT to make the necessary changes in the EHR to ensure that the problem with automatic default is fixed; investigate EHR tracking system to address issue Medium impact Change the process for front desk and clinical staff on how to handle results and who to contact when provider is not in the building Low impact Educate providers and staff to hand off to covering providers 26 Copyright ECRI Institute,

Creating Sustainable Plans 27 Model of Sustainability for Plans E F F E C T I

policies Automate Incorporate forcing functions Incorporate fail-safe

Minimize choices Increase detectability Optimize redundancy Low Medium

An evidence-based toolkit for the development of effective and sustainable

14 Creating Sustainable Plans 27 Model of Sustainability for Plans E F F E C T I V E N E S S High Moderate Medium Low Document Educate or train Implement policies Automate Incorporate forcing functions Incorporate fail-safe mechanisms Simplify the process Standardize to reduce process variability Minimize choices Increase detectability Optimize redundancy Low Medium Moderate High Sustainability 28 Adapted from Hettinger et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis safety system solutions. J Healthc Risk Manag 2013;33(2): Copyright ECRI Institute,

Model of Sustainability for Plans E F F E C T I V E N E S S High Moderate Medium Low Educate the staff on a new protocol Implement a new protocol with compliance requirements Low Medium Moderate High

15 Model of Sustainability for Plans E F F E C T I V E N E S S High Moderate Medium Low Educate the staff on a new protocol Implement a new protocol with compliance requirements Low Medium Moderate High Sustainability 29 Adapted from Hettinger et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis safety system solutions. J Healthc Risk Manag 2013;33(2): Test Drive First: Use PDCA Model (Plan, Do, Check, Act) Remember, with a new process comes new inherent risks Look to see how your changes affect other processes, not just the one you redesigned! Act Check Plan Do Don t jump the gun! 30 Copyright ECRI Institute,

16 PDCA Plan The action plan items Do Implement the action items Check Check to see if intended outcomes are occurring Act Make changes in the action plan or continue full implementation without changes 31 Developing Measures of Effectiveness 32 Copyright ECRI Institute,

17 Measures of Effectiveness Measurement sometimes looks like just more work Assists with ensuring the new process is occurring as planned Measures for the intended outcome 33 Measures of Effectiveness (cont) Process measure: The extent to which a new process is in place It is how you know that the action is actually taking place Outcomes measure: Net change in health status of designated population Measures the effectiveness of the recommendation achieving the overall aim (outcome) 34 Copyright ECRI Institute,

18 Measures of Effectiveness Will Contain: Numerators What is being measured for improvement? Denominators Out of what population/total group is the numerator being sampled? Threshold/target/goal What is the realistic expected level of compliance (percent)/result of the numerator? Timeframe How long will it be measured? 35 Measure of Effectiveness for Prescription Verification Process measure: # times prescription verification box is checked by the provider/# prescriptions ordered (current) Outcome measure: # providers and staff attending education on updated protocol/# health center staff and providers (retrospective) 36 Copyright ECRI Institute,

19 Measure of Effectiveness for Test Report Tracking Process measure: # reported malfunctions/# EHR upgrades (current) Outcome measure: # reports not automatically dropped to covering physician/# reports received by health center (retrospective) 37 Designing the Data Collection Did you define the data so that you get the intended outcome? Is it based on best practice? Who is collecting the data? Does your collection strategy work? Where will you report the data? Who will give input to see if the actions need to be revised based on the measures of effectiveness? What is your target or goal? 38 Copyright ECRI Institute,

20 Assigning an Individual to Implement the Plan The individual must have the authority to effect change Assigning committees or multiple individuals dilutes accountability for the action 39 Sample Tracking Sheet Root causes Preventive actions strength Responsible party/ due date Measure of effectiveness (process, outcome) High Moderate Low High Moderate Low High Moderate Low Copyright ECRI Institute,

21 Sample Tracking Sheet Root causes Preventive actions strength Responsible party/ due date Protocols and systems were not developed to require verification of prescriptions to intended medications before sending prescription to the pharmacy Hardwired pop-up requires physician to verify that the prescription has been matched against the intended medications before sending the prescription to the pharmacy Update protocol to require provider verify the prescribed medications are correct by clicking on the check box in the EHR High Moderate Low High Moderate Low Lee Patrick information technology manager 12/31/2016 Pat Stahura practice educator 11/15/2016 Measure of effectiveness (process, outcome) Report of the # or % of matches verified / # prescriptions sent to the pharmacy # times prescription verification box is checked in EHR/ # e-prescriptions Office-wide education on updated protocol High Moderate Low Pat Stahura practice educator 11/15/2016 # providers and staff attending education on updated protocol/ # health center providers and staff 41 Sample Tracking Sheet Root causes Preventive actions strength Responsible party/ due date Measure of effectiveness (process, outcome) Following the last EHR upgrade, automatic default malfunctioned and was not reported Schedule IT to make the necessary changes in the EHR to ensure that the break is fixed High Moderate Low Lee Patrick information technology manager 12/31/2016 # malfunctions reported by IT/ # EHR upgrades Change the process for front desk and staff to date and time telephone report received. Provider to date and time telephone report received High Moderate Low Pat Stahura practice educator 12/1/2016 # date and time telephone reports received by front desk and staff/# telephone reports AND # date and time telephone reports received by providers/ #telephone reports Educate providers and staff to hand off to covering providers High Moderate Low Pat Stahura practice educator 12/1/2016 # providers and staff attending in-service/ # health center staff and providers 42 Copyright ECRI Institute,

22 Evaluation of s What will be the frequency of measurement/data collection? What methods will be used? Chart audits/record reviews? Direct observations? Surveys? Incident reports? How long will this be monitored? Determine numerators and denominators Determine the threshold of expected compliance Where will the data be reported? Source: Bagian et al. Improving RCA performance: the Cornerstone Award and the power of positive reinforcement. BMJ Qual Saf 2011 Nov;20(11): item Compliance rate (month) Target Goal Recommendations Responsibility/ due date Hardwired pop-up requires physician to verify that the prescription has been matched against the intended medications 100% before sending the prescription to the pharmacy Update protocol to require provider to verify 100% the prescribed medications are correct and document the verification Office-wide education on updated protocol 100% Schedule IT to make the necessary changes 100% in the EHR to ensure that the malfunction is fixed Change the process for front desk and staff to date and time telephone report received. 100% Provider to date and time telephone report received Educate providers and staff to hand off to covering providers 100% 44 Copyright ECRI Institute,

23 45 Checklist Do the actions meet the following criteria? Has leadership support and approval Addresses the root cause and contributing factors Staff have provided feedback on whether action items make sense to them Are specific, concrete, and measurable Anyone can understand and implement Will be tested prior to implementation when feasible Are based on conclusions from data collected during the investigation Implemented in all applicable areas of the organization Adapted from VA National Center for Patient Safety, U.S. Department of Veterans Affairs. Root cause analysis tools Feb and National Patient Safety Foundation. RCA 2 : Improving root cause analyses and actions to prevent harm. Version Jan. Reference American Health Information Management Association (AHIMA). Integrity of the healthcare record: best practices for EHR documentation (2013 update): 46 Copyright ECRI Institute,

24 2016 FTCA Risk Management Virtual Conference Wrap-Up 47 Event Scenario: Conclusion After receiving counseling through the employee assistance program, targeted education on health center policies and conduct, and assistance from Dr. Mary Downs with time management, Dr. Smith s behavior improves: Follow-up performance reviews indicate improvement in all low-scoring areas and improved compliance with policies No complaints are submitted by patients or colleagues from February 2015 through September Copyright ECRI Institute,

25 Event Scenario: Conclusion Anytown Health Center implemented action plans: Updated protocol requires the provider to verify the prescribed medications are correct and document the verification (medium impact) and conducted staff training on the updated protocol (low impact) Changed process to on how to handle results (medium impact) and educate on how to hand off (low) 49 Event Scenario: Conclusion While implementing the low- and medium-impact actions, Anytown Health Center worked with its EHR vendor to make changes to the system (high impact) During the next round of EHR updates, new safeguards were implemented (i.e., pop-up requiring the physician to verify prescription before sending to the pharmacy) (high impact) Scheduled IT to make changes in the EHR to ensure that the problem with automatic default is fixed (high impact) There were no further incidents of delayed recognition of abnormal CT scans or incorrect medication orders 50 Copyright ECRI Institute,

26 Questions? (610) , x5200 Thank You Copyright ECRI Institute,

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