June 08, 2017 | | Comments 0
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TBT: Building a better self-reporting structure

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Does your organization have a formalized process for debriefing after an adverse event? And if so, is it working? For many organizations, reporting of adverse events can be problematic, with challenges ranging from time management and inefficient processes to the age-old challenge of shame?reporting near misses and adverse events can be a challenge in an industry where everyone pursues the field to help, not hurt.

“Everyone wants to leave work happy and feel like they did a good job,” says Anngail Smith, VP of operations and risk management for CRG Medical, Inc., in Houston. “Someone once said that healthcare is the intersection of care and being able to hurt people. A client told me that healthcare is a courageous activity.”

Because healthcare rides along that fine line between safe care and risk of harm, the industry needs to build an environment where people are willing to report errors and near misses so that the industry as a whole can work on the problem without being afraid.

“I think the fear of hurting someone is always there,” says Douglas Dotan, president and CEO of CRG Medical. “The question is, are you willing to incorporate that into learning how to make your processes better?”

The pressures to report are staggering for providers, Dotan says. Personal liability, risks to reputation, job security, and even peer pressure can all come into play with the issue of reporting. But the industry needs physicians to speak up and identify hazards to patient safety, share their knowledge about near misses, and propose actions to improve the delivery of care. This requires a culture change to create an environment in which providers feel safe to talk about these things without putting themselves at risk.

“If there is something that really stresses caregivers out, we need to find a way to fix it, and we need to share that fix,” says Dotan. “That won’t happen if they’re afraid.”

This is not a new issue, Dotan points out. Donald Berwick’s Institute of Healthcare Improvement talked about these factors 15 years ago, Dotan notes, and yet most events which occur today have occurred in the past, and the latest reports state that the industry has well over 400,000 preventable deaths in healthcare every year.

“That’s about 1,000 deaths that occur every day from preventable medical errors,” says Dotan.

And the contributing factors leading up to these preventable errors occur all the time. The same situation may occur 200 or 300 times before a sentinel event occurs, leading to hundreds of thousands of dollars spent in litigation and reparations because it wasn’t prevented the first 300 times, Dotan says.

This comes down to continual process improvement, he says.

“What we’ve been working on is identifying those hazards and unsafe conditions and putting an easier way for people to communicate in place,” says Dotan. “You need to have a way of documenting and giving feedback. If I continuously give you information I think is important to act on and leadership doesn’t act on it, I will stop communicating that information. So when future problems arise, they will not be reported.”

An open communication system will help overcome the fear of reporting, Smith says.

“Are you good at your job? If you did it badly would you want to tell someone? We spend more time doing our jobs than anything else. For an inexperienced person, if they make a mistake, they might report it. ‘I am new at this; I will make mistakes,’ ” says Smith. “But if the experienced person makes a mistake, they’d think they would be embarrassed to talk about it.”


Building a better process

There has to be something in place to make these professionals want to report, because culturally there is still a sense that many would rather not report for fear of ruining their reputation.

“That’s a huge motivator” [for not reporting], says Smith.

Smith first became involved in Joint Commission preparation in the 1980s and says that although she has seen change in terms of improving reporting, more needs to be done.

“Why is reporting and the debriefing process still a problem?” she asks.

Another problem: providers are far more likely to report adverse events than they are near misses.

“In reality, if a horrible event occurs, people know about it already,” says Smith. “But a near miss, one might decide not to report it. It’s harder to report an event that didn’t hurt someone.”

This isn’t always the case?certain organizations have done a better job at making it easier for people to report that helps the hospital look at intervening and contributing factors and build better training.

But for those without strong reporting cultures, what are the interventions? Does a “just culture” exist in the organization? “The first step is to conduct a custom just culture and engagement diagnostic survey to identify the perception of caregivers and the barriers to sharing patient safety knowledge,” says Dotan.

“If you have people who spot something wrong, stop, and take preventive action, they need a quick, easy, and safe way to self-debrief and communicate what they did and why they did it. Then someone needs to interview that person,” says Smith. “We need to ask what made them stop so that others can learn from it. It’s important to learn from near misses more than anything else.”

Using current technology

Dotan says the industry is currently riding the proverbial horse backward, looking in the wrong direction for solutions. “We should be engaged more in communicating how we prevent harm rather than having to report harm done.”

One simple solution his organization has devised makes use of something already in the hands of every physician and nurse.

“In nearly every physician’s pocket is a smartphone,” says Dotan. “Almost everyone is using mobile technology.”

So why not turn that technology already in hand into a self-debriefing tool and for capturing data about near misses?

“What if you can utilize what people are using every day, so it’s not a chore?” says Dotan. “You can pull out your smartphone, take a picture, and record a voice message. We’ve taken that technology and said, why don’t we empower every caregiver to show us what’s wrong in 60 or 90 seconds.”

Everyone wants safe care for patients, but a better system is needed to deliver the information that will lead to this, Dotan says.

“We need a means to communicate, and we’re talking about a self-debriefing,” says Dotan. “How can I debrief myself and utilize the system to trigger thinking about what we’ve observed and participated in?”

This reported information needs to be passed along to the quality, safety, and risk departments, who can then communicate back to the initial caregiver and continue the debriefing process.

“Nobody knows what the caregiver has observed and experienced,” says Dotan, “unless they tell us.”

To facilitate this, Dotan’s organization has developed an app, using the Agency for Healthcare Research and Quality (AHRQ) Common Formats, compatible with the iPhone® and Android, which is designed to communicate with electronic medical records and databases in the hospital?allowing the phone to scan bar codes, take pictures, and auto-populate forms from the bedside.

“It’s BYOD?bring your own device,” says Dotan. “The phone you carry in your pocket right now can populate a form with a click of a button.”

The app is securely encrypted and no patient information is stored on the phone?the information is sent directly and securely to the cloud.

“All the captured data disappears from the device,” explains Smith.

The documentation ability of the app eliminates the probability to type or write in the wrong name, wrong identification, and wrong medication involved in an event through the scanning of patient, medical device, and medication bar codes.

“The whole idea is looking forward,” says Dotan. “You do not need to only look in the rearview mirror to analyze the past, but also need to look through the front windshield to see what’s coming ahead. Today we are not preempting these events, we’re still reporting them.”

The sorts of situations immediate reporting can help alleviate are well known in healthcare. Take, for example, an event occurs somewhere in the facility and an investigation is made. When asked, there are staff members who would say they know the provider involved and they could have predicted the mistake based on past behavior.

“You know the unsafe conditions that would enable an event to happen, so you create a system or put a system into place that caregivers can use to document and communicate those unsafe conditions,” says Dotan. “Management can then provide feedback and take preventive action to prevent the occurrence of such an event.”

When people think of new technology they think their responsibility has somehow diminished,” says Smith. “That’s not true. It’s the medium that has changed, not the message.”

Items of interest will still need to be followed up on, but the technology should encourage and support reporting functions.

“Patient safety starts with the caregivers,” says Dotan. “If management wants to know what happens, we’ve got to make it safe for the caregivers” to report.

If caregivers do not feel safe to talk about errors, the patients are at risk, the institution is at risk, and the cost of being reactive and corrective rather than proactive and preventive far exceeds the cost of prevention, Dotan explains. The Patient Safety and Quality Improvement Act of 2005 charged AHRQ with the responsibility for developing the rules to create Patient Safety Organizations that will provide clinicians who want to share patient safety knowledge with the safety and protection from litigation.

“The old cliché about an ounce of prevention being worth more than a pound of cure is true,” says Dotan. “Even a frivolous lawsuit will cost you more than the preventive actions would.”

The ‘second victim’

Smith points out that prevention does not just make the patient safer and eliminate risk, it also benefits the caregivers, who often suffer from errors and near misses.

“It’s the pain of dealing with the situation, the pain of having to go back into that situation and not have it happen again,” says Smith. “There’s a lot of literature in nursing about the ‘second victim.’ “

Dotan and Smith work together toward the same end with complementary passions?Dotan, Smith says, has a passion about preventing events and injuries to patients, while Smith herself says she has a passion for assisting caregivers to do everything right the first time.

“If they are competent and know things are going to go well, but also know someone is there to help them if something does go wrong,” your patient safety system is stronger for it, Smith says.

By giving caregivers the tools to record and report near misses on the spot?not requiring them to remember and enter data into a computer later or fill out paperwork?your organization is streamlining the process.

“It comes from the bedside directly,” says Smith. “It blends into the workflow.”

The important thing is this information doesn’t reside on the device?the device is the conduit, but that information is entered into the system, and entered securely, immediately.

“It goes onto the cloud. It auto-populates,” says Smith. “It doesn’t solve the problem but it’s an enabling technology.”

The data collection aspect allows providers to jump right into what happened, what they did to prevent it from being worse, and how they think improvements could be made, rather than beginning from scratch with names, numbers, dates, and other information which can be gleaned from the patient record.

All of this builds toward an easier debriefing for the provider.

“We want to capture a picture of what’s going on,” says Dotan. “I was doing X, this happened, and here is what I gleaned from it.”

Dotan says we need hazard identification and early warning systems that help organizations be proactive, predictive, and preventive rather than reactive, corrective, and punitive, which are actions associated with traditional reporting systems.

Visit http://kbco.re/ for more on CRG Medical’s “Purple Button” app.

Entry Information

Filed Under: AccreditationPatient SafetyQuality


About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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