september 8, 2016 continuous quality improvement: learning from events … · 2016-09-07 ·...

Continuous Quality Improvement: Learning from Events

9/6/2016

Copyright ECRI Institute, 2016 1

©2016 ECRI INSTITUTE

Continuous Quality Improvement:

Learning from Events

September 8, 2016

©2016 ECRI INSTITUTE2

Action Planning Team

QI coordinator (facilitator)—Mary Beth Mitchell

Electronic health record (EHR) manager—Lee Patrick

Practice educator—Pat Stahura


9/6/2016



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


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

Systems Thinking


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Action Plans

A “thorough” system analysis is fruitless without

effective improvement strategies

Action plans should mitigate the risk and prevent a

reoccurrence of similar events


Adverse Event

Root Cause

Root Cause Root CauseRoot

Cause

Action ActionAction ActionAction

Causal FactorCausal Factor Causal Factor Causal Factor

Action

Root Cause

Root Cause

Root Cause

Action Action

Action

Adapted from Vanden Heuvel et al. Root cause analysis

handbook. 3rd ed. Houston (TX): ABS Consulting; 2008.

Actions Should Be Tied Directly to Causal

Factors and Underlying (Root) Cause


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Adverse Event

Root Cause

Root Cause Root CauseRoot

Cause

Action ActionAction ActionAction

Causal FactorCausal Factor Causal Factor Causal Factor

Action

Root Cause

Root Cause

Root Cause

Action Action

Action

Recognition of abnormal sinus CT

scan report delayed

Radiology report sent to ordering

physician’s inbox but she was on

vacation

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


Developing an Action 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


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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


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


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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



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 emailed 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


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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)


Developing Action 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

14


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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:

http://library.ahima.org/PdfView?oid=67876

■ American Academy of Family Physicians. Workflow &

redesign for EHR: http://www.aafp.org/practice-

management/health-it/product/workflow-redesign.html


Root Cause #1 (cont)

■ Office of the National Coordinator for Health

Information Technology, HHS. How to implement

EHRs: https://www.healthit.gov/providers-

professionals/ehr-implementation-steps/step-1-

assess-your-practice-readiness

■ American Medical Association. Error-proofing your

office: rules and protocols to help reduce risk:

http://www.amednews.com/article/20040112/profe

ssion/301129964/4/

http://library.ahima.org/PdfView?oid=67876

http://www.aafp.org/practice-management/health-it/product/workflow-redesign.html

https://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-1-assess-your-practice-readiness

http://www.amednews.com/article/20040112/profession/301129964/4/


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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

https://www.healthit.gov/safer/

■ Massachusetts Coalition for the Prevention of Medical

Errors (MA Coalition). Build reliability into the system

[online]. [cited 2011 May 24]. Available from Internet:

http://www.macoalition.org/Initiatives/CCTRDiscussio

n3.shtml

■ White B. Four principles for better test-tracking. Family

Practice Management 2002 Jul/Aug:41-4.

©2016 ECRI INSTITUTE18 ©2016 ECRI INSTITUTE

Creating Impactful Action Plans

https://www.healthit.gov/safer/

http://www.macoalition.org/Initiatives/CCTRDiscussion3.shtml


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Hierarchy of Action 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

Sources: VA National Center for Patient Safety, U.S. Department of

Veterans Affairs. Root cause analysis tools. 2015 Feb 26.

http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf;

National Patient Safety Foundation. RCA2: Improving root cause

analyses and actions to prevent harm. Version 2. 2016 Jan.

http://www.npsf.org/?page=RCA2


Low/ weak

•Document

•Education/information

•Rules and policies

•“Be more careful”

•Warnings and labels

•Double checks

Strength of Strategy: Low-Impact

Measures

http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf



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Medium/ intermediate

•Use checklists/cognitive aids

•Standardize to reduce process variability

•Minimize choices

• Increase detectability

•Optimize redundancy

•Train with simulation

•Standardize communication tools

Strength of Strategy: Medium-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

Strength of Strategy: High-Impact

Measures


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Example: Incorrect Medication

Prescribed in EHR

Problem #1: The prescribing physician did not double-

check 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


Action Plan Example

Problem #1: The prescribing physician did not double-

check the prescription she ordered for accuracy

Actions:

■ 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


9/6/2016



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


Action Plan Example

Problem #2: Abnormal CT scan report did not automatically

drop into the assigned covering provider’s inbox during Dr.

Smith’s absence

Actions:

■ 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


9/6/2016



Creating Sustainable Action Plans


Model of Sustainability for Action Plans

High

Moderate

Medium

Low

Low Medium Moderate High

28

• Document

• Educate or train

• Implement policies

• Simplify the process

• Standardize to reduce process variability

• Minimize choices

• Increase detectability

• Optimize redundancy

• Automate

• Incorporate forcing functions

• Incorporate fail-safe mechanisms

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):11-20.

EFFECTIVENESS

Sustainability


9/6/2016



Model of Sustainability for Action Plans

High

Moderate

Medium

Low

Low Medium Moderate High

29

Educate the staff on a new protocol

Implement a new protocol with compliance

requirements

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):11-20.

EFFECTIVENESS

Sustainability


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!

Plan

DoCheck

Act

Don’t jump the gun!


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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


Developing Measures of Effectiveness


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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


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)


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Measures of Effectiveness Will Contain:

•What is being measured for improvement?

Numerators

•Out of what population/total group is the numerator being sampled?

Denominators

•What is the realistic expected level of compliance (percent)/result of the numerator?

Threshold/target/goal

•How long will it be measured?Timeframe


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)


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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)


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?


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Assigning an Individual to Implement the

Action Plan

The individual must have the authority to effect change

Assigning committees or multiple individuals dilutes

accountability for the action


Sample Action Tracking Sheet

40

Root causes Preventive

actions

Action

strength

Responsible

party/

due date

Measure of

effectiveness

(process,

outcome)

High

Moderate

Low

High

Moderate

Low

High

Moderate

Low


9/6/2016



Sample Action Tracking SheetRoot causes Preventive actions Action strength Responsible

party/

due date

Measure of

effectiveness

(process,

outcome)

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

■ High

□ Moderate

□ Low

Lee Patrick—

information

technology

manager

12/31/2016

Report of the # or %

of matches verified /

# prescriptions sent

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

Pat Stahura—

practice educator

11/15/2016

# 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


Sample Action Tracking SheetRoot causes Preventive actions Action 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


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Evaluation of Actions

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):974-82.

http://qualitysafety.bmj.com/content/20/11/974.full.pdf+html


Action 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

before sending the prescription to the

pharmacy

100%

Update protocol to require provider to verify

the prescribed medications are correct and

document the verification

100%

Office-wide education on updated protocol 100%

Schedule IT to make the necessary changes

in the EHR to ensure that the malfunction is

fixed

100%

Change the process for front desk and staff

to date and time telephone report received.

Provider to date and time telephone report

received

100%

Educate providers and staff to “hand off” to

covering providers 100%

http://qualitysafety.bmj.com/content/20/11/974.full.pdf+html


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Action 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. 2015 Feb 26. http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf;

and National Patient Safety Foundation. RCA2: Improving root cause analyses and actions to

prevent harm. Version 2. 2016 Jan. http://www.npsf.org/?page=RCA2


Reference

American Health Information Management Association

(AHIMA). Integrity of the healthcare record: best practices

for EHR documentation (2013 update):

http://library.ahima.org/doc?oid=300257#.V5jrL-RTHIU

http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf


http://library.ahima.org/doc?oid=300257#.V5jrL-RTHIU


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2016 FTCA Risk Management Virtual

Conference Wrap-Up


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 2016


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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)



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


9/6/2016


©2016 ECRI INSTITUTE

Questions?

[email protected]

(610) 825-6000, x5200

Thank You

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september 8, 2016 continuous quality improvement: learning from events … · 2016-09-07 ·...

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