Establishing a Reporting & Learning Culture Jeri Reinhardt, RN

1. Establishing a Reporting & Learning Culture Jeri Reinhardt, RN Vice President of Clinical Services and Performance Excellence Benedictine Health System

2. Creating Reporting and Learning Culture Jeri Reinhardt, RN, CMOE Vice President, Clinical Services and Performance Excellence Benedictine Health System

3. Reporting & Tracking of Adverse Events • Why? • It the right thing to do • It is required by CMS in Nursing Facilities • Current F868 • RoP 11/2019 F865, F866, F867 • 3 categories – medication, care and infection related • Staff Engagement • Residents and Families

4. CMS Medication Related Adverse Events (Not Inclusive and subject to change) • Bleeding • Hypoglycemia • Ketoacidosis • Bleeding • Thromboembolism • Prolong Constipation • Electrolyte Imbalances • Drug Toxicity • Alter Cardiac Output

5. CMS Care Related Adverse Events (Not Inclusive and subject to change) • Falls, Abrasions, Skin Tears • Electrolyte Imbalance • Respiratory Distress due trach or vent care • Exacerbation of existing conditions dues lack of care • Tube feeding complications • In-house acquired or worsening pressure injuries • Elopement

6. CMS Infection Related Adverse Events (Not Inclusive and subject to change) • Respiratory Infections • Pneumonia • Influenza • Skin and Wound • Surgical site • Soft tissue • UTIs • Infectious diarrhea • Norovirus • C. Diff

7. Doing the Right Thing • Desired results are delivered by efficient and effective processes • Cannot create a safe care environment by: • Educating or training staff • Through punishment or corrective action • You can only improve results by improving your processes

8. What about near misses • They are the “canary in the mine” • With serious errors when asked the question – has anything like this ever occurred before – most often staff will state yes

9. Tracking of occurrences • Required by CMS • Can be completed • By hand • Electronically • Specialized software • Used to identify trends and opportunities for improvement

10. Conduct a RCA on Serious Events • Root Cause Analysis on death or serious issues • Conduct interview, focus on facts – no blame • Steps • Develop a timeline of events • Use tools to identify cause • 5 Whys • Cause and Effect Diagram • AHQR RCA • Create action plan on Root Cause(s)

11. RCA Requires • Critical Thinking Skills • A non-judgmental attitude • A desire to understand why • A belief that we can always do better • Time to stop riding the bike and see if the bike can be fixed – to look beyond the “Quick Fix”

12. Create a Timeline of Events • Can use post it notes and line up in sequential order • Can create a timeline and place (with post it notes) - when events occurred • Can create a Word document

13. BHS Investigation Areas • People • Process System • Resident Related • Environment • Equipment

15. Cause and Effect Diagram Materials Methods Medication Given after D/C Holes . Timing of Shift Change Manpower Machines

16. Joint Commission's Framework for Root Cause Analysis • 24 Analytical questions • What was the intended processes flow? • Any steps in process missed? • Did the equipment perform? • Were staff qualified and competent? • How do staffing level compare to ideal? • Was communication accurate, complete or unambiguous? • Does the culture support risk reduction?

17. Agency for Healthcare Investigation and Analysis Guide: Appendix D • Over 50 analytical questions • Did all caregivers have the access to information about the patients? • Was the medical record up to date? • Were the barriers to communication? • Were staffing levels appropriate? Staff trained? • Was the physical environment conducive to providing safe care? • Was the equipment function properly? • Where all the steps in the process followed? • Could a similarly qualifies person do the same thing? • Does a policy exist? Was the policy followed?

18. Determine Root Causes • If this cause was eliminated - could the event still occur? • Typically have multiple causes • Develop action plan What will be done? Who will complete the task? When will it be completed? How will you know the risk as been removed?

19. Human Factors in Error • Operator error is inevitable • Human error rates are high • To Err is Human • Exhortations to “be professional” or “to be more careful” are generally ineffective, because • Most errors are committed inadvertently by people who are already trying to do their job professionally and carefully. They did not intend to commit the errors.

20. National Center for Patient Safety Hierarchy of Solutions • Three levels • Weak • Intermediate • Strong • Easily accessible online • Located in CMS QAPI At-A-Glance resource

21. Weak Actions • Actions that depend on staff to remember their training or what is written in the policy. Weak actions enforce the existing processes. • Examples of Weak Actions • Double checks and audits • Warnings and labels • New policies and procedures/ memos • Training/ education • Additional study or re-training

22. Intermediate Actions • Actions are somewhat dependent on staff remembering to do the right thing, but they provide tools to help staff remember or promote clear communication. Intermediate action modifies existing processes • Examples of Intermediate Actions • Reduce interruptions /alter work load • Software enhancements/modifications • Eliminate/reduce distractions (the red circle) • Checklist/cognitive aid • Eliminate look and sound a likes • Read back • Enhanced documentation/communication • Redundancy

23. Strong Actions • Strong action changes or redesign the process • Actions that do not depend on staff to remember to do the right thing • The action may not totally eliminate the vulnerability but provides strong control • They help to detect or warn prior to an error occurring • They may include hard stops which won’t allow the process to go forward unless something is corrected

24. Examples of Strong Actions • Architectural/physical plant changes • New device with usability testing before purchasing • Engineering control or interlock • Simplify the process and remove unnecessary steps • Standardize an equipment or process • Tangible involvement and action by leadership in support of patient safety

25. Questions? • Jeri.reinhardt@bhshealth.org • 612-845-2833