a2: managing recommendations to improve quality & safety - a taylor
TRANSCRIPT
Managing Recommendations to Improve Quality & Safety
Annemarie Taylor, BC PSLSTamara Kennedy-MacDonald, FHA
Cathy Weir, FHA
“We’ve received a report…”
Patient Safety Review
Critical Incident Review
Coroner’s Report
Accreditation Canada Report
External Review
Patient Care Quality Review
“…with recommendations to…”• Improve communication between…
• Replace existing equipment with…
• Develop a policy on…
• Provide training on…
• Revise the guidelines for…
• Involve patients in…
• Establish a new procedure to…
…and more!
2005: Patient safety reviews using Root Cause Analysis framework• Single site: 18 reports with 90 recommendations
2007/08: 115 patient safety reports with 646 recommendations
2008: Joint audit with Canadian Patient Safety Institute• Developed an “auditing” tracking database• Adopted Larsen’s Utilization Scale to track implementation status• Identified need for a robust tool to manage recommendations
2008/09: 105 patient safety reports with 510 recommendations
2009/10: 68 patient safety reports with 340 recommendations• Identified need to track accountability for implementation of
recommendations and assess impact on quality and patient safety
Fraser Health
Current “system”It’s hard to know…who is responsible for what?What is the status of recommendations?Are they done yet?
Also…are the recommendations sound?Will they fix the problem?Should we implement them?Who should we assign them to…and how?
And…are we sure the changes were made?Are they being sustained?Did they fix the problem?
Oh, and could you put a report together on that?
And…haven’t we done this before?
There must be a better way.
New system requirements• Create one-to-many relationships between components• Attach documents and keep them confidential• Link to safety event, complaint and other records• Track recommendation review and approval process• Assign recommendations to owners• Track recommendation implementation status• Support workflow• Facilitate status reporting
…and…
• Evaluate strength of recommendations pre-implementation• Assess effectiveness of changes post-implementation• Support analysis of report topics, actions taken• Share learning
BC PSLS:•The province’s on line safety event reporting and learning tool•In use across BC in all Health Authorities and settings•Familiar to quality/safety staff and operational leaders•Used to capture and manage safety events and complaints
With configuration complete, the Recommendations Manager meets all identified requirements
BC PSLS Recommendations Manager
Report
ActionsRecommendations
One-to-many
File Handler
Workflow
Accountable Leader
Board CommitteesRecommendation
OwnersAction Owners
Recommendations Manager: A quick look
Recommendations Manager:Options
Recommendations Manager:List all review reports
Recommendations Manager:Show recommendations
Recommendations Manager:Open report with recommendations
Recommendations Manager: Open recommendation with action
Recommendations Manager:Recommendation scoring tool
• Targets contributing factor? (0 - 5)• Implementation is feasible? (0 - 5)• Impact on risk? (-1 - 4)• Evidence-based? (0 - 3)• Type of action? (hierarchy of effectiveness) (0 - 3)• Highest score possible = 20• Recommendation should receive a score of 10 or more to be considered for implementation
Recommendations Manager:Post-implementation assessment guide
• Measurement used (type of evidence)• Impact of change on risk or hazard
Assessment toolsRecommendation Score
+
Post-implementation Assessment Results=
Opportunity
• Compare scores and evidence to determine most effective recommendations
• Inform future implementation decision-making
Reports & LibraryMy Reports section of Recommendations Manager• Listing reports to assist users with tracking• Reports for Boards and Committees
BC PSLS Reports (Business Intelligence tool)• Support for analysis of de-identified data
Library• Separate BC PSLS module• Allows users to store and share implementation project plans,
evaluation tools and other documents
Thank you!
Questions & Comments
Contact:Annemarie Taylor: [email protected] BC PSLS website: www.bcpsls.ca
Tamara Kennedy-MacDonald: [email protected] Weir: [email protected]