a2: managing recommendations to improve quality & safety - a taylor

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: ataylor@phsa.ca BC PSLS website: www.bcpsls.ca

Tamara Kennedy-MacDonald: tamara.kennedy-macdonald@fraserhealth.caCathy Weir: cathy.weir@fraserhealth.ca