g1 rapid fire: designing a foundation of quality for mental health - l. bond and r. gibson
TRANSCRIPT
The Application of Lean Theory to Improve Patient Safety Event Reporting and Follow-up
Lynda BondDirector, Quality, Safety & Performance Improvement
Ross GibsonQuality & Safety Leader
March 9, 2012
Presentation Overview
1. Process Flow for Reporting and Following up Events Reported
in the Patient Safety and Learning System (PSLS)
2. Current State Analysis
3. Barriers to Effective Patient Safety Event Management
4. Project Goals
5. Application of Lean Theory
6. Process Improvement Strategies
7. Key Findings
Patient Safety Event Occurs
Address immediate needs of patient
Report event in PSLS
Handler notified of event via automatic
PSLS report goes to Holding Area
(Awaiting Review)Start of Review
Awaiting Final Approval
Being Approved
Implements changes
Finally Approved
Handler Rejects Report
Identify event as reportable
Assign staff member to write PSLS
report
Handler reviews report
Delegates Followup
Handler gets more info
(chart review/team)
Handler summarizes
findings
Handler determines next steps
Process Map for Reporting and Responding to Patient Safety Events
Current State Analysis
Metric Unit A Unit B Unit C Unit DSite Total
Average # of days to complete a patient safety event investigation (turnaround time)
35 days 26 days 80 days 66 days 53 days
Average # of days to report a patient safety event in PSLS 0.8 days 0.6 days 1.2 days 11.9 days 2.6 days
Average # of days to begin investigation 12 days 8 days 4 days 23 days 9 days
Average # of days to complete a patient safety investigation once it has begun 21 days 21 days 72 days 22 days 43 days
% of PSLS reports with a date entered at the beginning of the review 94% 48% 99% 35% 73%
% of PSLS reports with a date entered when the review is completed 95% 57% 98% 46% 77%
Current State Analysis
Percentage of PSLS Reports Completed within Established Timelines:
88% reported within 1 day
45% Near Miss and No Harm completed within 20 days
46% Minor and Moderate Harm completed within 30 days
100% Severe Harm completed within 60 days
Patient Safety Event Occurs
Address immediate
needs of patient
Report event in PSLS
Handler notified of event via
automatic email
PSLS report goes to Holding Area
(Awaiting Review)Start of Review
Awaiting Final Approval
Being Approved
Implements changes
Finally Approved
Handler Rejects Report
2.6 Days
Freeing up people to debrief on
event
Identify event as reportable
Assign staff member to write
PSLS report
Handler reviews report
Delegates Followup
Reporter does not know how to complete
report
What makes a PSLS event?
Handler batches reports or
opens email when has time
Not always easy to schedule time to see reporter (e.g. different
shifts, days off)
Handler gets more info (chart
review/team)
Handler summarizes
findings
Not always clear who handler is
Visibility of recurring
events (unit, site)
Anonymous report
prolongs info gathering
Handler determines next
steps
9 Days 43 Days
Targets
Level 1 = 20 Days 55% Defective
Level 2 & 3 = 30 Days 53% Defective
Level 4 & 5 = 60 Days 100% Defective
Does not mean all
changes are implemented
Track Recommendations vs actual process changes
Review can begin before PSLS report
opened
Barriers to Effective Patient Safety Event Management
Project Goals
1. Strengthen the reporting and follow-up of actions arising from patient safety events, with the ultimate goal of enhancing safety for our patients.
2. Decrease the length of time from patient safety event notification to investigation and to final signoff.
3. Decrease the turnaround time from review to implementation of actions.
4. Enhance the level of detail, data quality and completion of fields in PSLS to allow for more timely follow-up and action arising from patient safety events.
5. Develop strategies to improve sharing of PSLS data/trends with staff and collaborative approaches for identifying safety issues on units and making improvements.
6. Improve the effectiveness of actions taken to reduce recurrence of future events.
7. Decrease the length of time required to complete a PSLS report by streamlining the reporter and handler forms to ensure only information that is critical for safety event management is captured.
Application of Lean Theory
Key Concepts:
Increase efficiency by eliminating waste
Design and improve systems from the customer’s perspective
Remove defects by correcting problems as they arise
Focus on continuous quality improvement
Process Improvement Strategies
1. Simplify and Streamline PSLS Reporting and Follow-up Forms
2. Develop Standard Work Processes for Reporting Safety Events in PSLS
3. Develop Standard Work Processes for Following-up Safety Events in PSLS
4. Implement “Mini Kaizen” Patient Safety Mistake Proofing Campaigns that address patient safety issues at the unit level
Background Challenges exist with following up on patient safety events in a timely manner: events can sit in the “holding area” for several days to several months (the policy is to move an event out of the holding area within 24 hours) and events that do get moved out of the holding area can sit in the “being reviewed” stage for similar periods of time. In addition, there is a lack of detail describing the event and action taken that makes it difficult to learn from the event and make improvements. 65% of Level 1 events meet the target of review and signoff within 20 days, 47% of Level 2 & 3 events meet the target of review and signoff within 30 days. 100% of Level 4 & 5 events (critical events) meet the 60 day target. VSM Name, Date & related goal: Process Map for Reporting and Responding to Patient Safety Events created on July 21, 2011 to identify improvement opportunities (see attached).
Current State
Problem Statement There is variability in the amount of detail provided in PSLS reports and completion of PSLS fields by both reporters and handlers. This variability contributes to longer followup times required to investigate patient safety events and contributes to less effective actions being implemented to improve patient safety.
Sustainment Plan:Audit tracking Who: What: By When:Ross/Karin PSLS event turnaround time 3, 6, 9 months post
implementation
Kaizen Event Proposal: Improving the Reporting and Follow-up of Patient Safety Events to Reduce Harm Team Lead: Lynda Bond, Graham Worsley
AnalysisConfusion exists with respect to how PSLS reports get completed. There is inconsistency in the completion of PSLS reports and in the amount of detail provided.It is not clear what fields are important for contributing to effective patient safety event management.Completing a PSLS report takes 20-30minutes.
Sub-Team Lead: Ross Gibson, Rafal Grzyb
Sponsors: Dr. Jana Davidson, Betty Kerray
Sponsor Sign-off Date: September 1, 2011
Title: Streamlining PSLS Reporting and Followup Forms
Team Members: Cynara R, Raymond B, Caroline C, Joan S, Jesslyn B, Shar B, Kathy T, Dave B.
Process Owner: Lynda BondQuality, Safety & Performance Improvement
What is a safety event?
Identify event as
reportable
Determine who writes
PSLS report
Event reported in
PSLS
Handler notified of
event
Patient Safety Event
Occurs
PSLS fields confusing
Lack of knowledge
Countermeasures1. Streamline PSLS data fields to capture
information that is only relevant for reporting and followup.
2. Develop standard work process for PSLS report completion and remove non-value added steps.
What is the primary objective? To improve the level of detail and completion of fields in PSLS to allow for more timely followup and actions arising from patient safety events.
What is the key measure? • 100% of required PSLS fields completed• 100% of PSLS events completed within established timelines
Action Plan Who: What: By When:
1. Lynda Conduct analysis of completion October 31, 2011rates for PSLS fields andturnaround time completion
2. Ross/Dave Identify fields critical for safety December 31, 2011event reporting and followup
3. Ross/Lynda Lead kaizen event to identify February 15, 2012 standard work process
4. Ross/Dave Work with PSLS Central Office March 15, 2012 to streamline forms for BCMHAS
Mini Kaizen with Cascading Involvement and Feedback Loop
Unit A
Unit C
Unit D
Unit B
Work Standard – Handler Follow-up
Key Findings
8 fields removed from the Reporter Form
3 fields removed from the Handler Form
Language has been simplified and only those fields pertaining to mental health are retained
Removal of anonymous reporting feature reduces follow-up time for Handlers by 2 hours
Creating standard work for reporters and handlers reduces variability and increases accuracy in entering information in PSLS
Lean methodology provides a strategy to improve patient safety by allowing for active and full engagement of staff and physicians in safety solutions
Questions
For More Information:
Lynda Bond
604-524-7309
Ross Gibson
604-875-2345 (x4991)
Disclosure Statement
• Nothing to disclose/no conflicts of interest