Health Management – Performance Improvement

Group 9 Performance Improvement Final

Lynda Pham

Nelly Secer

Nathalie Sper

Rosalina Dorvilus

Week 8: Risk Management – Event Reporting

Hospital D uses an electronic system (application) to record events or incidents occurring within the hospital system. Currently, 40% of the events reported in the system need to be revised due to inaccurate initial categorization, which doubles the amount of work related to this function. Furthermore, additional notes from a prior internal interview of nurses indicate that between 40-50% of the incidents that occur are not being reported in the system at all because of misperceptions of what constitutes patient harm.

Issue: underreporting of incidents & inaccurate categorization

QI Toolbox Techniques used:

Unstructured brainstorming: all members generate ideas as they come to mind

Evaluating all potential factors (causes) of the problem

Identifying & categorizing factors that contribute to the problem

3

Brainstorming

Root Cause Analysis (RCA)

Cause & Effect diagram (Fishbone diagram)

Our Process:

We used RCA to identify proximate causes and used the cause-and-effect diagram (fishbone diagram) to categorize those factors as well as identify any underlying causes that may have contributed to the problem (underreporting of incidents).

Factors identified:

People

Policies/Procedures

Measurements/Methods

Communication

Training

Computerized Physician Order Entry (CPOE)

Suggest one information system or technology that could contribute to enhancing at least one aspect of quality at Hospital D, and briefly explain how it could be used or impact that aspect of quality. You will need to do some research for this one.

Our Group Culture

Our group culture was easy-going, friendly, & flowed smoothly.

As a group of 4 students, we all had different strengths that added to the group dynamic in different ways.

We were able to utilize email, group texting, & shared Google sheets to connect & communicate with one another & keep all members up to speed.

Cooperation & reliability among the group members went well, without much conflict. The use of a shared Google sheets for each assignment made it easier for each member to contribute on their own time.

When discussing ideas or assignments, we were all open to each other’s ideas, not one member outwardly declined any suggestions and each member felt heard. We were able to allocate specific goals to each person in order to spread work evenly when it came to assignments with multiple factors.

We had no conflict or disagreements when the specifics were being decided, as each member was easy going and willing to contribute.

Strengths & Challenges

The groups biggest strength came from each members willingness to work together & cooperate as smoothly as possible to be able to complete assignments.

Our biggest challenge as a group was finding an open window of free time for all the members to be able to meet at once due to conflicting schedules & personal obligations (jobs, school, family, etc.)

We each were able to contribute to the assignments on our own free time but were unable to hold group discussions or meetings

This course being 100% online presented a barrier in terms of communication & being able to connect with one another easily.

Future Approaches

Using other forms of communication besides texting, as it can limit the real meaning of a message & can lead to misinterpretations

Making sure to schedule short weekly meetings (15-20 minutes), just to iron out some of the details of upcoming assignments & allow anyone to voice any questions or share their ideas & thoughts & go deeper into the issues

Holding discussions after assignments to clear any misunderstandings & address challenges anyone may be facing

Overall, the group dynamic was easy, friendly, and flowed well. Given the unique challenges of online learning & communicating, we felt we did well in working within those challenges & completing the assignments to meet our deadlines.

References:

Feldman, S. S., Buchalter, S., & Hayes, L. W. (2018). Health information technology in healthcare quality and patient safety: literature review. JMIR medical informatics, 6(2), e10264.

Gand, K. (2017, July). Investigating on requirements for business model representations: the case of information technology in healthcare. In 2017 IEEE 19th Conference on Business Informatics (CBI) (Vol. 1, pp. 471-480). IEEE.

Khezr, S., Moniruzzaman, M., Yassine, A., & Benlamri, R. (2019). Blockchain technology in healthcare: A comprehensive review and directions for future research. Applied sciences, 9(9), 1736.

Negash, S., Musa, P., Vogel, D., & Sahay, S. (2018). Healthcare information technology for development: improvements in people’s lives through innovations in the uses of technologies.

Levinson, Daniel R. (2012). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Department of Health and Human Services: Office of Inspector General. https://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf

Stavropoulou, C., Doherty, C., & Tosey, P. (2015). How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. The Milbank quarterly, 93(4), 826–866. https://doi.org/10.1111/1468-0009.12166

40-50% Incident Reports NOT

being reported

People

Communication

Training

Policies/Procedures

Measurements/ Methods

Lack of standardized measurements for Incidents

Lack of effective training among all staff

No Incident Reporting Training

Misperceptions/ misinterpretations

Time consuming from other tasks

No clear guidelines to refer to

Collaboration among all departments & staff

When to report an incident

How to report an incident

Who should report

Negative stigma placed on Incident reporting –

fear of reporting

Policies not developed by multidisciplinary team

lack of collaboration among departments

Policies not updated & revised regularly

Doctors RNs (nursing staff) Health Care Professionals

Structured code sets for incidents

Technicians

Safety Officer

Any employee/staff member that witnesses

an incident

No effective Feedback Mechanism

Policies not clear – misinterpret

No clear classification for incident types

Supervisors/Managers

Risk Manager/

Incident Reporting is not enforced

No policy training

No encouragement from administration in use of Incident Reporting systems

Hospital Administrators

Patient

No list of reportable incidents that is easily accessible

IT staff

No specified quality indicators to measure

40-50% Incident

Reports NOT

being reported

People

Communication

Training

Policies/Procedures

Measurements /

Methods

Lack of standardized

measurements for Incidents

Lack of effective

training among all staff

No Incident

Reporting Training

Misperceptions/

misinterpretations

Time consuming

from other tasks

No clear guidelines

to refer to

Collaboration among

all departments & staff

When to report an incident

How to report an incident

Who should report

Negative stigma placed

on Incident reporting –

fear of reporting

Policies not developed

by multidisciplinary team

lack of collaboration

among departments

Policies not updated &

revised regularly

Doctors

RNs (nursing staff)

Health Care Professionals

Structured code

sets for incidents

Technicians

Safety Officer

Any employee/staff

member that witnesses

an incident

No effective Feedback

Mechanism

Policies not clear –

misinterpret

No clear classification

for incident types

Supervisors/Managers

Risk Manager/

Incident Reporting is

not enforced

No policy training

No encouragement from

administration in use of

Incident Reporting

systems

Hospital Administrators

Patient

No list of reportable incidents

that is easily accessible

IT staff

No specified quality

indicators to measure