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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. ).

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. 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. 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 Avail the suitable and reliable Adjustable computer desk online!

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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. ).

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. 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. 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

Paper for above instructions

Enhancing Quality Through Information Systems in Hospital D's Incident Reporting
In the healthcare sector, incident reporting is critical for enhancing patient safety and quality of care. However, Hospital D faces significant challenges with its current event reporting system, as highlighted by a troubling 40-50% underreporting of incidents and a high rate of inaccurate categorization of reported events. This essay will suggest the implementation of a Clinical Decision Support System (CDSS) as a technology that could greatly improve the quality of incident reporting at Hospital D, and it will also discuss the factors contributing to the ongoing challenges.

Identifying the Issue

The current electronic event reporting system at Hospital D struggles with inaccuracies and underreporting. According to Levinson (2012), traditional incident reporting systems in hospitals often fail to capture the majority of patient harm events due to inefficiencies and complexities in their design. As a result, the initial categorization of reported incidents has a 40% inaccuracy rate, and nearly half of the actual incidents go unreported.
Identifying the root causes of these challenges through techniques such as Root Cause Analysis (RCA) and Fishbone diagramming, the group identified various contributing factors:
1. People: Lack of awareness about what constitutes patient harm among nursing staff.
2. Policies/Procedures: Inadequate definitions of reportable incidents.
3. Communications: Ineffective channels for communicating the significance of reporting.
4. Training: Inconsistent training on the incident reporting system and its importance.
5. Technology: Inefficiencies in the current computerized reporting systems.

Clinical Decision Support Systems (CDSS)

A Clinical Decision Support System (CDSS) can significantly enhance the quality of incident reporting at Hospital D. A CDSS is a health information technology system that provides clinicians with knowledge and patient-specific information, intelligently filtered and presented at appropriate times, to enhance patient care (Feldman et al., 2018).

Using CDSS to Improve Incident Reporting

1. Real-Time Alerts: A CDSS can be programmed to provide real-time alerts about potential incidents based on patient data input. For example, if a certain set of symptoms or readings indicates a potential medication error or adverse event, the system can alert the healthcare provider immediately. This proactive approach could help mitigate incidents before they escalate (Negash et al., 2018).
2. Guidance on Reporting: The CDSS can include clear guidelines and checklists that help healthcare staff understand what constitutes reportable incidents. This feature may utilize easily accessible definitions and flowcharts for quick reference, addressing the existing misperceptions about patient harm (Khezr et al., 2019). For instance, if a nurse encounters an unusual patient reaction, the CDSS could prompt them with questions to determine if the event should be reported.
3. Cross-Disciplinary Collaboration: Involving various departments in establishing the CDSS parameters can address the identified communication shortcomings. A well-designed CDSS can foster communication among different healthcare providers by providing insights into past incidents and patient outcomes, thereby promoting a culture of safety and openness (Stavropoulou et al., 2015).
4. Standardized Training Modules: The CDSS can include training modules that can educate staff on incident reporting protocols and the implications of underreporting. The inclusion of case studies and examples could further enhance the learning experience (Gand, 2017).
5. Data Analytics: By actively analyzing incident data, the CDSS can help identify trends and patterns in incidents that occur within the hospital. Leveraging data analytics can inform hospital policy changes or enhance procedures to minimize incidents over time (Feldman et al., 2018).

Impacts of an Improved Incident Reporting System

Implementing a CDSS tailored to enhance incident reporting will not only address the underreporting issue at Hospital D but also improve the overall quality of patient care. By ensuring that every event is reported and accurately categorized, the hospital can address systemic issues that lead to patient harm, ultimately fostering a safer environment for both patients and healthcare providers.

Future Considerations

The introduction of a CDSS necessitates careful planning and execution. Hospital D must ensure that the system is user-friendly and accessible. Additionally, ongoing training and support should be provided to nursing and clinical staff to encourage consistent utilization of the reporting system. Regular evaluations of the impact of the CDSS on incident reporting and patient safety metrics will be essential for continuous improvement.

Conclusion

Hospital D is faced with significant challenges in incident reporting that can adversely impact patient safety and care quality. However, the implementation of a Clinical Decision Support System has the potential to revolutionize how incidents are reported, ensuring accurate documentation and enhancing the overall effectiveness of the reporting system. By leveraging technology, training, and improved communication, Hospital D can create a safer healthcare environment.

References

1. 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.
2. Gand, K. (2017). 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. 208-215). IEEE.
3. 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.
4. Levinson, D. R. (2012). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Department of Health and Human Services: Office of Inspector General.
5. 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.
6. 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.