health management - performance improvement
lynda3495
FinalPresentationVisual.pptx
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
