Like many facilities, one acute care hospital in Hawaii used a homegrown event reporting process that was paper-based. “It was a two-pager with different categories. Basically, only the facts. No commentary, no real description. Just checkboxes,” said the Quality & Performance Improvement leader at the facility.
The inherent challenge to a paper-based system is a slow collection process that produces less actionable data. “After frontline staff completed an event report, it would go to their manager. Their manager would review and sign off on the event, then send it to us,” she said. “Sometimes it took days if not weeks for events to make their way to us, which was an issue. It was definitely a labor-intensive process from a staffing standpoint in the quality office.”
After the quality department received the event forms, they manually entered the data into their hospital’s care performance tool to be able to get some form of reports for analysis.
“We would look at the paper event reports as we received them. If it was something that needed a quality or performance improvement action, we would start that process. And then, I took one day every month to sit in front of the computer and put them all in.”
Such a long lag time between when an event occurs and when the quality team learns about it causes problems on multiple fronts. Quick and timely interventions are virtually impossible. Additionally, the quality of the data that could shed light on the root cause of an event decays with each passing day.
“By the time we would get the event and start doing our investigation, people either were on vacation, or they couldn’t remember, or any number of things. And so we basically did chart reviews to try to glean whatever was documented at the time of the event and were relying on people’s memories two or three weeks later to recall the chain of events. A lot of times we were stymied because people couldn’t recall and because documentation in the EMR was sometimes sparse,” the Quality & Performance Improvement leader said.
Another issue the hospital struggled with was incomplete data. Capturing actionable data was hindered by the staff’s fear of the legal ramifications of what they included in an event report. Often, frontline staff might have illuminating information about the circumstances surrounding an event but worry that including those details in the event report could put the organization at legal risk. Having now partnered with American Data Network (ADN), the leadership team is able to encourage staff to include any and all relevant information because that event data has safe harbor under the confidentiality protections of ADN’s Patient Safety Organization.
Oftentimes, while members of the quality department who experience the shortcomings of an inadequate event reporting process yearn for a better one, the barriers to change can be abundant.
For this facility, having a forward-thinking champion in senior leadership who understood the value of electronic event reporting was critical to overcoming the common barriers many hospitals face when wanting to implement a new application.
“About a year or so prior to us going to ADN, we had a new hospital executive join the senior leadership team. And he basically was the catalyst to really push this forward to go electronic so he would be aware instantaneously of events happening house-wide.”
With so many competing priorities in a hospital, too often, much-needed improvements are forced to take a backseat to other projects. Fortunately, the facility’s leadership had the foresight to recognize that while implementing a new application is an investment from a financial and onboarding perspective, it would pay dividends by providing them better and timely data, which would become a much more powerful engine for improving outcomes than a paper-process ever could.
Moving to ADN’s electronic event reporting application has been transformative to the hospital’s ability to act swiftly on event data.
“We’re able to act on events much quicker. And a lot of times our actions, not only because we’re notified faster but because we have more information at hand immediately, we can do things faster,” she said.
She recalled a recent event in which her team’s newfound speed was unmistakable. “We had an event where a patient fell and was injured while leaving our facility. I got an application alert about it immediately. When I talked to our manager, she showed me the place where the fall happened. The patient came down the steps but didn’t see the curb, even though it was painted yellow, and fell off the curb and landed in the parking lot.”
The team immediately summoned the maintenance crew and tasked them with building a railing that would enforce the use of the wheelchair ramp and prevent stepping off the curb.
“So, within literally two days, we had a railing built where that curbing was located. Whereas if we had still been using paper reports, we may not have known the fall happened until longer than it took us to get the fix,” she said.
In addition to anecdotal evidence, the team also has data to support the prudence of their decision to move to electronic event reporting. Since transitioning to ADN’s application, after about 6-8 months the team achieved a 9% decrease in falls from their enhanced ability to analyze and react to data around fall events, near misses, and unsafe conditions.
The ADN event reporting application has equipped the hospital with analytics reports that provide much more detailed insight into trends and patterns that lay hidden under their previous process.
“The ADN application has helped us pinpoint certain areas that were unavailable when we were using paper. We were unable to get reports quite at the granular level of subcategories because in our previous reports, we just put them in the major categories.”
As a result, the quality team has instituted several new subject matter-specific committees, including a workplace violence committee and a medication safety committee, as well as fall debriefings, based on the insights unearthed from better event analytics.
While the tangible benefits of faster data with better analytics were anticipated, and in fact the driver to transition to electronic event reporting, their team has experienced a benefit that they didn’t expect — the effect it would have on frontline staff’s thought process about events.
“They feel that it’s thought-provoking. It allows staff to really think through the process of what happened.” Instead, ADN’s proprietary event reporting form is helping to hardwire a Systems Thinking approach, the Quality & Performance Improvement leader said. “Why did this person fall? What did we do after the person fell? What are some things we could have done to prevent the fall?”
“Staff are taking more ownership,” she continued. “Our falls rate has improved over the last 6-8 months. The falls committee meets twice a month, and we go over each and every fall that occurs. And they started doing a fall debriefing that addresses details such as ‘What kind of bed was this patient on? When was the last time that patient was rounded on?’. It’s a pretty labor-intensive form, but it gets them thinking ahead about proactive actions staff can take to help prevent patient falls.”
And that kind of thinking is the culmination of the overarching goal for the hospital — moving away from a slow and reactive event reporting process and becoming a more proactive, preventive patient safety team.
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