Continuous Quality Improvement

Case Study MHHS-6
Serious Safety Events Classification System
M. Michael Shabot, MD, and Rachna Khatri, MPH, MBA
Documentation of serious safety events is critical to any healthcare organization, as timely reporting of serious safety events enables the organization not only to keep track of errors but also to create methods to prevent such errors from reoccurring.

To better understand and react to serious safety events, the Memorial Hermann system adapted a classification system originally developed by Healthcare Performance Improvement, Inc., for its internal purposes. The classification system in general is used by several hundred hospitals nationwide and helps organizations categorize and prioritize serious safety events. Potential or actual safety events are initially classified into three groups: good catches, close call events, and serious safety events (Figure 10-29).
Good catches are errors or potential accidents that were caught by one of multiple safety barriers that have been created in various systems of care. At Memorial Hermann, our EHR makes upwards of a thousand good catches a month, warning and convincing physicians, nurses, and pharmacists to avoid certain medications, combinations of medications, and treatments.*,†
Close call events are potentially adverse events not related to the patient’s illness, injury, or underlying condition that could have caused significant harm, but did not. Close call events are carefully investigated.
Serious safety events (SSEs) are actual adverse events not related to the patient’s illness, injury, or underlying condition that actually did cause a degree of harm. SSEs are investigated with a root-cause analysis.

FIGURE 10-29. Serious safety event classification (Memorial Hermann Healthcare System, as modified from Healthcare Performance Improvement, Inc.). RCA: Root Cause Analysis; ACA: Apparent Cause Analysis. Courtesy of Healthcare Performance Improvement, LLC.

FIGURE 10-30. Serious safety event classification system (Memorial Hermann Healthcare System, as modified from Healthcare Performance Improvement, Inc.). Courtesy of Healthcare Performance Improvement, LLC. NME = Near Miss Safety Event

FIGURE 10-31. Hospital safety event categories (Memorial Hermann Healthcare System, as modified from Healthcare Performance Improvement, Inc.). Courtesy of Healthcare Performance Improvement, LLC.
A finer level of detail is required to classify the degree of harm associated with SSEs and close call events. That detail is provided in Figure 10-30, which provides five levels of SSEs and four levels of close call events. Close call events are abbreviated as “PSEs” for potential safety events.
In the Memorial Hermann Healthcare System, all SSEs and PSEs are reviewed monthly in a special meeting of chief medical officers, chief nursing officers, chief executive officers, and system executives. Actions plans are formed and managed to prevent similar SSEs and PSEs across the healthcare system in the future.
An even finer level of detail is provided for hospital safety event categories in Figure 10-31. This allows events to be classified in terms of cause: procedural, environmental, patient protection, care management, product/device, and criminal. Subitems that are classified as “sentinel events” by The Joint Commission or “never events” by CMS are marked with a special indicator.
Case Study MHHS-7
Quality Performance Dashboards
M. Michael Shabot, MD, and Rachna Khatri, MPH, MBA
Memorial Hermann Healthcare System in Houston, Texas, has created a Flash Report Dashboard to keep track of quality and safety performance metrics. The dashboard is not only an effective means of identification of problem areas but also enables the organization to track performance and determine whether an intervention was effective. Furthermore, the Flash Report Dashboard promotes department- and facility-level comparisons, which could be invaluable in recognition of areas with best practice. The flash report is available as an intranet Web application on all management computer workstations via a special icon that resides in the “system tray” at the bottom right of PC screens and that flashes when new data have been loaded. Administrative, volume, and financial data are current to midnight of the prior day. Quality and safety data are also available in real time, although monthly results are not complete until a few days after the month closes. Figure 10-32 shows a flash report of core measure compliance for a Memorial Hermann acute care hospital. Figure 10-33 shows a flash report of hospital-acquired infection measurements and central line safety bundle compliance for a different acute care hospital.
Additionally, Memorial Hermann has found performance dashboards to be an effective tool for process improvement. After an extensive strategic planning process, leaders from the adult ICUs from across the Memorial Hermann system believed they needed a comprehensive monthly report to assess the effectiveness of care in each individual ICU. A steering committee was created, and performance measurements were eventually selected from a long list. After several months of development, a totally automated process was developed to produce individual monthly ICU metrics dashboards for each of 20 adult ICUs and a summary of combined performance. The report is automatically generated in portable document format (PDF) form and e-mailed to each ICU director, nurse manager, and chief medical officer (Figure 10-34). Each person receives a complete report for all 20 ICUs and the summary, which provides total transparency for ICU performance across the health care system. Performance in almost all areas has improved since the report went into production several years ago. Comparative results are discussed at ICU director and nurse manager meetings throughout the year.

FIGURE 10-32 Core measure flash report (internal web, Memorial Hermann Healthcare System). Courtesy of Memorial Hermann Healthcare System (MHHS).

FIGURE 10-33 Hospital-acquired infection and bundle compliance flash report (internal web, Memorial Hermann Healthcare System). Courtesy of Memorial Hermann Healthcare System (MHHS).
Figure 10-35 shows a highly summarized dashboard for quality, safety, patient experience, physician satisfaction, employee satisfaction and retention, and financial and growth performance measures developed at the Memorial Hermann Healthcare System.

FIGURE 10-34. Monthly ICU metrics dashboard (Memorial Hermann Healthcare System). Courtesy of Memorial Hermann Healthcare System (MHHS).

FIGURE 10-35. Board of directors dashboard. Note: Certain measures have been redacted. Courtesy of Memorial Hermann Healthcare System (MHHS).
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Sarmad Sadeghi, Afsaneh Barzi, Osama Mikhail, M. Michael Shabot

 

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