Safety Event Reporting in the Ambulatory Setting:

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Presentation transcript:

Safety Event Reporting in the Ambulatory Setting: A Story of Success Beverly Loudin, MD, MPH Ailish Wilkie, MS, CPHQ

Atrius Health- Who we Are Non-profit alliance of six leading independent medical groups and VNA network Granite Medical Dedham Medical Associates Harvard Vanguard Medical Associates Reliant Medical Group Southboro Medical Group South Shore Medical Center VNA Care Network and Hospice Providing care for ~ 1,000,000 adult and pediatric patients 1096 Physicians 1450 other healthcare professionals across 35 specialties 7483 Employees 3.8 Million Ambulatory Visits Per Year VNA Care Network covering Eastern and Central Mass with 750 employees

It’s a Journey, not a Destination! 2008: The Department of Patient Safety & Risk Management is created and consists of a Director and a Senior Project Manager 2009: An electronic reporting system (SERS) is implemented and there is an immediate increase in reporting 2010: The Director leaves; now a department of one! 2011: A Medical Director is hired in early 2011 2011(late)/2012: Three Patient Safety and Risk Management specialists and a systems administrator are hired

It’s a Journey! System Interventions: Simplified WebForm used to enter events in SERS Reduced from 7 pages to 1 Constrained pick lists for ease of use and less scrolling Incorporated additional reporting mechanisms Staff messaging within the EMR Direct phone line to Patient Safety & Risk Management

It’s a Journey! Staff Interventions: Specialists assigned to individual groups and sites to: Work directly with site and group leaders on patient safety initiatives Sit on local safety committees Provide education and training at the local level Feedback to reporters Email to all reporters when event is closed in the system - has limitations Developed monthly email for reporters during that month to highlight lessons learned Developed monthly Safety Champion initiative to celebrate individual contributors Email to all clinician reporters when their events are closed with detail of outcome Developed patient safety dashboards for each Atrius Group and Harvard Vanguard site

It’s a Journey! Leadership Interventions: Development of Atrius-wide Hoshin Metrics 2010 – Report an event on .25% of patient encounters 2011 – Increase the number of unique reporters 2012 – Increase the number of unique reporters 2013- Event closure within 30 Days

Lessons Learned Change doesn’t happen overnight You can’t train everyone! Find the balance between quality and quantity The more visible we are the greater the result

Data doesn’t lie, reporting has increased 213%! SERS Implemented

Continuing the Journey… Culture of Safety Survey – Fall 2013 Upgrade rL Solutions software- Fall 2013 Provide training to event reviewers on systems thinking