HEARTLAND HEALTH REGION

Size: px

Start display at page:

Download "HEARTLAND HEALTH REGION"

Dortha Marshall
8 years ago
Views:

1 Incident management An Integrated Process Jeanette Abbott, Manager of Quality Improvement Chris Olson, Manager OHS

2 Incident Management Process (IMP) Objective Integrate Quality and OHS Incident Processes Why?.... Gather statistical data staff incidents Support quality root cause analysis/corrective action Ensure incidents are seen by the right people and required reporting done. Reduce confusion - which form to use and when? Confirm accountabilities who does what? Reduce duplication the process is the same.

Ensure incidents are seen by the right people and required reporting done.

3 Incident Management Process (IMP) Normal reporting structure to level required by the code Incident Occurs Immediate Response Determine severity of incident Incident Communicated Staff Incident Client Incident Property Damage Regulatory Investigation and detailed report Determine if investigation team required Complete and send initial report Quality trending OHS trending Code 3, 4 requires investigation team as per IMP flow chart. Initial report ASAP Detailed report according to IMP flow chart

Investigation and detailed report Determine if investigation team required Complete and send initial report Quality trending

4 What we did.... Created a change management plan for integrated process April Present Blended staff & client incident reporting form Page 1 all incidents, id page 2 client Cross checked with fall reduction tools to remove duplication New reporting requirements New option for incident reporting privacy issues Single point of contact Coding done by staff on floor or front line supervisor Communications and reporting structure

incident reporting form Page 1 all incidents, id page 2 client Cross checked with fall reduction tools to

5 What we did.... Revised Incident Investigation form Includes triggers for root cause and section for SMART corrective actions Incident Management Flowchart Visual tool to quickly identify requirements for Codes 1 4 Accountabilities reporting structure, supervisor responsibilities

cause and section for SMART corrective actions Incident Management

6 What came next.... Tested report form and elicited feedback (July 2010) Focus groups provided scenario s and asked to use new form (Kerrobert, Biggar, St Joseph, Dinsmore fall prevention committee) Scenario and forms sent it OOS corporate office Additional tweaking completed based on feedback Complete round med errors Clients usual state

scenario s and asked to use new form (Kerrobert, Biggar, St Joseph, Dinsmore fall

7 uator Eval Incident Report Form Evaluation Summary IMP Change Management Plan Steps to change.... Develop forms & tools May 2010 Forms, guideline and flowchart Test report form and elicit feedback July 2010 Focus groups provided scenario s and asked to use new form (Kerrobert, Biggar, St Joseph, Dinsmore fall prevention committee) Scenario and forms sent it OOS corporate office Ease of use for the incident form Additional tweaking completed based on feedback Revise and/or create database for staff/cline incident information November 2011 Implement Pilot Rosetown, Biggar, Elrose and Outlook Orientated to process Evaluated in 2 3 months Further massage the blended process Confirm regional implementation strategy Implement IMP March On this scale 1 indicated not very useful and 7 indicated very useful. Clear flow of incident form

Joseph, Dinsmore fall prevention committee) Scenario and forms sent it OOS corporate office Ease of use for the incident form Additional tweaking completed based on feedback Revise and/or create

8 What came next.... Implemented Pilot Rosetown, Biggar, Elrose (Oct 2011) No time resources available to train!! Orientated to process Provided real time support Pilot Evaluation (April 2011) Real time feedback Quality of reports completion, investigation, coding Focus groups Key stakeholders Pilot sites, falls reduction coordinators, CTM, Directors Evaluation form

! Orientated to process Provided real time support Pilot Evaluation (April 2011) Real time

9 Evaluation... Orientation to some employees not enough for smooth transition to the new process Staff completing both incident report and investigation report for all incidents when not required for codes 1, 2 falls. Components of forms were confusing, page 1 & 2 were user friendly. Guide and flow chart not often used to understand process Dedicated training time required for supervisors and persons in charge to support process and good root cause analysis. Competing priorities (Falls reduction, SOD/Accreditation initiatives) added to staff workload, orientation availability and lack of ownership to this process. The well is full!! Improvements to existing forms and tools were reviewed and revised where needed.

required for codes 1, 2 falls. Components of forms were confusing, page 1 & 2 were user friendly.

10 Recommendations to SLT... Training and orientation must be mandatory Retrain and orientate t pilot sites 4 6 hours for training for supervisors and persons in charge Target 85% of staff with completed orientations Will be measured Need support re accountabilities at all levels in the organization front line to senior leadership Compliance is not optional Help define consequences for non-compliance Implementation of training and orientation to begin mid- June

supervisors and persons in charge Target 85% of staff with completed orientations Will be measured Need support re

11 What s next... Train Supervisors and persons in charge on the Incident Management Process and Root Cause Analysis (4 6 hours) Orientation to Incident Report Form for all employees (target 85% orientated) Implement by facility Reorientate and train at pilot sites Unity PHSA Kindersley PHSA Outlook PHSA Use all communication venues to raise awareness of change Generate more comprehensive reports for staff incident Measure corrective action completion rate

Orientation to Incident Report Form for all employees (target 85% orientated) Implement by facility Reorientate

12 Questions?

Manage Compliance with External Requirements

Manage Compliance with External Requirements Description IT is subject to requirements that are highly complex and constantly changing. The school jurisdiction s senior leadership is ultimately accountable