Quality and Safety Scoop: Summer School Disclosure Academy

Throughout the month of July, we have shared information on the organization’s Adverse Event Disclosure Program. The primary goal of this program is to afford providers practicing within Children’s enterprise support and resources to assist them with the disclosure of adverse events to patients and families. As the month of July comes to a close, we want to leave you with some final words of guidance from Bridget Norton, M.D., MBA, Pediatric Hospital Medicine, and Chief Quality & Safety Officer:

In my role as an ICU physician, I have had numerous disclosure conversations, and I have received questions from my peers regarding disclosure. These questions are most commonly related to whether or not an event needs to be disclosed and/or what should be included in the conversation. These are both really good questions because the answer isn’t always simple.

What events need to be disclosed?  

That is not always an easy question to answer. When you are unsure if an event or situation needs to be disclosed, ask yourself, “What would a reasonable family want to know?” The list below is not meant to be exhaustive, but these guiding questions can provide direction on what events to disclose.

  • Did this event result in a change in the treatment plan, now or in the future?
    • Did the event require the patient to be placed in a higher level of care?
    • Did the event result in a need for increased patient monitoring?
    • Did the event result in the need for specialist consultation?
  • Will the patient experience be impacted by this event?
    • Will the event result in additional charges?
    • Will the event result in an extended hospital stay?

Answering yes to any one question is not dispositive, but the more “yes” responses you have, the more likely it is you should disclose. All of this information can be found in the Disclosure Guiding Questions support document. Disclosure coaches are also available to discuss individual cases if you have questions.

What should this conversation include?

There is a big difference between a family being aware or present during rounds and an actual disclosure conversation taking place. A disclosure conversation is very purposeful and contains the following foundational elements:

  • Expressions of empathy
  • Description of what happened (details known to be factual at the time of the disclosure discussion)
  • Description of patient’s current status
  • Description of patient’s current health care needs
  • Outline of next steps in patient’s care
  • Description of the potential adverse event consequences now and in the future
  • Assurance of further review of the adverse event and follow-up discussion(s) with the family, if appropriate
  • Documentation of the conversation using the “.disclosure” note template.

All of this information, along with additional tips and specific phrases, can be found in the Disclosure Conversation Guide support document. I encourage you to set yourself up for success by utilizing all the disclosure resources available to you. Click here to visit the Disclosure Page on MyChildren’s.

Summer School: Disclosure Academy

Video Series on Adverse Events Continues

Throughout the month of July, Children’s Disclosure Committee has been sharing new information regarding Children’s Adverse Event Disclosure Program. A primary goal of this program is to support providers with resources to assist them with the disclosure of adverse events to patients and families.

Children’s providers do an outstanding job taking care of patients and often forget to take care of themselves. We know disclosure conversations are taking place, and they are often not documented in the electronic medical record (EMR). Without documentation, there is no proof the conversation took place; this may put you at risk. Take care of yourself: Document, Document, Document! Adding, “parents participated in rounds” or “discussed plan of care with parents” to your note is not enough. Documentation needs to specifically state that a disclosure conversation has taken place. We recommend you use the disclosure .phrase in the EMR.

Click here to view a video message from Ryan Sewell, M.D., J.D.

Summer School: Disclosure Academy

New Video Series on Adverse Events Continues

Throughout the month of July, Children’s Disclosure Committee will share new information regarding Children’s Adverse Event Disclosure Program. A primary goal of this program is to support providers with resources to assist them with the disclosure of adverse events to patients and families.

“The majority of health care workers believe that adverse events should be disclosed to patients,” said Thomas Gallagher, M.D., associate professor of Medicine, University of Washington School of Medicine. “However, when questioned about their actual experiences of conducting disclosure, health care workers often fall short of this ideal. Currently, most disclosures fail to meet patient expectations or contemporary standards for these conversations.” 

Children’s has trained professionals available to assist you with the disclosure of adverse events to patients and families. A list of disclosure coaches is available on MyChildren’s under the Healthcare Professionals tab. We encourage you to set yourself up for success by using the resources available to you.

Please click here to view a video message from Sidharth Mahapatra, M.D., Ph.D., FAAP, Pediatric Intensivist. Contact Kimberly Peterson, Quality & Patient Safety, with any questions.

Quality & Safety Scoop Announcements: PolicyStat Goes Live; CIHQ Survey Coming

By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer

PolicyStat Launched
On June 22, Children’s launched a new policy management software program called PolicyStat retiring PolicyTech. This program is part of the RLDatix platform and will help ensure we have a connected framework between patient safety and risk management. This change moves us closer to our goal of proactive prevention of events rather than retrospective review.

PolicyStat is light years ahead of where we have been – utilizing a Google-like search functionality. As you begin typing letters, the system searches the titles and content of all the documents to best match the letters/words being typed. It even has enough intelligence to catch typos and/or letter combinations that may be part of the intended search. A top five closest-match listing will appear, but a full table of all the possibilities is only a click away. Watch this short 5 minute video to see all of this in action.

For those who participate in the reviewing of policies, procedures, forms, etc., PolicyStat brings the entire approval process into one location. It is our new Mission Control for document management.

These are just a few of the features you can begin getting excited to see in action. To boost your PolicyStat awareness, please click on the link below for a short video on what PolicyStat can do: https://hub.rldatix.com/SupportHUB/s/article/What-is-PolicyStat

2021 CIHQ On-Site Survey Coming Soon
Consultants from the Center for Improvement in Healthcare Quality (CIHQ) will be conducting a mock Joint Commission Survey from July 13-15. The CIHQ consultants will be surveying the hospital, the Specialty Pediatric Center and Children’s Home Healthcare. They are not scheduled to survey the Hubbard as it will not be open yet. This will provide an opportunity to review best practices and identify any potential areas for improvement prior to our next Joint Commission survey. The consultants will be reviewing selected documents, policies, procedures, medical records and personnel files. They will also conduct interviews of key leaders and staff, so some of you may be contacted with questions. The Life Safety Specialist will tour the general facilities and support areas with our Facilities Operations and Maintenance team.

Thank you in advance for your preparation and participation in this mock Joint Commission survey as we strive to provide the safest and highest quality care for our patients. 

Summer School: Disclosure Academy

New Video Series Focuses on Adverse Events Program

Throughout the month of July, Children’s Disclosure Committee is focusing on more than just sandy beaches and pool floats. Each week, new information will be shared regarding Children’s Adverse Event Disclosure Program. A primary goal of this program is to support providers with resources to assist them with the disclosure of adverse events to patients and families. Please watch the video below for a message from Kaitlyn Pellegrino, M.D., Pediatric Anesthesiology and Disclosure Committee co-chair.

Click here to watch the video.

Contact Kimberly Peterson, Quality & Patient Safety, with any questions.

Quality & Safety Scoop: Sepsis Project Update

Every year, 80,000 children are hospitalized for sepsis in the U.S. Almost 5,000 children die from sepsis, more than from cancer, and as many as 40 percent of those who survive sepsis suffer from long-term health issues. (Source: childrenshospitals.org)

Despite excellent clinical care, we are contributing to these numbers. In 2019 at Children’s, we treated a total of 107 cases of sepsis and had 9 sepsis attributable mortalities. 

Our response

In January 2020, our organization joined the Children’s Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. The collaborative is made up of more than 57 children’s hospitals working together to successfully challenge sepsis and generate ideas for improvement. 

Collaborative Goals:

  • Reduce sepsis-attributable mortality by 25 percent.
  • Reduce hospital-onset IPSO critical sepsis by 25 percent.

IPSO focuses on five key processes to improve sepsis outcomes. Through screening and huddles, early recognition of sepsis can be achieved. Order sets drive standardized care and reduce variation. Time to first antibiotic (within 1 hour) and time to first bolus (within 30 minutes) allows for timely, early resuscitation.

As the Chief Quality & Safety Officer, I am the executive sponsor for this project. The following physicians are also part of the IPSO steering team and helping to lead this important strategic initiative.

  • Stephen Dolter, M.D., Hospitalist & CMIO
  • Sidharth Mahapatra, M.D., Ph.D., Pediatric Intensivist
  • Zebulon Timmons, M.D., Division Chief, Pediatric Emergency Medicine

As we work to implement changes in our organization, we want to ensure that we share our organizational data with you. Please click here to view our progress in the biannual Executive Report from IPSO.

Quality & Safety Scoop: RLDatix “Eye on Safety” Data – First Quarter Report

By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer

Reported errors and near misses play a significant role in identifying safety risks for patients and staff. Since Eye on Safety (EOS) reporting has been in place for more than a year, we can now use the RLDatix system to assist in identifying trends related to patient and employee safety events. EOS reports are reviewed daily by a dedicated team of nurses in the Quality & Patient Safety Division. This process facilitates identification and prioritization of patient safety risks and assists in coordinating systematic, non-punitive investigations into those reported events. The Daily Safety Brief is also a venue where these EOS reports are discussed.

We are now able to aggregate this data over time to discover any trends that may be happening across the continuum. Aggregating data can detect systemic process issues, which can lead to process improvements, redesign of policies, changes to clinical care practices and workflows of individuals and teams. A report from the first quarter of 2021 has been posted on Children’s intranet to provide transparency on the most common themes identified and the actions put in place to mitigate some of the risks associated with these events. 

Click here to view the aggregated data.

Please freely share and discuss this information with your team. We want everyone to know that we are listening and making changes as a direct result of their EOS reports.

If you have questions, please email me, bnorton@childrensomaha.org or rladmins@childrensomaha.org.

Quality & Safety Scoop: NEW RLDatix Data Trending

By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer

Reported errors and near-misses play a significant role in identifying safety risks for patients and staff. Since Eye on Safety (EOS) reporting has been in place for more than a year, we can now use the RLDatix system to assist in identifying trends related to patient and employee safety events. EOS reports are reviewed daily by a dedicated team of nurses in the Quality & Patient Safety Division. This process facilitates identification and prioritization of patient safety risks and assists in coordinating systematic, non-punitive investigations into those reported events. The Daily Safety Brief is also a venue where these EOS reports are discussed.

We are now able to aggregate this data over time to discover any trends that may be happening across the continuum. Aggregating data can detect systemic process issues, which can lead to process improvements, redesign of policies, changes to clinical care practices and workflows of individuals and teams. First and second quarter data trends from 2020 are posted on Children’s intranet to provide transparency on the most common themes identified and the actions put in place to mitigate some of the risks associated with these events. 

If you have access to Children’s intranet, click here to see the EOS aggregated data.

Please share this information with your team. We want our staff to know that we are listening and making changes as a direct result of their EOS reports. If you have questions, please email RLAdmins@ChildrensOmaha.org.

Quality & Safety Scoop: RLDatix Utilization Workgroup

By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer

It has been just over a year since Children’s implemented RLDatix as our safety event reporting system. We have had over 8,000 Eye on Safety (EOS) events submitted in that time, which is amazing! A new workgroup has been created to ensure our utilization of RLDatix continues to grow and develop. Currently, Children’s has implemented the following four RL modules: Risk, Feedback, Peer Review and Root Cause. The functionality of these modules allows for the capture and exchange of safety event information into a single system, thus giving Children’s the ability to comprehensively manage reported safety events. 

The RL Utilization Workgroup will focus solely on the Risk module, the module where staff enter EOS events. This workgroup will provide guidance on system enhancements, improvements and optimizations for this module, as well as evaluate both the submission and reviewer workflows to ensure ease of use, standardized practices and consistent data capture.

Workgroup membership is a multidisciplinary representation of clinical and non-clinical employees functioning as event submitters and/or event reviewers from across the enterprise.  Members will serve as representatives of their respective areas and subject matter experts for their submission and/or reviewer roles. 

RL Utilization Workgroup members:

Alicia Bremer, Quality & Patient SafetyJennifer King, PharmacyMelisa Paradis, Quality & Patient Safety
Allyson Stepanek, Quality & Patient SafetyJessica Kjar, CPRachel Jacobs, 6MS
Andrea Peery, PICUJill Jensen, Quality & Patient SafetySandra Jameson, Lab
Annie Kline, NICUKari Hamrick, RadiologyStacy Kreikemeier, CP
Bridget Norton, MD, MBA, CQSOKatina Shapland, CCUStacy Nissen, Clinic Float
Erin Heisler, SPCLee Hulbert, 5MSTammy Ausenbaugh, PICU

The metrics the workgroup will track this first year include:

  • Process Measure: All general event-type forms will be assessed for relevance as evidenced by form usage, form length, mandatory fields and discrete field selections by the end of 2021.
  • Outcome Measure: Captured event data will provide tangible tracking and trending information by the end of 2021, as evidenced by completed discrete submission and reviewer fields.
  • Balancing Measure: The number of events being reported will remain the same or increase as evidenced by the monthly event submission rate per adjusted patient days throughout 2021.

Quality & Safety Scoop: Social Distancing and Multidisciplinary Rounds

 By Bridget Norton, M.D., MBA, Chief Quality & Safety Officer

Multidisciplinary rounding is essential to providing quality patient care and a robust educational experience. Children’s recognizes the rounding challenges you are experiencing and is committed to supporting the staff by addressing needs as they evolve during the COVID-19 pandemic. These concerns were taken to our Incident Command clinical operations group, as well as our Physician Advisory team, for discussion and to generate recommendations.

Through the efforts of the above groups, we conducted a benchmarking effort and received data from 31 hospitals throughout the country. As expected, we received a wide range of responses, but ultimately, we were unable to adopt a uniform rounding guideline due to the unique needs and limitations of each individual unit and clinical area. 

Moving forward, the recommendation is for teams to develop a rounding model that is as safe and socially distanced as is feasible within each area. Some areas may utilize a completely virtual process, some a hybrid approach of bedside and virtual rounding and others a bedside approach. 

We are asking all staff to do their best to support the following recommendations:

  • Wear masks at all times
  • Wear goggles in patient care areas and during rounds when unable to achieve the appropriate 6 feet of distance between team members
  • Avoid other teams during bedside rounds
  • Close surrounding doors to maintain HIPAA compliance
  • Remind those in the area who are not actively participating in rounds to be as quiet as possible to facilitate better communication
  • Do not eat or drink when in the presence of others (rounds)
    • Wear goggles if sharing a space with someone while eating or drinking (break/lunch) 
  • Maintain necessary social distancing in all situations
    • Conference rooms
    • Bedside rounds
    • Break rooms
    • Shared offices 

Check with your unit leadership for specific information and guidance regarding how to best utilize all available conference rooms to maximize social distancing while eating, as well as to allow residents, APPs and students to spread out further while doing their daily work. Thank you for your dedication to keeping our patients and staff safe. Please reach out to Bridget Norton, M.D., or send an email to IncidentCommand@ChildrensOmaha.org with any questions and/or concerns. 

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