The background, key features and main steps of the concise analysis method are described, discussed and applied in this module together with the main tools used during a concise analysis (timeline, guiding questions, constellation diagram, and statements of findings).
3. Learning Program
What was learned?
What can be done?
How and why?
What happened?
Multi-incident
Concise
Comprehensive
4. Learning Objectives
• The similarities and differences between a comprehensive
and concise individual incident analysis
• The main steps in conducting a concise analysis
• Give examples or scenarios of incidents where concise
analysis is recommended
5. Agenda
3-parts
• Knowledge expert + Q&A
• Practice leader + Q&A
• Facilitated discussion or Q&A
6. Introducing: WebEx
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
6
14-Mar-13 6
7. About You
0 Experience with [any] CONCISE analysis 10
9. Background and Features
Need for a “concise” method
• Informal (mini-RCA) Formal (NPSA, M&M)
Consistent with the principles and methodology of
analysis
Conscious and deliberate decision to focus on the:
• Agreed-upon facts
• Key contributing factors and findings
• Actions for improvement (if any)
• Evaluation
10. Concise and Comprehensive
Action Concise Comprehensive
Include person(s) with knowledge of IA, HF, solutions
development
Facilitated by an individual with input from patient,
local staff & physicians
Conducted by an inter-disciplinary medium to large ad
hoc group (includes also external experts / consultants)
facilitated by a knowledgeable individual.
Short Longer
Time taken for analysis (hours-days) (45-90 days)
Identifies contributing factors as well as remedial
action(s) taken (if any) and recommendations for
improvement
Reflects intent Incorporates all
Principles of Incident Analysis principles
Evaluation Component
12. Case: Medication Incident
Setting:
Community hospital & busy home care services
Current process:
hospital faxes referrals to fax line
if 9-5, M-F, home care coordinator reviews faxes & accesses the
home care central record schedule home care visits
if outside business hours home care nursing staff periodically
check faxes sorts by ongoing and new clients referrals for
ongoing given to responsible nurse
pharmacist dispense meds from drug stores in the community.
some attending physicians at comm. hosp fax prescriptions to
patients’ drug store for ease of pickup
Incident
Client (discharged from hospital with meds) found in bathroom.
Moderate amount of bright red blood. Transfer to ED.
14. Case: What Happened
Based on the
• incident report
• a review of the home care record
• hospital chart
• referral form
…the facilitator responsible to conduct this concise analysis
started to draft a timeline of the incident.
Timeline confirmed and expanded by
• Interviews with the client, pharmacist and RNs,
• Examination of the drugs involved in the incident
17. Analyze Information
• Use guiding questions to briefly explore all
categories (Appendix G, Page 89)
• Use some questions or develop incident specific questions to
informally discuss the incident with those involved and
external experts
• Ask
• What was this influenced by?
• What else affected the circumstances?
• Use constellation diagram
• Systemic approach
• Visual representation
• Linkages
• Summarize findings
19. Case: Findings
Work environment
• The lack of a standardized home care risk assessment tool or protocol
increased the likelihood that clients discharged from hospital back
to the community would not be accurately triaged to ensure appropriate
and timely home care services are provided.
Patient
• The deterioration in the client’s physical and cognitive abilities
increased the likelihood of a medication error in his self medication
management.
Care team and organization
• The lack of a formalized, system-wide and communicated Discharge
Medication Reconciliation process (including an updated Best Possible
Medication History) decreased the likelihood that the client would
receive the appropriate and timely support required for safe medication
management.
20. WHAT CAN BE DONE…?
WHAT CAN BE DONE TO REDUCE THE RISK OF
RECURRENCE AND MAKE CARE SAFER
23. WHAT WAS LEARNED?
The ultimate objective of analysis
Feedback
• To the organization: patient family, those involved in
the incident, the analysis team, etc
Feed-forward
• Externally to prevent similar incidents from
occurring in other organizations, systems, countries
• Informing the public and/or media
26. Safety at Home: A Pan-Canadian Home Care
Safety Study, Root Cause Analysis Sub-Project
- Project #4 – Falls by Home Care Clients
(Canadian Patient Safety Institute)
Gordon Luy, BSW, MSW
Patient Safety Consultant
Winnipeg Regional Health Authority
Quality Improvement & Patient Safety Unit
27. Safety At Home Study
Led by Dr. G. Ross Baker of the Institute of Health Policy,
Management and Evaluation, at the University of Toronto.
A qualitative study to investigate the root causes and contributing
factors that lead to {Falls-; Medication-} related adverse events
suffered by patients in home care, and help to form
recommendations to prevent similar events in the future.
The study was conducted at three provincial sites:
Alberta Health Services - Edmonton Zone Home Living Portfolio.
Winnipeg Regional Health Authority
Community Care Access Centres (CCAC) of the Greater Toronto Area (GTA)
28. Winnipeg Regional Health Authority
Quality & Patient Safety Unit
Part of the Research and Applied Learning
Division of the WRHA
3 Units in division
Health Information Services
Research and Evaluation
Quality Improvement & Patient Safety
29. WRHA Quality Improvement & Patient Safety Unit
• Under the Chief QIPS Officer
• Composed of 3 teams each under a regional
Director:
o Clinical Office of Patient Safety: 2 Analysts; and, 1
Auditor
o Quality Improvement Team: 7 Quality Managers; 2
Coordinators; and, 3 Analysts
o Patient Safety Team: 8 Patient Safety Consultants;
1 Patient Safety Pharmacist; and, 1 Education
Consultant
30. WRHA Patient Safety Consultant
A Patient Safety Consultant (PSC) works in collaboration with
healthcare sites/settings/program leaders and other members of
the Quality and Patient Safety Unit to facilitate the development,
implementation and maintenance of the quality and patient safety
strategy.
Through system safety reviews (Critical Incident Reviews),
PSCs assist staff and physicians throughout the Region to gain an
understanding of the complex systems in which people work for
potential healthcare system improvements.*
* The Regional Health Authorities Amendment And Manitoba Evidence Amendment Act (2005)
31. Safety At Home:
Sub-Project #4 – Falls by Home Care Clients
Five specific Home Care cases were selected
from the Manitoba site (WRHA) for a detailed
review using the CPSI Concise Methodology.
The review included interviewing caregivers,
managers, clients and their families regarding
events related to a fall which occurred during the
period of time that the client was receiving Home
Care.
32. CPSI Concise Analysis Methodology
I. Understand WHAT HAPPENED:
i. Information gathering (medical records; interviewing clients, case
coordinators and direct service providers (nurses, health care aides)
ii. Construct a a brief timeline.
II. Analyze information to identify contributing factors and the
relationships among them:
i. Systems theory and human factors
ii. Describe the incident and outcome
iii. Identify and define relationships between potential contributing
factors
iv. Formulate findings
III. (Develop and manage Recommended Actions)
The final report contains the facts, contributing factors, a brief context
analysis, and where applicable, recommended actions and a plan for
evaluation and dissemination.
33. I. Understand WHAT HAPPENED:
1. We reviewed the client’s medical record: (assessments; client
characteristics (e.g. co-morbidities), medications and changes; equipment;
professional consultation; process(es) of care delivery (e.g. history,
frequency and purpose of visits); circumstances of fall; etc.
2. We interviewed:
- Clients (and family): (recollection of event, factors (e.g. environment –
photos taken), services)
- Case coordinators: (organization, policies, care plan; roles, workload,
resources, training, communication, etc.)
- Direct service providers (nurses, health care aides): (roles,
workload, scheduling, resources, etc.)
3. We constructed a brief timeline (chronology) of event
34. Incident Analysis – Systems Theory
A system is described as the coming together
of parts, interconnections and purpose.*
Human Factors: how humans interact with the world
around them. Human error is viewed as a symptom of
broader issues within what may be a poorly designed
system, such as an adverse physical or organizational
environment.**
* Institute of Medicine. Crossing the Quality Chasm: A new health system for the
21st century. Washington, DC: The National Academy Press; 2001.
** Dekker S. The Field Guide to Human Error Investigations. Aldershot, UK: Ashgate
Publishing; 2002.
35. II. Incident Analysis
• Task (care/work process)
• Equipment
• Work environment
• Patient (client) characteristics
• Caregiver
• Care team (direct service providers and support
team)
• Organization (policies, culture, capacity-resources)
37. Case Example
• Equipment: Motorized wheelchair; manual wheelchair;
hospital bed; transfer poles in bedroom and bathroom; bath
seat; Hoyer Lift and slings; Life line.
• Work environment: Customized private bungalow; guide
dog; client alone at times.
• Patient characteristics: Parkinson’s Disease; chronic
back pain and hip pain; physically compromised; alert &
oriented but at times has impaired judgment and memory
issues; quiet and slurred speech; functional hearing; wears
glasses.
38. Factors of Influence in Event
Equipment: Motorized wheelchair: client sits too far forward and does not use
the seatbelt.
Client: Lack of leg strength to push self
Environment: The client and family
back in the seat of the motorized
prefer that the client lives in the
wheelchair. Seating position increases the
residence as long as possible. While
risk for a fall. Motorized wheelchair is
cared for by extended family and
preferred for mobility over the manual
through Home Care much of the day,
wheelchair even though the seating
there are periods of time when the
position is safer in the manual wheelchair.
client is alone. Due to compromised
Risk for a fall is increased if the client falls
judgment and toileting issues, the
asleep in the wheelchair - tendency to fall
client may attempt to transfer when
asleep is exacerbated by medications.
assistance not available which has
Also, the client at times attempts to reach
led to falls in the past and increases
or ambulate without assistance present.
the risk for a fall.
39. Summary Statements/Findings
• The client is more at risk for a fall when using the motorized
wheelchair, than the manual wheelchair, due to the seating
position in the motorized wheelchair and consequent inability
to use the seat belt.
• Preference for using the motorized wheelchair at home
predisposes the client to this risk especially if the client falls
asleep while in the wheelchair or forgets that he/she in the
wheelchair.
• The tendency to fall asleep is exacerbated by medications
prescribed to address medical conditions.
• The Home Care services provided were maximized according
to the funding formula.
40. Report Format
• Date of Event
• Date Event was discovered
• Brief Description of event
• Date Event Analysis process was initiated
• Date Event Analysis process was completed
• Describe what Home Care Services received prior to the fall.
• Describe what Home Care Services received after the fall
• Describe the Client’s primary and secondary medical conditions.
• Does the Client live alone?
• The extent of harm as assessed 24 hours post event.
• Outcome of event
• Additional Issues
• Medications and how related to event
• Chronology
• Constellation Map
• Identification of factors that contributed to the occurrence of this
event
• Summary Statement
41. Reflection
• CPSI Concise Methodology
– Very similar to the what we have been using in the
region to review some Critical Incidents (falls and
pressure ulcers).
– Is a useful framework for the review of an adverse
event of limited harm to the patient (client):
• Conceptualizing;
• Planning;
• Conducting; and
• Documenting.
44. Options
1. Learn from each other
• Suggested topics
o Do you use concise now? For what cases?
o Is it helpful? How long it takes? How is it done?
o How did you get started? How did you spread it?
2. Q&A with the 2 presenters
45. Breakout Session
Some participants will Some participants will
stay in the main “move” to breakout
room rooms
- No phone next to
your name
- Say no when
invited to breakout
47. Recap and Next Steps
End of session evaluation; Follow up survey
• Follow-through and share
what was learned
March 28, 2013
• Recommendations
management
March 7, 2013
• Multi-incident analysis
February 21, 2013
48. Resources
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/Inci
dentAnalysisLearningProgram/Pages/Session-
Recordings-and-Documents.aspx
National Health System – UK
• Three Levels of RCA Investigation – Guidance
• Example concise RCA investigation reports
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsReso
urces/IncidentAnalysis/Pages/Tools.aspx
Good morning/ afternoon Welcome back those who were part of the our previous modules Welcome those who just came on board
I am Ioana P., PM with CPSI responsible with the management of the framework revisions, design and delivery of the education program and other resources to support you analyze incidents more effectively in order to make care safer. I will be your moderator today.The wonderful people that you see on the screen are contributors to today’s session and you will meet them later in the program
Previously on the learning program AND the scope of today’s call Assume that the previous steps in the incident management continuum have been executedConcise method is NEW additionWHAT HAPPENED; HOW AND WHY IT HAPPENED; WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER; WHAT WAS LEARNED
Ioana: due to the increase in the number of participants and their learning needs (the registration form has a few questions about the level of experience and learning objectives)…. And the feedback received following module 1-3 … and iN AN EFFORT TO GIVE EVERYONE AT LEAST ONE NUGGET OF LEARNINGWe changed the original performance elements and decided to offer a deep dive
Lines will be muted. Enter questions in the chat box or put your hand up during Q&A and you will be able to ask your question live. The first 2 parts of the meeting are recorded but not the facilitated discussion
1. Raise hand: have you participated in previous modules 2. In chat: what is your learning objective for today? 3. Pointer: next slide
Profile experienced participants as experts and encourage them to share their wisdom in the chat box or breakout room. In the evaluations we heard that real life stories are very valuable to you and we should continue to include them. Try to pick names?
Carolyn is the Vice President, Clinical Performance Improvement for Alberta Health Services, the largest healthcare delivery organization in Canada. In this role, Carolyn leads a variety of teams including Patient Safety, Clinical Quality, Design & Delivery, and Capacity Building. She is also Senior Advisor to the World Health Organization’s High 5s Initiative with responsibilities that include chairing the Event Analysis Subcommittee. Carolyn is one of the authors of the CIAF and a faculty member for the learning program. Carolyn`s relationship with CPSI is as long as CPSI`s existence. I had the pleasure to learn from and work with her since 2009 and I must say that no matter what the project or task both the journey and reaching the destination was a true joy. I am confident that you will enjoy the concise analysis learning journey Carolyn will take us through in the next 20 minutes. She is expecting some very good questions from you, so make sure you type them in the chat box or write them down so she can answer them in the Q&A following her presentation. Ladies and gentlemen, our concise analysis knowledge expert Carolyn Hoffman!
Comprehensive: permanent harm or death occurred (or risk thereof), incident is complicated or complex, area impacted is micro, meso or macro; contextual pressures are high Concise: incidents or concerns that resulted in no or low harm; may focus on a new incident for which a comprehensive analysis was conductedCarolyn, can you provide an example here?
Note that this is an iterative process – not a straight step 1, then 2, etc.May be an opportunity here to engage the participants such as asking them where they USUALLY do to gather information and understand what happened?
After gathering all the information, those gaps can start to be filled.Provide in the form of a narrative chronological description.The Detailed Timeline is a collation of information from various sources.This is your starting point for identifying system based factors underlying the incident.You may have IA team members who were not directly related to the event…in fact, consider involving such individuals as appropriate. Often, these “outside eyes” can ask different questions, or identify other factors for team consideration—improves credibility of the review while fostering and nurturing the just and trusting culture.
The guiding questions are meant to facilitate a thorough and complete picture of informationThe intent is to leave no information behindBased upon and adapted from international experts in incident analysisFocus on the person is like plucking Kleenex from the box. If you just pull the person and do nothing else…there will be another person coming behind who can potentially experience the same event because we have done nothing to address the system of contributing factors.
We don’t expect participants to read. Refer to pg. 115The facilitator created a constellation diagram to visualize and better understand the factors that contributed to the incident and their interconnections.The factors were confirmed by consultation with those engaged in the incident and operational and/or medical leaders. This step was very helpful in summarizing the findings and developing recommended actions.
The ultimate goal of incident analysis is to take action to reduce the risk of recurrence and make care saferWhether you are a member of the analysis team, or you are facilitating the analysis process, maintain focus by reminding yourself that if we do nothing, the dark persists, if we use facts as our illumination (not judgement, not punishment, not discipline), we are better able to determine exactly where we can focus attention and effort to make care saferAn upcoming learning module focuses entirely on developing and managing recommended actions. Refer to Section 3.6.6 in the CIAF (Canadian Incident Analysis Framework) document
• W1: Establish a standardized home care risk assessment tool for screening patients that are transitioning back to the community from hospital. Consider the feasibility and effectiveness of the regularly assigned home care nurse beginning the screening process with a call from the acute care nurse planning for the patient discharge then completing the assessment with a telephone or in-person client assessment.• CO 1: Develop, implement and evaluate a system-wide Discharge Medication Reconciliation Process. Consider using a pilot test approach initially to determine a successful strategy for spread.
Follow-throughAn evaluation was completed by the QI Director one year after the incident analysiswas completed:
Raise your hand, your line will be unmuted
Gordon is a Patient Safety Consultant with the Quality Improvement and Patient Safety Unit of the Winnipeg Regional Health Authority. His background is in Social Work with a graduate degree in Social Policy and Administration and his work experience includes Children’s Mental Health and Child Welfare. He has been leading Critical Incident Reviews for about 3 ½ years. We heard about the great work Gordon and his team are doing only 2 months ago. In November, Sandi and me met one of Gordon’s colleagues at a learning event organized by our colleagues from the HQCA. Shirley she told us about the great work the Winnipeg team is doing with Concise analysis. Excited to find a great organization to profile and put in the spotlight for the rest of the country we begin to learn more about the team, had a few calls and email exchanges with Gordon and felt very confident that the experience of this team will be valuable to all of you. As you listen to this very practical application of the concise method Carolyn introduced please make sure you capture your questions and comments in the chat box or on paper. Gordon will answer your questions following his presentation. Please join me in welcoming Gordon to our session. Gordon Luy, BSW, MSW WRHA Patient Safety Consultant364-99 Cornish AvenueWinnipeg, MB R3C 1A2Telephone: 204-788-8361Fax: 204-788-8430
Raise your hand, your line will be unmuted
Facilitated small group discussion20 minute breakout session. Ioana: recognize different levels of experience. Our goal is that each person leave having learned something - if you are new share your questions and challenges- If you are experienced share your solutions If chat box is “hot” say no to breakout Facilitation tips:Begin with a roundtable: name, organization and what you’d like to take home at the end of the sessionAsk to use the pointer to share their level of experiencePick on people to break the ice – point to what was presented earlier and use the one pager for comprehensive as guideCareful not to overwhelm them – ask, listen then talkMake sure they have the feeling that they accomplished something.Additional facilitation questions:What does one need to do to make this completely fail What is the role of patient/ family in the analysis process Describe the steps to create a timeline of the eventPerform the main steps to analyze information to identify contributing factors and relationships
Most participants will “move” to breakout roomsSome participants will stay in the main roomThose prompted: click YES to bothpop-up screens to “move”If chat box is “hot” say no to brekout
NadineFacilitators report back on process
Quick review of what was discussed during the call: Carolyn – background, features and comparision with comprehensive, overview of the steps in concise as presented in CIAF Gordon – practical application of the steps in CIAF concise in both a research study and regular work processesLearn from each other’s experience tips, stories, examples, scenarios Participants will be sent a link for an evaluation of the session immediately following. Please complete in 1 week while fresh in mind. You will need to complete in order to receive your certificate of completion for the module.We will also send you a survey in 6 months to let us know how you are doing and how you have used the principles and learning from the Framework and Learning Program to improve your practice with incident analysis and management.Of course, we invite your feedback, questions or suggestions at any time as to how we might improve the learning program
NadineDuring our discussion today, we have referenced a number of resources which can provide you with additional information. Links for these references are provided above.We hope that you will join us for subsequent learning modules.Thank you so much for the opportunity to speak with you today.