Event reporting in a paper record world
Getting the most from your reports and data
After reading this article, you will be able to:
- Describe the initial challenge of creating an improved event reporting form for a small facility
- Describe what resources the organization sought out to help design its own event reporting form
- Discuss how information is tracked and trended from the event reporting form
Event reporting varies widely from facility to facility, and the kind of medical record system a facility uses (paper or electronic) can have a dramatic effect on its data collection and what can be done with that work. So when Jennifer Trallo, RN, MSN, MBA, director of quality management at AcuityHealthcare's Acuity Specialty Hospital of New Jersey in Atlantic City, joined the team at the then newly minted hospital, she made sure to put event reporting at the top of her list.
"Event reporting was my baby," says Trallo. "When I came here it was a brand-new little hospital-we were building from nothing and going up." From the beginning, she knew the existing event reporting form might be improved upon.
The hospital's options were somewhat limited, being on a paper system, but Trallo did not want to limit the options to traditional paper-based reporting systems.
"This project was near and dear to my heart. I've worked with both paper and electronic systems. I figured we'd start with targeting what attributes of an electronic system were more desirable than paper beyond the ease of data collection," says Trallo. What was undesirable about existing paper systems? What, beyond the data collection component, was different about the two systems, and what could be imported into a paper system from an electronic one?
"The old-fashioned safety reporting forms had some data fields, but by and large when you got to the meat of it, it's a narrative note," says Trallo. "The narrative note really does nothing for tracking and trending data collection over time."
A narrative note relies on another party to interpret that information-which is, essentially, the original note-writer's interpretation of the event. What is missing is some sort of uniform process for that interpretation.
"An electronic reporting system provides decision trees, questions asked specifically about that kind of event," says Trallo. "At the back end, you end up with meaningful data."
So Trallo proposed creating a paper reporting system that mimicked what an electronic system would use.
"I'd worked a lot with order sets and guideline creation in my past life," she says. "I had an idea of how to do this in another direction. I actually started writing one for falls-what specific information would I want?"
It didn't take long to realize that she might be reinventing the wheel. "About halfway through the first homegrown form, I thought: This is ridiculous. Someone, somewhere, has created this language already," she says.
Her research led her to language used for Patient Safety Organization (PSO) reporting, which fit precisely with her own needs. It also served a dual purpose: When the hospital grew to the point where it might join a PSO, it would be further ahead in its event reporting process. This added benefit was a great selling point to help push the new form and process to leadership at a time when, as a fledgling facility, there were many competing priorities.
Transitioning from a narrative report to something more like an electronic form turned out to have a big learning curve for everyone involved, says Trallo.
"The thought at the time was: This concept has been in existence and using event reports for a long time. What makes this better?" she says.
In addressing this, though, being a smaller hospital worked in the organization's favor. "Every orientation group comes through, and everyone who touches a patient gets an overview of our safety program from me, including everyone in a leadership role," says Trallo.
But this communication is a two-way street. Everyone in the orientation program is told that their opinion is important. While many of the decision-makers have a clinical background-Trallo herself is a nurse-they know they need the feedback of those at the bedside who will be using the tools and forms, to make sure they are done right.
Trallo spoke with staff about the new report form. Initial reactions were that it was too long and would add time and energy to the reporting process. However, once staff began to get accustomed to the form, the reduced amount of writing and additional guidance about what the report should include became selling points. "We are a tiny facility, so it takes a while to get data," says Trallo. "It's hard to track and trend with a smaller daily census."
Another step to build buy-in among staff was an offer to help. "I told staff: 'The most important thing is that we track this information. If there is a time you are overwhelmed and can't get it done, call me and I'll write down the information while you tell me what happened,' " Trallo says. The offer itself seemed to be more important than actually taking her up on it-in two years, only once has anyone called to ask her to work through the form in this manner. And in that one case, it worked out well.
"I took the information from them over the phone and populated the data fields for them," says Trallo. "The thought that this is important enough for someone to come down and help and to know that the support is right there has worked out really well."
The organization is still small enough that Trallo is able to track report results in Excel®. Her goal within the next two years is to join a PSO so that the information will be collected in the same way, and either submitted to the PSO electronically or on paper.
"If our volume of reports gets bigger before then, we could do something a little fancier," she says.
The data fields in the form have had another benefit: Because they are identifying what is important after an event occurs, they are helping staff identify and get ahead of where challenges and problems are most likely to occur.
"The specific data fields on specific reports, such as for falls or blood transfusions, really highlight what is important in those areas," says Trallo. "They are things that might not have been put down in a narrative report, and it almost becomes a checklist for care-it supplements our process of care." If this form is how the organization assesses fall risks, it is possible to assess those risks before they ever occur. "Staff know what will be asked about on the other end of an incident."
The information gathered through the reports is shared with the staff for educational and awareness purposes. "We post all of our data in staff areas," says Trallo. "Our goal for 2013 is to post it in the lobby so everyone can see our entire dashboard from beginning to end."
Posting data in the main staff lounge is of particular importance to bedside staff. Data is posted every month in a format that is accessible and understandable to all staff. "If we have a specific area we see that might be at risk for a particular issue, we do root cause analyses," says Trallo.
The process even garnered a bit of positive feedback during the organization's last survey. The facility is DNV accredited. "We were complimented on it," says Trallo. "They said this is really state of the art for such a tiny hospital. It helped reinforce that there are different types of best practice." It also reinforced that best practices aren't always clinical. "Our leadership team has always given their buy-in if we wanted to do something clinically that was a best practice," says Trallo. "This showed that there are administrative best practices that can improve our safety program as well."
Ironing out the details
Every process has its growing pains, and there are a few improvements that the organization intends to make.
"We found a trend in the data that an increase in falls was happening on off-shifts or weekends, which is odd because we've got the same staffing numbers at those times," says Trallo.
The organization looked at quantitative information from the form and requested qualitative information from the staff. It found that the cause was not a staffing shortage, but that there were more ancillary staff during weekday shifts who might do a quick check on a patient-an unofficial yet beneficial practice. This discovery led to implementation of 15-minute rounds for high-risk patients.
Another change implemented as a result of the new process was a "stoplight system." If a patient's call light is on, no staff member is permitted to walk by without stopping to see what the patient needs. "Our initial concern was that you'd answer a light and not be able to help," says Trallo. But patients seemed to warm to the idea that everyone was looking out for them, even if it was a matter of checking in and offering to find a nurse.
"There's a huge overlap between patient satisfaction and patient safety," says Trallo. "No matter what processes you have in place, if someone doesn't feel cared for, you have a problem."
1.Decannulation/self-extubation: Number of reports of unintended decannulation or extubation by month over the number of trach collar days plus the number of vent days in the month.
2.Unintentional line dislodgement: Number of reports of unintended central line dislodgement by month over the number of central line days in the month.
3.Unintentional tube dislodgement: Number of reports of unintended tube dislodgement by month over the number of tube days in the month. (Tube days include all types of enteral feeding tubes, surgical drains, indwelling catheters, chest tubes, etc. Tube days are collected manually in the same way that line and vent days are.)