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Performance Improvement Committee

“Good Catch” Program

Implementation Toolkit

September 2010

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“Good Catch” Program

Introduction As part of the ongoing efforts at North Shore Radiation Therapy and the Performance Improvement Program to develop a patient safety culture, North Shore Radiation Therapy is implementing a “Good Catch” program to encourage the reporting of “near misses”. What is a “Good Catch”? At North Shore Radiation Therapy the following definition of a “good catch” will be used:

• Recognition of an event or circumstance which had the potential to cause an incident or critical incident but did not occur, due to the corrective action and/or other timely intervention following it’s discovery by an employee

• Also known as “a near miss” The “Good Catch” Program at North Shore Radiation Therapy is a quality improvement initiative that encourages the identification of potential systemic errors or problems before they reach the patient and/or cause harm. The program recognizes staff and physicians for identifying “good catches” and is designed to share key findings across the practice. It is hopeful that the “Good Catch” Program will:

• Further strengthen the culture of quality and safety; • Allow staff to be recognized for their contributions thereby creating a

culture of safety; • Continue to build staff confidence in the quality improvement processes

through a non-punitive environment and taking action to address the issues and concerns identified.

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Definitions It is important to differentiate between incidents, adverse events, sentinel events and near misses. Incident

• An unexpected and undesirable event/situation that is not consistent with the routine care of a patient.

Adverse Event

• A negative of unfavorable reaction or result that was unintended, unexpected or unplanned.

Sentinel Event

• An unexpected incident, related to a system or process deficiency leading to the death or major and enduring loss of function for a recipient of health care services.

• Loss of Function – Sensory, motor, physiological or psychological impairment not present at the time of service and not related to the underlying condition.

• The impairment lasts for a minimum of two weeks. Near Miss

• An event or circumstance that has the potential to cause serious physical or psychological injury, unexpected death or significant property damage, but did not actualize due to chance, corrective action and/or timely intervention.

• A near miss is a free lesson in proactive risk management and error prevention.

“Good Catch”

• Recognition of an event or circumstance which had the potential to cause an incident or critical incident but which did not occur (i.e. near miss) due to corrective action and/or other timely intervention following recognition.

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Program Overview 1. Goals To reduce the overall number of incidents and adverse events. 2. Objectives To build a culture of trust by creating and maintaining an environment of non-punitive reporting. To recognize staff and physicians for their contribution to quality and patient safety. To strengthen the quality culture across the organization and enhance the quality and safety of services provided. To provide the practice with the opportunity to proactively identify and implement risk reduction strategies. To increase the rate of recognition of unintentional errors or problems before they occur, to identify and implement corrective action, and to share learning across the organization. 3. “Good Catch” Reporting Near misses are daily occurrences in the healthcare sector simply because healthcare professionals are human. Healthcare professionals hesitate to report “near misses” for a variety of reasons:

• Lack of understanding • Fear • Blame • Belief that reporting may not result in improvement • Complaints about tedious or lack of reporting processes

Good Catch” Reporting is described in the attached procedure – “Good Catch” Program. 4. Review and Selection Criteria – refer to policy for details

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All submissions will be reviewed by the Chief Operating Officer on a quarterly basis. The submission that best meet the following criteria will be selected and recognized:

• Impact on patient safety • Impact on quality of patient care • Impact on service (timeliness, efficiency, effectiveness) • Opportunity to spread and increase a positive impact across the

organization Process for a “Good Catch” Selection Protection Strategies for Submissions (HIPPA) The Performance Improvement Committee is directed within the parameters of the Health Insurance Portability and Privacy Act (HIPPA). The Committee’s designation is for the purpose of ensuring that any submissions made through the “Good Catch” program are protected from being used as evidence against the submitter or other healthcare members. Suggestions to assist in assuring and reassuring staff to remain compliant with HIPPA:

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• Inform all staff that submissions are treated as HIPPA protected documents • Emphasize the importance of making the submissions as factual as

possible and leave the analysis to the Performance Improvement Committee

• Emphasize the importance to all staff and the Performance Improvement Committee members the necessity of maintaining confidentiality of the information generated

• “Good Catch” submissions should not include and patient identifying information

• No patient information or healthcare providers information are involved in any communications

• Ensure all improvement opportunities are done in a general non-specific form

How Will Staff be recognized? The quarterly recognition program will include the following:

• “Safety Star” pin awarded to the staff member and/or physician “Good Catch” of the quarter

• All recipients will receive a letter signed by the CEO, COO and Medical Director

• A thank you card signed by the COO will be sent to all individuals who report a near miss

• All near misses and follow-up will be logged into the database and published in the monthly newsletter

Frequently Asked Questions (FAQ)

1. Who will see the forms?

Your manager, the members of the Performance Committee and Executive Leadership.

2. How will confidentiality be maintained?

You are not required to sign the initial submission if you choose not to be identified

Your name will only be used with your permission

3. Will my immediate supervisor be notified of the “Good Catch”?

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The initial form will be submitted to your supervisor so that it can be discussed at the “frontline” level

Frontline staff are often in the best position to make

recommendations regarding process improvement

Remember that this is a non-punitive process and we encourage reporting in order to ensure a safe environment and establish a culture of reporting and continuous quality improvement

4. Can I fill out the form and not sign my name?

Yes, but without your name, we cannot recognize your contribution

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Purpose: The procedure will describe how staff and physicians can report “near misses” and how that “Good Catch” will contribute to an overall environment of quality and patient safety through reduced error. Distribution: All Practice Areas Equipment/Supplies: None Definitions: “Good Catch”: Recognition of an event or circumstance which had the potential to cause an incident or critical incident but which did not occur (i.e. near miss) due to corrective action and/or other timely intervention following discovery. This event did not reach the patient/staff/visitor/physician Near Miss: An event or circumstance that has the potential to cause serious physical or psychological injury, unexpected death or significant property damage, but did not actualize due to chance, corrective action and/or timely intervention. Procedure: The following process is to be followed in the event of a “Good Catch”.

1. Complete the “Good Catch” Report Form – Appendix A 2. Complete as much detail as possible to assist with the analysis 3. Submit to the immediate supervisor 4. The supervisor reviews the report with frontline staff within 5 days (where possible) using

the “Good Catch” Case Review Tool – Appendix B 5. The completed form is submitted to the Chief Operating Officer or delegate for entry into

the database 6. If immediate corrective action is needed, the plan is immediately reviewed and

implemented 7. The completed form is included in the agenda package for the next Performance

Improvement Committee Meeting

Procedure Name: “Good Catch” Program Policy Area: Performance Improvement Approved Date:

Reviewed Date: Approving Manager: _________________________ Chief Operating Officer Revised Date: Documents or Policy Replaced (if any):

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8. The Performance Improvement Committee will review the analysis and action plan for the opportunity to spread improvement teaching across the practice (i.e. policy or procedure changes, staff education)

9. The Performance Improvement Committee will apply the Risk Matrix to determine hierarchy fro corrective action – Appendix C

10. Final report with recommendations and timelines for evaluation and reporting back are provided to the Chief Operating Officer

11. Implementation of recommendations are based on urgency 12. Recognition letter is sent to the individual(s) responsible for identifying the near miss by

the Chief Operating Officer 13. The near miss(es) with the greatest impact will be recognized quarterly using the criteria

below Risk Assessment Process The Performance Improvement Committee, acting within HIPPA guidelines will review each report. A Risk Priority Matrix will be utilized to determine events that require immediate follow-up and/or a more in depth analysis. See Appendix C. Recognition Process On a quarterly basis, each submission will be evaluated against the following criteria:

• Impact on patient safety • Impact on quality of patient care • Impact on service (timeliness, efficiency, effectiveness) • Opportunity to spread and increase positive impact across the practice

The individuals who submitted the near miss repot which demonstrated the greatest impact to patient safety will be awarded a “Safety Star” pin and will receive a letter signed by the CEO, COO and Medical Director thanking them for their contribution. A thank you card signed by the COO will be sent to all individuals who report a near miss. All recipients will be acknowledged in the practice newsletter “As the Gantry Turns”. Health Insurance Portability and Privacy Act (HIPPA) The Performance Improvement Committee is directed within the parameters of the Health Insurance Portability and Privacy Act (HIPPA). The Committee’s designation is for the purpose of ensuring that any submissions made through the “Good Catch” program are protected from being used as evidence against the submitter or other healthcare members. Appendices Appendix A – “Good Catch” Reporting Form Appendix B – “Good Catch” Case Review Appendix C – “Good Catch” Risk Assessment Matrix

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Appendix A

“Good Catch” Reporting Form

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“Good Catch” Reporting Form

Name (optional): ____________________________________________________________ Department: Therapy Physics Nursing Physicians Clerical Administration Date of “Good Catch”:____________________ Description of “Good Catch” (Please use as many facts as possible without identifying the patient or staff member by name.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Suggestions for Improvement (You may start this section. Ideas can be added when your manager meets with staff in your department.): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of Submission: _______________ Date of Staff Review and Discussion: _______________ Administration Review: ____________________ Date of Review: ______________

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Appendix B

“Good Catch” Review Tool

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PRIVILEDGED & CONFIDENTIAL

(PREPARED FOR Performance Improvement Committee)

“Good Catch” Review Tool

INITIAL REVIEW DATE: ____________________ INTERNAL REFERENCE: ____________ What happened (Briefly describe the “Good Catch”): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Contributing Factors?

Information Management

Patient correctly identified? Documentation provides a clear

picture? Training issues? Communication Issues? Others? ____________________________

______________________________________ ______________________________________

Equipment

Display and controls understandable? Equipment detects & displays OK? Maintenance/upgrade up to date? Warnings/labels understandable? Lack of appropriate training? Others? ____________________________

______________________________________ ______________________________________

Environment

Noise levels too high? Lighting adequate? Adequate temperature? Adequate space? Clutter or inadequate storage? Security concerns (i.e. family at

treatment console)? Others? ____________________________

______________________________________

Policies and Processes

Audit/quality control for process? Official policy followed? Use of checklists or other tools? Policies available? Policies accessible? Others? ____________________________

______________________________________

IDENTIFY POTENTIAL

CONTRIBUTING FACTORS…

i.e. environmental, equipment…

Safety Mechanisms

Did anything stop or decrease risk of injury?

Equipment safety mechanisms functional?

Others? ____________________________ ______________________________________

Human Resource Issues

Staffing levels adequate? Proper orientation and training? Fatigue? Proper staff supervision? Others? ____________________________

______________________________________

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Why did it happen (Root cause/contributing factor statements): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How to Prevent Recurrence

Standardize/Simplify

Standardize or simplify equipment Standardize or simplify protocol Institute policy Education/communication Other

______________________________________________________ ______________________________________________________ ______________________________________________________

Automation/Computerization

Automatic calculation Provide reminders Assist in decision making Improve technology Other

_______________________________________________________ _______________________________________________________ _______________________________________________________

Improve or add Devices/Equipment

Better controls, displays or integration Adjust tolerances Additional equipment Clutter or inadequate storage? Other

_______________________________________________________ _______________________________________________________ _______________________________________________________

Improve Environment

Improve workflow Improve lighting, noise or clutter Improve storage, signage, etc. Other

_______________________________________________________ _______________________________________________________ _______________________________________________________

Create an Action Plan

Risk reduction strategies Timelines Person Responsible

Evaluate Effectiveness

Indicators Review Date

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Appendix C

“Good Catch” Risk Assessment Matrix

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Evaluative Criteria

• Negative impact on patient safety • Negative impact on quality of patient care • Negative impact on service (timeliness, efficiency, effectiveness) • Potential re-occurrence

High Risk

Low Impact

High Risk

Medium Impact

High Risk

High Impact

Medium Risk

Low Impact

Medium Risk

Low Impact

Medium Risk

High Impact

Low Impact

Low Risk

Medium Impact

Low Risk

High Impact

Low Risk

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