Good evening, colleagues!
This week, I’d like to talk a bit about the importance of quality reporting. Our goal is to provide excellent care with the best possible outcomes to our patients, and quality reporting is essential to identify potential safety concerns to patients.
Einstein once wrote that “the definition of insanity is doing the same thing over and over again and expecting different outcomes.” Recording and investigating incidents could reduce – or altogether eliminate – similar incidents from happening again. Timely reporting also allows us to recognize clusters and trends of incidents, including potentially serious incidents (i.e., near misses). This, in turn, provides an opportunity for us to address root causes.
I, along with our Quality Department, would like to remind everyone that it is imperative to take the extra time in your busy day to note patient or safety concerns in your daily activities. Please see below for more details about individual processes at Children’s, Froedtert and the VA. Your attention to quality reflects not only on you, but also on the Department, the Medical College and our Regional Medical Center as a whole, so I wholeheartedly thank you in advance for your diligence!
“Quality means doing it right when no one is looking.” – Henry Ford
Cindy
CHILDREN’S HOSPITAL
How to report: The cases are identified, for the most part, at the time of case closure in Epic, CHW’s current electronic health record.
CHW pediatric anesthesia quality reporting is a faculty-driven initiative that identifies, tracks and peer reviews perioperative events. These events are divided into a) discrete parameters defined in “Appendix 2” of the Children’s Surgical Program through the American College of Surgeons and b) other events in need of discussion identified by CHW pediatric anesthesiologists. In addition, cases may be referred by surgeons, nurses, surgical technicians or other individuals who indicate a need for case review.
Once a case is identified, the CHW faculty members peer review the case. The peer review process occurs outside of the electronic health record, in a password-protected Redcap database, using a scripted review process to identify the following: adequacy of preoperative assessment; management of the event; and assessment as to the likelihood that the event was due to anesthetic management. The scripted form also addresses whether systems issues, human factors, technical issues and mechanical failures are associated with the event. A self-review is performed by the responsible anesthesiologist, followed by two blinded reviews by CHW faculty. The blinding of the reviews allows the secondary reviewers to provide a candid review of the care of the child.
Outcomes: The CHW Quality process has benefits to clinical, academic and administrative missions of our department. The cases serve as a source for CHW Anesthesiology weekly M&M, a monthly SQIRT (surgical quality improvement team) committee and a quarterly combined anesthesia, critical care and surgery conference. As well, they are a rich source for PBLDs, case presentations and series reviews for academic discussion. We received 25 hours of MOCA credit for the design and implementation of the process, and have faculty members interested in submitting their individual reviews for MOCA credit. At present, the cases have been reviewed in aggregate and have been presented at the ASA annual meeting discussing factors associated with improvement in care and increases in adverse events.
Questions? Contact: Richard Berens, MD
FROEDTERT HOSPITAL
How to report with Safety Event Report (Midas events) or SharePoint:
- Safety Event Reporting System is located under Quick Links on FH website. Follow very simple instructions once opened.
- SharePoint: One of the important elements to our department’s QA event tracking is self -reporting through our SharePoint site:
– Link to site: https://datacollectionrb.sp.froedtert.com/sites/1270/default.aspx
– Who is accountable to report every case (whether there is an event or not): Residents, CRNAs and CAAs will do most of the reporting. The attending anesthesiologist will have the final accountability for submissions.
– Contact Nicole nprospeck@mcw.edu if you have issues with the SharePoint site or access requests
– Note: The submitted form will only be marked as complete when a complication box is checked or if the no issues box is checked.
Questions? Contact: Kathryn Lauer, MD, Nicole Prospeck, MSHI, or Sheila Blogg, MSN
VA HOSPITAL
How to report: Intraoperative- and PACU anesthetic-related events are recorded on a paper form with event descriptions selected from the Anesthesia Quality Institute templates.
The VA has 3 mechanisms to report and track anesthetic and surgical outcomes and to report patient safety concerns:
- Outcomes with the highest potential for resident and CRNA education are selected for discussion at MCW and VA education conferences.
- VA Surgical Quality Improvement Program (VASQIP): This is the VA equivalent of the AQI. Data from our VA are extracted by a VASQIP coordinator and transmitted to the VA National Surgery Office. It is a quality assurance activity-derived database containing information on all patients who undergo surgery within the VA.
- Joint Patient Reporting System (JPRS): This is run by the Department of Defense and the VA hospital and is open to reporting from any employee in administration, nursing or the medical field.
Questions? Contact: Thomas Ebert, MD, PhD
Cynthia A. Lien, M.D.
John P. Kampine Professor and Chair
Department of Anesthesiology
Medical College of Wisconsin
9200 W Wisconsin Avenue
Milwaukee, WI 53226
Phone: (414) 805-8703