EP - Exemplary Professional Practice

EP31: Culture of Safety-Describe and demonstrate how the organization uses a facility-wide approach for proactive risk assessment and error management.

Risk Management at Jersey City Medical Center is responsible for identifying, analyzing, evaluating and treating actual and potential risks to patients, visitors and staff within the organization. This process is driven by communication, a review of incident trends, response to potential and actual risk, and ongoing monitoring. The Department is committed to sharing resources and knowledge across disciplines to ensure a culture of safety. To this end, interventions are tailored to ensure limited risk, reduced litigation and an environment in which patients, visitors and staff are engaged and motivated. The goal of the Risk Management Department is to act proactively to identify organizational risk at all levels and implement plans to reduce liability and financial losses. The goals of the Risk Management Department closely align with the organizations strategic plan and the four pillars of excellence, safety, quality, engagement and economic health.

Karen Caldas MSN-BC, RN

The Clinical Risk Manager, Karen Caldas MSN-BC, RN, works collaboratively with clinical staff, nursing leaders and the organization’s executive leadership team to identify patient safety issues, system processes that require improvement, and practice issues that affect patient outcomes. Ms. Caldas also works with the staff, managers, and department directors of ancillary departments to assess actual or potential risk, implement action plans to mitigate those risks and evaluate the effectiveness of interventions.

Incident Reporting

Incident reporting is one method utilized to identify actual and potential organizational risk. Jersey City Medical Center uses an electronic incident reporting system through rL solutions that is available to all employees. This system, rL Solutions is easily accessible via the employee intranet. Information collected in a patient safety report includes: patient demographics, date and time of occurrence, type and location of occurrence, and severity of the injury. Additional information that is included in the patient safety report is a brief factual description of the event, contributing factors, and the notification of appropriate parties. Once completed, the, the patient safety report is submitted electronically, reviewed by the Risk management Department and sent to the unit manager or department director for follow-up and resolution. Once the incident is resolved, the report is closed; however, when further investigation is needed, the Clinical Risk Manager conducts a chart review, interviews the staff, and collaborates with the management team to find resolution.

The Clinical Risk manager is the administrator of the electronic incident reporting system, and is responsible for adding and removing users, maintaining up-to-date information in the drop down menus and the provision of educational sessions for all end-users. The Clinical Risk Manager also monitors the frequency of incident reporting, the assignment of severity levels, and the trending of incident types. See screen shot below:

Frequency of reporting is crucial to the functioning of this department and Ms. Caldas carefully monitors the frequency of reporting to determine if barriers to reporting exist. Some barriers to reporting include: difficulty accessing the electronic system, fear of embarrassment, fear of retribution, and lack of confidentiality. The term ‘incident report’ has a negative connotation, implying that the writer did something to cause the event. For this reason, the electronic incident reporting system was re-named the Patient Safety Reporting System. There is an option to report anonymously, which would insure complete confidentiality. Incident reporting rose from 900 reports annually in 2009 and rose to 3,165 in 2011 (review graph below):

Incident or event reporting analysis allows the risk manager to evaluate processes, systems, protocols, and practices that leave the organization vulnerable to litigation and financial losses.

Trending types of events is also something that Ms. Caldas monitors very closely. In 2011 safety and security comprised 22% of all events, skin integrity comprised 21% of all events and falls comprised 12.8% of all events (see complete list below):

Root Cause Analysis (RCA)

Ms. Caldas conducts a full review of each chart when a quality, safety or risk issue is identified. The chart review details the patients stay with special attention to the event. Chart reviews are forwarded to the Senior Vice President of Patient Safety, Quality Management and Regulatory Affairs, Brenda Hall MS, RN, NE-BC, for review. Any patient event that involves a breach of the standard of care, a breach of policy or a patient complaint is considered for a root cause analysis. Additionally, the Department of Health and Senior Services requires an RCA for any preventable adverse event. Ms. Caldas completes the chart review detailing the patient’s care from the time of admission to the time of discharge, compiles a list of required attendees, and schedules the RCA. The Adverse Event Team is an interdisciplinary team that attends each RCA. This provides attendees with a varied perspective of the event and the issues that contributed to an adverse outcome. See below for team members:

Adverse Event Team

The RCA is completed within 45 days of the event and outlines an action plan, assignment of responsibility, a time-frame for completion, and a plan for monitoring. RCAs rely on objective facts, rather than opinion, and are non-punitive in nature (Appendix EP31-A). In 2011, 42 RCAs were performed and 12 were reportable to the Department of Health and Senior Services of New Jersey.

Assistant Director of Nursing (ADN)/Vice President Report

The ADNs are responsible for covering the evening and night shifts as well as holidays and weekends at the Medical Center. The ADNs provide an end of shift report which documents any patient safety, quality or risk issue which may have occurred during their particular shift. The information in this report is compiled into a document which is reviewed by Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer, and Ms. Caldas. Any information contained in this report is investigated as necessary. This report also contains the current census including admissions and discharges, Emergency Department holding information, Emergency Department/Critical Care hours of care and agency usage (Appendix EP31-B).

Bed Huddle

Ms. Caldas is visible in all areas, encouraging open dialogue and promoting a culture in which the staff is comfortable seeking assistance from and working with the Risk Management Department. Ms. Caldas attends the daily bed huddle in the morning which is a discussion from the charge persons on the day shift to plan and prepare for the coming day. This is an interdisciplinary meeting, with Housekeeping, Facilities, and the CNO, x-ray Department, the nurse managers and/or charge nurses and the Staffing Office attending. Nursing Units usually involved include: Telemetry, Cardiac Catheterization Laboratory, Critical Care, and the Emergency Department. Attendance is not limited to just these units and representatives from any unit are invited to attend and join in the discussion. Issues resolved include: bed availability, types of patients holding in the Emergency Department, availability of Critical Care beds, laundry and housekeeping issues. During this meeting, Ms. Caldas notes potential safety and/or patient care issues. In a recent bed huddle meeting it was reported that the Emergency Room patients were waiting 4-6 hours for admission orders to be written by the Resident. Karen Caldas advised that the Emergency Department complete an incident report in rL Solutions so that Ms. Caldas can follow-up on this issue.

Failure Mode and Effects Analysis (FMEA)

This process is conducted annually by the Quality Management Department in conjunction with the Risk Management Department. This risk control technique is a proactive approach to risk identification used to prevent the occurrence of a serious adverse event by analyzing a situation that might create risk at a later time. The Joint Commission requires that health care organizations conduct an FMEA annually on the most frequently occurring patient safety event. As patient events are analyzed, significant trends are identified and suggested for an annual FMEA.

Potentially Compensable Events

When a patient event has a significant effect on that patient’s outcome, it is reported to the Liberty health Insurance carriers as a potentially compensable event (PCE). Ms. Caldas collects all documentation relative to the event, i.e., incident reports, patient safety reports, chart reviews, and RCA notes, and forwards them to the insurance carriers to ensure a prompt response to potential litigation. Ms. Caldas works closely with the Director of Risk Management and Corporate Compliance, Shani Newell BS, JD, to insure that PCEs are reported consistently and accurately.