Healthcare organizations are realizing that their approach and address to patient safety issues directly impact their ability to maintain quality care. The goal of this post is to teach you how to identify quality events, understand their root causes, and apply a systematic approach to preventing them from recurring.
In addition to reading, you can watch this blog about Quality Events too!
Quality events and the triggers
Identifying quality events and the triggers that lead to them are critical to the success of any improvement effort. Quality events are patient harm, a near miss, or a failure to follow a process. People who experience quality events or observe them can identify these events.
You will want to look for quality events in your organization that can help identify where improvement efforts should be focused.
A quality event is an opportunity for change because they lead to an opportunity for improvement.
The root cause or causes of quality events
The first step to addressing a quality event is to develop an understanding of its root cause or causes. This includes:
- Understanding the impact on patients and families
- Understanding the impact on staff
- Understanding the impact on your organization’s reputation among patients, other healthcare providers, and other stakeholders in the community
You can also do a 3×5 why analysis to find the root cause.
Not all incidents are quality events
To address a quality event, you must first understand what it is. The term quality event has two main definitions:
- An incident that has occurred as a result of poor quality; and
- A set of conditions that cause an incident to occur (quality-related).
The definition of a quality event trigger is the set of conditions that causes a quality event to occur (quality-related).
In addition, there are several types of triggers:
- Quality Event Trigger – An event in which an individual makes a decision based on inadequate information or data. Example: A doctor gives you incorrect instructions because he did not have access to all your records before treating you for your cold sore. This can lead to worse outcomes than if he had read all your medical history before diagnosing and treating.
Address every quality event as if it could result in patient harm if it recurs.
- It’s important to address every quality event as if it could result in patient harm if it recurs.
- Make sure you are aware of the potential for recurrence, which means you need to know how often similar events occur in your practice and what factors increase their likelihood.
- Make sure you’re aware of the potential for harm to patients because that will help you assess whether an event should be considered serious enough for further investigation or intervention.
- If there is any possibility of harm to staff members, this should be a red flag for immediate intervention because it would affect other employees’ ability to do their jobs well and safely.
Isolocity has an entire module to address this concern. In our corrective and preventative action module, all erroneous actions are recorded. To prevent quality events from recurring in the future, organizations must submit a plan and automate most tasks. For example, real-time statistical process control automates the updating of a graph on the quality KPI dashboard as each part is inspected. This graph indicates if machine maintenance is needed even before any waste is created.
How important a methodical technique is
When dealing with great events, it’s important to do things in a planned way. It gives a structured way to look at problems, find answers, and put them into action. Healthcare organizations can ensure a thorough understanding of quality events, identify their root causes, and take appropriate actions by utilizing a systematic method.
The Plan-Do-Study-Act (PDSA) cycle is a popular method for improving quality that works well. This cycle includes planning the change, putting it into action on a small scale (Do), studying the results and collecting data, and then acting on the results to improve and expand the change. This iterative process lets companies learn, change, and get better all the time.
Creating a culture where people share and learn
To deal with quality events successfully, the organization needs to have a culture of reporting and learning. Staff members should feel free to report quality events without fear of repercussions. This provides an open environment where they can quickly find problems and fix them.
Setting up a strong, easy-to-use method for reporting incidents can make the process of reporting easier. By looking over reported events on a regular basis, analyzing trends, and sharing what the group has learned, similar events are less likely to happen again.
Always getting better and keeping an eye on things
Taking care of quality events isn’t a one-time fix; it takes ongoing monitoring and improvement efforts. Organizations can track their success and identify areas for improvement by establishing performance indicators such as key performance indicators (KPIs) and quality metrics.
Regular audits and assessments provide insights into the effectiveness of implemented solutions and highlight areas that require additional attention. By consistently monitoring and reviewing processes, organizations ensure their readiness to identify and address potential quality events in a proactive manner.
Education and training
Investing in staff training and education is a must for avoiding and dealing with bad things that happen. Healthcare professionals who receive comprehensive training on patient safety, quality improvement methods, and error prevention techniques are better equipped to identify risks and take appropriate actions.
Organizations that provide employees with the necessary information and skills can cultivate a committed staff that actively works to prevent adverse events and delivers safe, high-quality care.
Taking a proactive approach to quality events helps in preventing future occurrences and promptly reducing patient harm if they do happen. It’s important to recognize that not all quality events pose high risks. However, as demonstrated today, even small problems can potentially lead to significant harm. Therefore it is critical to address every event as if it could result in patient harm if it recurs.