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MYAN Copy of Incident management tutorial

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Medical Development Team

on 29 February 2016

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Transcript of MYAN Copy of Incident management tutorial

the client
client experience
clinical effectiveness
client safety
what is quality?
the basic tenet of quality healthcare is 'do no harm', but we can all make mistakes! it's only by learning from mistakes that MSI can strive to achieve clinical excellence!
why is our approach changing?
Under-reporting
not enough learning from incidents!
Not clear when to report incidents, or to whom they should be reported
no way for programmes to analyse incident data
Benefit or purpose of incident reporting is not clear
incomplete or inadequate investigations, and lack of capacity to carry out root cause analysis
Not clear what should be reported
incident forms and paperwork end up locked away in files, where information and trends cannot be analysed to support programmes to learn from past experience
so what's the purpose of this tutorial?
we want to introduce you to the new incident management system by highlighting some key concepts and processes that you will need to get the new system up and running!
let's start by bringing our client out into the real world....
i'm on my way to marie stopes!
daisy smith
i made it!
but where are the service providers?
marie stopes outreach here today!
daisy smith
faith smith
i have been waiting 2 hours already!
phew! we've made it!
nurse
driver
tick tock...
we must get started right away, there are so many clients waiting!
i will start doing counseling and taking consent while the doctor sets up!
daisy smith
faith smith
i'm 16 years old, and don't have any children yet. i also don't want any kids anytime soon! that's why i'm choosing get have an IUD inserted today. i wish that your team spoke my local dialect better though, i'm not very comfortable in english!
i'm 35 years old and already have 5 kids. i don't want anymore!! that's why i'm getting a tubal ligation today.
counseling and consent
marie stopes
waiting
staff arrives
getting organised
daisy's consent and medical history
nurse
counseling and consent
faith's consent and medical history
nurse
immediately after counseling
nurse
here are all the client files and consent forms
doctor
great!
i'm all set-up. let's get started!
doctor
ms. smith, please come for your procedure!
faith's consent and medical history
daisy smith
coming!
5 minutes later
nurse
daisy smith!
we're ready for you!
daisy smith...?
hmm... she
must have gone home?
community health worker
your tubal ligation is all done!
daisy smith
at the centre of everything we do
INCIDENT MANAGEMENT TUTORIAL
why is quality important?
quality is important to our business because we value our clients!
we strive to provide our clients with services that meet and even exceed their needs, wants, and expectations
we are committed to continuous quality improvement and have developed a system for measuring and improving our performance
at the outreach site
getting started
the procedure
after the procedure
3. sample incident
1. introduction
4. response processes
service delivery level
secure safety of client
immediately complete the notification form
escalation and submission
incident notification forms must be submitted immediately. why?
this ensures that teams get the support they need
this ensures that risk grading can be confirmed and the form escalated further if necessary
this ensures that the incident receives an appropriate level of investigation
the client
providers involved
who?
+ site manager
daisy smith
complete the incident notification form
top tip!
type of incidents
top tip!
risk grading
top tip!
primary provider information
top tip!
brief description
the incident notification form only requires 1-2 sentences about an incident. this is to encourage incident reporting and make the process quick and easy!

the third section of this form will ask you to indicate what type of incident this was...
RECALL: there are two types of incidents:
clinical incidents and near misses
it is important to note that both clinical incidents and near misses may also relate to a product!
section 3 of daisy smith's notification form...
what type of incident was daisy smith's case?
did you get the answers right? if not, you can always refer to the policy for more guidance!
2. key concepts
incident data management and trend analysis
types of incidents
risk-grading
levels of investigation
safety alerts
there are two types of incidents:
clinical incidents and near misses
it is important to note that both clinical incidents and near misses may also relate to a product!
Why Risk Grading?
if an incident cannot be managed on site, and client requires referral, the initial risk grading is always Red
identifying the appropriate level of investigation
Section 4 of daisy smith's notification form...
daisy smith received a tubal ligation when she was 16 years old, without her consent, when she wanted an IUD. Clinically, she has suffered permanent and irreversible health effects -- she will not be able to have children. Depending on the cultural context, inability to have children may also have serious social repercussions. Therefore, the consequence to the client is critical, and the incident receives a 'red' risk grading.
the fourth section asks you to give the incident an initial risk rating
RECALL: an incident's risk grading corresponds to the actual or potential impact on the client
what was the consequence of this incident to daisy smith?
this form can be filled out on paper or electronically and shouldn't take more than a couple of minutes
the incident notification form is NOT an investigation. this form simply flags to appropriate team members that an incident has occurred, and ensures that staff receive appropriate support.
Section 5 of daisy smith's incident notification form...
the fifth section asks you to give information about the provider involved
RECALL: the purpose of incident report is learning!
including provider information in the notification is an important part of being able to identify gaps in training, spot trends, and support providers to prevent recurrence!
doctor X
although there was also a nurse involved in the daisy smith incident, it was the doctor who failed to verify that she was performing the procedure on the right client
it is important to include the designation and contract status so that your programme can track and identify trends. for instance, a programme might notice that a group of incidents related to a particular group of government health workers, and additional support is required.
what is it?
what kind of information does it require?
remember! this incident notification form should be completed immediately, which means the final impact to the client may not be known yet. it is important to record the impact at the time of filling out the form, it can always be amended later (this might alter the risk grading).
remember! if the incident receives a 'Red' risk grading, more information will be required as part of the in-depth investigation. if you've given an incident a red risk grading, we recommend writing a brief chronology of events for your own records while the incident is fresh in your mind.
when?
How?
to whom?
once you have completed the incident notification form, it must be submitted...
red incidents must reach MDT within 24 hours. this is so that MDT can provide immediate support to programmes . this is also because MSI's accountability systems require MDT to report all fatalities to the CEO within this timeframe.
if using the electronic form...
if you click the submit button, all of the information you have entered into the form will appear in the 'data' tab of the Excel document
submitting to database
saving a copy
clearing the template
the second page of the electronic form has 3 buttons....
on the 'data' tab you will see all of the information you entered into the form on a single row
top tip! you can go back to the form by clicking back on the 'form tab'
if you scroll over to the right, you will see there are some orange columns which remain blank. this is where middle management at the 'programme-specific' level will be able to confirm the risk grading.
when you're submitting the notification form to the 'programme specific' level, you can copy and paste this row of information into a new document and email it directly to the next level up. they can then quickly enter in whether they confirm the risk rating, and escalate up to the support office if necessary.
it's likely that you will want a copy of the form for your own records! clicking the 'save' button will bring up a box enabling you to save ONLY THE FORM TAB as its own document
you can select a name for the document, as well as where you want to save it.
you will receive notification that the incident has successfully been saved.
now that you have submitted the incident to the database, and saved a copy of it for your records, you're ready to click the 'clear' button.
all of the fields are now blank again. the template is ready for you to enter your next incident
please note that pushing the 'clear' button only deleted information from the 'form' tab. the incident information will continue to appear on the 'data' tab!
next time you enter an incident into the template, and click submit, information will appear here, just below the last incident you entered...
second incident entered into the template appears in the next row, after the daisy smith case
top tip! slowly but surely site managers are able to build their own incident databases. they can use the filters to display incident information by service, client age, etc., to track and monitor trends! For Excel help, please see the list of helpful YouTube tutorials!
by clicking the little arrow here on the 'service' cell, you can select which incidents you would like to see. in this example, i have ticked that i would only like to see incidents related to MSL.
if using a paper version...
in the absence of computer or internet access, incidents may have to be initially reported telephonically, with the paper copy of the incident notification form to reach the next level of staff at a later stage. it will be up to programmes to devise a system for managing this.
it is the responsibility of the site manager to submit incident notification forms
the form should go to middle management -- whomever comes between the point of service delivery and a programme's support office. in some programmes, this may be a regional manager, in others it could be a channel manager.
it will be up to programmes to ensure the identity of these managers is clear to staff.
programme-specific level
confirmation of risk grading
escalation
paper forms
upon receipt of an incident, the risk grading should be immediately reviewed and confirmed.
if you are changing the risk grading, be sure to provide feedback to your team about why you have done so!
remember! an incident's risk rating may change as the incident progresses if the final client impact is not yet known. be sure to update the documentation and keep a record if this happens!
if you confirm an incident's risk grading as 'red' at the time you receive it, it must be escalated immediately.
red incidents
green and amber incidents
how often information (notification forms and investigations) about green and amber incidents must be escalated is at the discretion of country programmes
incident notification forms received on paper should be inputted into the electronic tool at this stage. this will enable you to have your own mini-database of incidents reported by teams in your catchment area
who?
whomever comes between the point of service delivery and the support office in your programme
this will change from context to context
it is up to programmes identify staff operating at this level
support office level
remember, this level should receive the incident in a spreadsheet, with all information about the incident on 1 row.
if you scroll over to the right of the spreadsheet, you will see a set or orange columns which must be completed at the programme specific level.
receiving the incident notification form as a spreadsheet makes it easy to copy and paste the rows of information you receive into a single document, so you have a database of incidents for all the sites reporting to you that looks something like this...
How?
top tip!
the risk rating of the daisy smith incident would not change because the actual or potential impact to the client was already known at the point of service delivery, and graded appropriately by the site manager
top tip!
the risk rating for the daisy smith case would have changed at this point if the site manager had graded the incident incorrectly, for instance as green or amber
would you change the risk rating of the daisy smith case?
The challenge?
how to most efficiently and effectively transmit information about an incident across different levels of staff involved?
in an analysable format?
without requiring different levels of staff to repeatedly input the same information in different documents?
The solution?
an incident database built in Excel
Incident at point of service delivery
Incident at point of service delivery
Incident at point of service delivery
Incident at point of service delivery
Centre manager
Social franchise manager
Incident at point of service delivery
Incident at point of service delivery
Outreach manager
Incident at point of service delivery
Progressive database creation
Incident at point of service delivery
Obstetrics manager
1x excel doc per per point of service delivery
1x excel doc per channel/region/etc.: incidents collated at programme-specific level
1x excel doc per programme: master incident file
The result?
improved learning and trend analysis
levels of staff involved in incident reporting
there are 4 levels of staff involved in incident reporting:

global level
the support office level
the 'programme-specific level' (any middle management that may come between the point of service delivery and the support office)
service delivery level
the excel version of the incident notification form allows information inputted to autopopulate a spreadsheet that looks like this...
each point of service delivery now has their own mini-excel database of clinical incidents
when incidents are escalated, information is copied and pasted into a single document, with additional fields completed at the programme specific level. each middle manager now has their own mini-database of incidents with information submitted from multiple points of service delivery
incidents are copied and pasted once more at the support office level, with additional fields completed against each incident. the designated senior manager now has their own programme-wide incident database with information submitted from a handful of middle-managers at the programme specific level
red incidents submitted to MDT London are also copied and pasted into a single spreadsheet, with additional fields completed against each incident. MSI now has a global database of incidents with a red risk grading.
use excel pivot tables to analyse data and generate reports (more information on how to create a pivot table provided in later sections of this course)
5. red incident investigation
who?
Designated senior manager
escalation of red incidents
ensure timely and appropriate investigation
appoint a lead investigator and ensure that a level 1 investigation is completed
within 30 days MDT must receive the case notes, investigation, and action plan for all incidents with a red risk grading
collation of the master incident file
although red incidents are submitted to the support office immediately, green and amber incidents should also be submitted regularly
dissemination of learning
investigation outcomes should be shared with MAT as well as with teams

trends in incident data should also be shared with MAT and fed back to teams
the incident notification form for cases with a confirmed red risk grading must reach MDT within 24 hours of the incident occurring (mdt@mariestopes.org)
Master incident file
collating the master incident file
copy and paste incidents submitted to you into the master incident file.
analysing the data
dissemination
data analysis should be presented to your MAT, and important lessons shared with your teams
the master incident file is designed to help programmes manage incident data, and ensure that all clinical incident data is contained within a single document
for instance, you will receive this document from each of your reports 1x per month
these rows must be copied and pasted into the master incident file, with additional fields completed against each incident at the support office level
the rows of incident information from each of these documents must be copied and pasted into the master incident file, with additional fields completed against each incident at the support office level
you now have all incident data from your programme in one document!
step 1: go to the insert ribbon at the top of screen, and select pivot table (on the left)... a pop-up box will appear
step 2: with the pop-up box open, select you data with your mouse. click ok
step 1
step 2
top tip! you can use your mouse to highlight your data and the 'table/range' field in the pop-up box will auto-populate. this dotted line shows which data has been selected! if you look at the pop-up box, it will also tell you that you have selected rows 3-24 on the data tab of this document.
once you have clicked 'ok', a new worksheet will open up. on the right hand side, you will see a list of all your column headings.
step 1: drag the 'date' heading into the values box so that it counts how many incidents were entered into your spreadsheet
step 2: drag other fields into the row or column to view the data in different tables
step 2: in this case i have dragged the final risk grading and service into the row box. the table accordingly show you how many red, amber, and green incidents you have, broken down by service.
step 1
each of your column headings will appear here. you can 'grab' them with your mouse and drag them into any of the 4 boxes below
for more help on pivot tables, please see the links provided at the end of this course
global level
who?
MDT, P&L, link Medical Advisors
step 1: receipt of red incidents
step 2: assignment of MDT lead, to whom investigation, action plan, and case notes should be submitted
step 3: review of red incidents
step 4: formal provision of feedback using a standard form
6. resources
the policy
contains more information on key concepts
useful 1 page flow diagrams outlining key processes and reporting requirements
templates and proformas
excel support
watch these short videos on key excel topics (or refer to the links in the back of the policy)

Filtering:



Pivot tables:
your designated senior manager or link medical advisor!
if you continue to have questions, please don't hesitate to reach out to the designated senior incident manager or your programme's link MA
there are a number of tools and resources to look to for more information!
9:40 AM
10:00AM
10:40
10:15AM
8:30AM
7:20AM
MSI team arrives at ministry of health outreach site
'Ms. Smith' called for her procedure.

Daisy Smith enters the procedure room.

outreach team's planned departure time from centre

1. chronology + root cause analysis
root cause analysis
2. the report
purpose
overview
MSI
classifying incidents based on their consequence to the client helps us to identify proportionate responses, to ensure we can focus our attention on the most serious
the risk matrix allows you to identify different consequence scores for incidents...
top tip! if an incident is a near miss, it is the potential rather than actual consequence to the client which is important.
A risk grading determines the proportionate response to an incident. There are 3 levels of investigation that correspond with each possible risk grading.
levels of investigation
safety alerts are a way to communicate action required by programmes or staff in response to clinical or product safety incidents
they can be issued by MSI London or programmes
there are 3 classes of safety alerts
country programme support office
MSI global
client arrived at outreach site requesting an IUD. client received a tubal ligation against her wishes and without her consent.

outreach team actually departs centre and commences the 80km drive to outreach site

commence group counselling. large attendance noted.
Clients brought in for individual counselling and consent
10:35 -- Daisy Smith receives counselling and signs consent form for IUD
10:40 -- Faith Smith receives counselling and signs consent form for a tubal ligation

MSL carried out on Daisy Smith
10:55AM
Daisy Smith asks a community health worker why she has had an operation
11:05
WRONG PROCEDURE, WRONG CLIENT IDENTIFIED!
11:30
was there a delay in departing?
the team didn't have a steriliser and had to source additional equipment
why...
because...
didn't the team have a steriliser?
there are 2 new outreach teams, steriliser cannot cope with new demand. requests for additional equipment haven't been met by the senior management team
why...
because...
didn't the senior management team purchase another steriliser?
cost-saving measures and no clinical quality representation on the senior management team
why...
because...
root cause #1
root cause analysis
didn't the client have a good understanding of the procedure and what to expect after counselling (when the procedure and process should have been explained using pictures and an interpreter if necessary)?
client did not speak english very well and interpreter was not present
why...
because...
wasn't the interpreter present?
no interpreter was booked
why...
because...
wasn't an interpreter booked?
no discussions with mobilisers in advance by the team co-ordinator to identify the need for one
why...
because...
root cause #2
root cause analysis
didn't the provider know she had the wrong client?
the doctor was supposed to verify the clients' full name with the agreed procedure
why...
because...
didn't the doctor verify that she had the right client for the right procedure?
first, she was rushing to try and catch-up to ensure all clients would be served. second, the team in general had become relaxed about this policy/standard process and verifying client identity
why...
because...
root cause #3
beginning...
5 sections
introduction
key concepts
sample incident
response processes
red incident investigation
resources
you can navigate through the presentation sequentially using these arrows on your screen
or you can click directly on any particular section that interests you and start there
navigating the tutorial
you can always get back to the home screen using the house icon
more detail can be found in section 4 of this tutorial
page 1
page 2
in other words...
please allow 1 hour to complete this course!
page 3
root cause 1 and 2 are linked! the provider didn't follow procedure because the team was rushing, which ultimately was because the programme was short equipment/lack of clinical representation on senior management team

Product-Related Incidents
Unexpected events
Contraceptive products - LARC failures
MA drugs - misoprostol, mifepristone (>2/10)
MSI-branded or procured products
Work-in-Progress: RAG Flowchart
Group Activity: Let's Try!
Global Learning
Group Exercise!
MDT Root Cause Classification
Action plan template
Principles of Successful Reporting
Goals of Reporting at MSI
Purposes of Reporting
learn
improve
prevent recurrence
Full transcript