outline

KEA Best Practice Rounds Background Patient safety is a huge issue, and one that is overwhelming to address as a “single” solveable problem. One component that is clearly missing from our emergency department is the organized approach to examining adverse events: the (historic) Morbidity and Mortality Rounds. I think we can all agree that we are not interested in the rounds of our distant (surgical) memories. What would be valuable, and indeed likely some of the best learning experiences we can attend, would be the safety and support of examining cases with less-thanideal outcomes using a systems-based approach to identify areas for change and improvement…the KEA “Best Practices Rounds.” While there is parallel work being done at other levels (ie city level, resident level), there is a need and role for doing our own departmental rounds, with our work environment, and our people.

Case Selection Currently, the plan would be for case selection on a volunteer basis. This initiative requires your participation in order to succeed. The criteria for case selection is further detailed in the attachment but in summary, any case that meets the following criteria would be appropriate: -Involves an adverse event or potential for adverse event (ie near miss) -Was (likely) preventable (note that this does not necessarily mean a mistake was made) -Has a lesson to be learned from a cognitive or systemic perspective Ideally, the case presented would be by the staff involved. This is seen as an important part of changing the culture of “shame” of these cases and normalizing these events. However, there may be instances where this is less desirable for the staff involved, and that’s okay. I would be happy to present others’ cases, or another physician could be assigned. This could also occur if our chief or another staff person requests that a case be reviewed.

Time and location Currently we are planning for 3 sessions per year. Although initially the plan was to have these sessions occur within our KEA meetings, I believe evening sessions may be more successful, given the large number of topics currently needing to be covered at our meetings. Evening meetings would allow for a bit of relaxation and socializing as well.

The plan would be to have these sessions occur at a restaurant with a private dining area. Given the potential for funding for these events (see below) it was thought best to occur in this setting rather than the more casual setting at a staff person’s house.

Format -2 cases per session (same staff or, ideally, 2 different staff presenting) -Each case to follow the Ottawa Model (see attached). In brief: -10 minutes to present a case -10 minutes for presenter’s analysis (cognitive and system errors)

-10 minutes for discussion, including bottom lines and actionable items -For the first 3 sessions, I will follow the cases with a short presentation on some of the patient safety themes. After these sessions, it would be up for discussion as to whether we want to have a short content-based presentation or leave it at just the cases.

Who will attend These rounds are for KEA staff physicians only.

What is required of you -Volunteer a case. You can submit cases to me any time and may be asked to present them at a later session, or you can volunteer for a specific session.

-Prepare the case -I am happy to review cases with the volunteer to ensure they are appropriate and to help out with the review (this is not necessary if you prefer not to and are comfortable with the process). There may be some degree of research on your part (ie a brief lit search if relevant) to support recommendations, but the goal is not to have this be a very extensive undertaking.

-Review the relevant parts of the case for presentation -Use the attached format to examine the case for systemic/cognitive errors that may have occurred, and use this as the basis for group discussion.

-Formulate preliminary “bottom lines”- general reminders or learning points raised from the case. These will be disseminated to the larger group (see attachment for examples) -Present your case to the group, either verbally or with accompanying powerpoint (see below for points related to this).

-The moderator (me, for now) will help keep the discussion on time and on track.

End goal -At the end of each case, the goal is to formulate 1-2 “bottom lines” which are brief practice reminders that may be disseminate-able to the group at large and to other groups (ie nursing, RT’s) as appropriate/decided upon by the group.

-This will lead to potential “actionable items” or ways that we can institute change to support the bottom lines.

-My hope would be to create a small committee who can then be responsible for: -Disseminating the bottom lines to the group -Creating a database for the bottom lines for group access -Determining/enforcing courses of action for the actionable items. This may include appealing to AHS on a systemic level, liaising with nursing regarding policies, or helping to organize educational sessions.

Funding/CME opportunities -An application to the Northeast Special Funds is underway, with potential for stipends for the presenters, facilitators/committee, and ideally, for dinner to be covered for the participants (this will most likely be as a stipend format).

-For a variety of reasons, it is deemed less desirable to try to seek accreditation for formal CME credits. You can still claim CME for the time spent on preparation/review of cases and participation in the sessions, however.

Medicolegal Aspects I spoke to CMPA about this (as well as anecdotally to many other physicians across the country who have been doing this for years). In a nutshell, these rounds are not only desirable to have but actually SHOULD be part of our practice. Medicolegally, there is very little possibility of medicolegal consequences for any participant in the group. This cannot be guaranteed, of course, but CMPA has not encountered this as an issue. There are a few caveats that need to be addressed: 1. These rounds are considered an extension of the Quality Improvement committees that exist for the hospital and thus should be afforded the same protections(confidentiality).

As such, discussion that occurs within these meetings should be confidential and protected from medicolegal ramifications.

2. However- IF a medical error is discovered to have occurred that was NOT addressed at the time (ie appropriate patient disclosure and follow up), there is an obligation for the group to report the case (likely to the hospital Quality Improvement committee for analysis/management). This gave me pause at first, but in discussion with CMPA is actually very seldom an issue. Most of the cases brought to these rounds are not disclosing new errors. Missed diagnoses, judgment calls and different practice patterns, unless grossly negligent, are not considered reportable errors in this context. An example of one that WOULD be reportable would be making a major medication error that caused harm to the patient but was never addressed/disclosed as an error (note that an error like this that was properly disclosed/addressed/discussed with CMPA is perfectly fine for presentation as it has already been addressed). Thus, this is pretty much a non-issue, just a reminder that we can’t be “complicit� in covering up relevant errors any more that we could be on a clinical shift.

3. It is advised that NO patient identifiers be included. It is recognized that within the private group this is often impossible on a practical level (ie people may still know the case or patient being discussed) but that every effort be made to minimize this otherwise.

4. It is advised that no notes be taken during the presentations, except with regards to the bottom lines, as these are general enough for dissemination.

5. It is advised that if powerpoint presentations are used, even without identifiers, that these be deleted after the session, and not disseminated outside the session (ie should not be emailed out to the group at large).

6. Discussion which occurs in the room needs to remain within the group attending.

Future ideas -I would like to explore the possibility of developing a small Best Practice Rounds committee, as indicated above, to act upon the intentions we have of changing practice where identified as appropriate. This is extremely important to this process, because while there is certainly benefit

in holding these rounds alone, it is also important to take measures to change poor practice and correct systemic issues that put us and our patients at risk. Please let me know if you are interested!

-There are many other forms that this could take in the future. The UAH has begun similar rounds and may be interested in doing a joint rounds session at some point. In addition, there are parallel processes in the works at the zone level for City Wide rounds. Currently, I am also running internal rounds of this nature with the residents.

-At the group’s discretion, there is potential to open these rounds to residents or allied health.

At this time, we have chosen to begin with a closed group.

-We can also choose to do cases during one of the sessions which analyze a case with either a good or bad outcome that was exceptionally well run- this is suggested in the “What Works� section of the Ottawa attachment. Doing some of this review as well is great for morale and probably just as important to analyze why something went well, when it did.