Event Reporting Event Analysis QI Project PSQI National Resources
PSQI 1: Event Reporting
Teach how to report events to residents and faculty (level 2)
Tools:
Implementation:
- Review how to report an event at the start of every patient safety conference
|
Set a standard for event reporting by trainees and faculty (level 3,4)
Tools:
- Regularly review the list of events reported by your trainees (this can be obtained by contacting Claire Poehler RN Safety lead)
- Event report log like a procedure in New Innovations (coming soon)
Implementation:
- Create an expectation for event reporting and add it to your program manual
- Deliberately consider who should report key system issues that are discussed at program M&M or patient safety conferences
- Include a review of program event reporting in the CCC
- Add this as a checklist on the semi-annual review
- Add a question on the end of rotation evaluation regarding if the trainee participated in entering in an event report based on something during the time on the rotation
|
Disseminate lessons learned and outcomes from event reporting (Level 5)
Tools:
Implementation:
- Disseminate or discuss the quarterly Patient safety tips at the program's patient safety/M&M conference
- Share a summary/update of what has happened related to past event analysis at the start of each M&M
|
PSQI 2: Event Analysis
The program didactics/conferences includes some analysis of events (level 2)
Tools:
Implementation:
- Invite GME PSQI leaders or Play the “When Errors Happen” conference once per year and facilitate a discussion with your program’s PSQI leaders
- Use event analysis with residents/fellows when addressing a program issue through application of tools like a fishbone diagram
|
Every trainee has documented participation in an event analysis (level 3)
Tools:
Implementation:
- Have a resident/fellow participate in a hospital level event analysis. The chair of the GME PSQI subcommittee sends alerts when they are happening with information about the date and time.
- Create a self-reflection assessment form for participation in event analysis as part of New Innovations- Trainees complete it like a procedure log and it is part of a check list.
- Have a program standard that all trainees present an event analysis as part of an internal conference or through participation with the PSQI subcommittee. Completion of this standard is tracked and known to all
|
Regularly create reports on the Trainee participation in Event Analysis and use it to improve (Level 4)
Implementation:
- Record attendance at program conferences where residents participate in event analysis. Add that as a checklist for their semi-annual review to make it clear that they have participated
- PEC and CCC have safety event reporting and analysis on their checklist to review data
- Program has a record of trainee participation in program level conferences for event analysis
|
PSQI 3: QI Project
The program didactics/conferences includes some didactics related to QI principles (level 1)
Tools:
Implementation:
- Adjust your program’s didactics to attend the multi-specialty patient safety conferences
- Ensure that you have at least one program representative on the GME PSQI subcommittee
- Require completion of some of the modules in the tools above as part of a research/QI curriculum.
|
Residents/Fellow participate in a QI project during their training (level 3)
Tools:
Implementation:
- Have a Program PSQI faculty lead to support project mentoring
- Add a requirement that residents/fellows complete a QI project during their training
- Create a NI self-assessment form where trainees enter their project, outcomes and reflections. Make completion required at a time no later than 6 months of graduation.
|
Annual review of participation in QI projects by the PEC (level 4)
Implementation:
Add to the PEC agenda- How many of our residents/fellows participated in QI? Are their projects appropriately aligned, supported and sustained? How could the program improve the results?
|
Residents/fellows share the outcomes of their engagement in QI activities (level 5)
Tools:
Implementation:
- Add AED/HVI key dates to the program calendar
- As a program, disseminate information about AED/HVI and encourage presentation.
- Ensure that program leaders attend AED/HVI to support trainees and create additional ideas for the next year.
|
Do you have a tool to share or need more help? Contact Brian.MacArthur@bannerhealth.com or LeighAnne.Goodman@bannerhealth.com
PSQI National Resources (update quarterly)