Event Reporting Event Analysis QI Project PSQI National Resources

Program leaders are encouraged to use institutional and national tools, as well as the implementation ideas collated by the leadership of the University of Arizona College of Medicine – Phoenix GME programs and listed on these resource pages to support their improvement efforts.

PSQI 1: Event Reporting

Level 1 Level 2 Level 3 Level 4 Level 5
Education provided to residents/fellows and faculty on an annual basis regarding how to report an event and what happens after reporting. When asked, residents/fellows know how to report a patient safety event. Residents/fellows apply the knowledge of how to report an event in the system by reporting at least one event per year. Program has evidence that the residents/fellows can show how to report events and discuss the importance of such. The Program has evidence of patient level outcomes as a result of the regular integration of this in the work of the residents/fellows.
💡Idea 1: Teach how to report events to residents and faculty
Tools: Implementation:
  • Review how to report an event at the start of every patient safety conference
💡Idea 2: Set a standard for event reporting by trainees and faculty
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
💡Idea 3: Disseminate lessons learned and outcomes from event reporting
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
Literature search 

PSQI 2: Event Analysis

Level 1 Level 2 Level 3 Level 4 Level 5
Education provided to residents/fellows and faculty on how to analyze a patient safety event. When asked, residents/fellows know how to analyze a patient safety event. Residents/fellows apply the knowledge of how to analyze an event in the system by participating in a simulated or real event analysis. Program measures how many residents participate in the analysis of a patient safety event and uses the data to improve. The Program has evidence of patient level outcomes as a result of the program/resident engagement in patient safety event analysis.
💡Idea 1: The program didactics/conferences includes some analysis of events 
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
💡Idea 2: Every trainee has documented participation in an event analysis 
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
💡Idea 3: Regularly create reports on the Trainee participation in Event Analysis and use it to improve 
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
Literature search 

PSQI 3: QI Project

Level 1 Level 2 Level 3 Level 4 Level 5
Education provided to residents/fellows and faculty on quality improvement principles. When asked, residents/fellows indicate that they have opportunities to be or are involved in a quality improvement project. Residents/fellows apply the knowledge of quality improvement in a project that aims at improving patient outcomes and serves as a lead in the work. Program measures how many residents participate in QI projects and uses the data to improve. The Program has evidence of patient level outcomes as a result of the program/resident engagement in QI activities.
💡Idea 1: The program didactics/conferences includes some didactics related to QI principles
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.
💡Idea 2: Residents/Fellow participate in a QI project during their training
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.
💡Idea 3: Annual review of participation in QI projects by the PEC
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?
💡Idea 4: Residents/fellows share the outcomes of their engagement in QI activities 
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.
Literature search 

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)

Choosing Wisely
IHI open school
Team Steps