Previously Published in PHC News | Jul 31, 2019
In 2016 PHC learned of an opportunity to work in a collaborative with the Mayo Clinic on a multidisciplinary, multi-specialty mortality review process. At its core, this work is about using a standardized method for case review to “diagnose” process and system failures (versus provider failures) occurring during episodes of patient care.
“Dr. Jeanne Huddleston, a hospitalist at Mayo with an internal medicine background, had been charged with Morbidity and Mortality (M&M) reviews but her experience with them was that one person would look at a case and decide whether you did/didn’t do a good job, and if it was decided that you didn’t, you’d get a letter saying, “try to do better next time” and everyone moved on,” explains Camille Ciarniello, corporate director, Quality, Patient Safety, Risk Management, Patient Relations & Infection Prevention and Control, when asked about Providence’s reason for undertaking the Mayo Clinic’s Safety Learning System/Mortality Reviews methodology.
“She thought there needed to be a better way – you still need to look at individual practice but so many things that cause care to not go well are system issues, like an inability to access the right resources. Failures in optimal health care delivery can happen to any health care provider on any day. Many occur because of a constellation of seemingly unrelated factors,” says Camille. “Dr. Huddleston started to create a new process for these review types, using human factors and reliability science.”
The outcome of Dr. Huddleston’s work was the Safety Learning System Collaborative, which invites participating organizations like Providence to utilize their unique case review methodology to integrate organization learning, quality improvement and research. This system aims to identify the process of care and system failures that get in the way of providers doing their best job every day.
“It’s essentially a standardized process for system and process reviews – so, not meant to replace M&M reviews but layer on top of them. A key difference is the lack of silos and more of a focus on connections. We look at how teams work together, how units and departments work together,” says Camille. “Another key difference is understanding that wherever you are in the organization, you see a case through that perspective. So a nurse reviewing a case will see things very differently from how a physician reviews a case. One isn’t right or wrong, but in the past we just haven’t honoured those perspectives.” Dr. Nardia Strydom, Department Head, Family & Community Medicine and one of the physician co-chairs of the PHC collaborative, also points out that different specialities also have different perspectives. This process brings forward these different voices too.
What the Safety Learning System Collaborative looks like at Providence
In early 2018, Providence committed to participating in this ever-growing collaborative of hospitals and organizations that are implementing this methodology.
“We don’t pick the cases; we picked a starting date and we’re doing 100 consecutive deaths so no sampling methodology – that’s why it’s a clean, no-bias, sample,” says Camille. “Rather than looking into why they died and the evidence of errors, we’re looking to see if we could have done better. The lens we put on it is, if this was someone we loved, could we have stood idly by and watched or would we feel compelled to intervene?”
A dedicated team of approximately 30 physician and nurse reviewers, joined by social work, ethics and a patient partner, have completed reviews of 128 cases and come to consensus on a total of 299 Opportunities for Improvement (OFIs) over the course of 15 monthly meetings, dubbed “Chart Club”.
“What’s really interesting, again comparing to M&M reviews, is if you had a 100-year old patient who came in and had a ruptured aneurysm but we decided to take them to the OR and they died in the OR, we wouldn’t do a review of that case. They’d look at it and go, we tried but they were 100 and they had a life-ending condition so not surprising they died. But because we’re not looking at why they died — we’re looking at their care — we still review their case.”
Every case is reviewed by a doctor and a nurse, who do their reviews independent of one another. Each reviewer has a standardized methodology and a list of uniform opportunities for improvement (OFIs) that they categorize their findings into. Because reviewers are encouraged to not spend more than an hour on each review, Dr. Huddleston gives direction on where and where not to look in a patient’s chart. The goal is to maximize the benefit of the review time and to not get mired down in certain parts of the record that have not proven to elicit good information.
“Some of the things we look at are, did they die in pain? How long did it take us to control their pain before they died? Did they have delirium, was there mental distress, was there good communication?” says Camille. “Essentially, the types of things that we normally wouldn’t be discussing because we were never looking for that before.”
Reviewers add their identified OFIs into the database that’s provided as part of this collaborative, and then every month at “Chart Club” the reviewers get together to talk about the cases that have been reviewed in the last month. The reviews are all anonymous; there are no patient or provider identifiers, and the group sits together to discuss each of the OFIs that have been identified.
“At the end of each case’s discussion, there needs to be 100% consensus in the room that the recommended OFI(s) is something that we agree could have done better. If there is a lot of tension or consternation around one, the response is to step away and move on,” explains Camille. “The logic being that if it’s truly an opportunity for improvement for your organization, a better case will come along that will be more persuasive for people.”
This work has been happening for more than a year now and enough information from these reviews has been amassed to create a compelling argument for change. More information on the ways that this work will help to influence culture and practice will be outlined in future PHC News stories – stay tuned!
Why this type of review, now?
“When I saw Jeanne’s presentation, it resonated for me because it felt like a place where I was lacking in terms of what I brought to the organization; I feel like I haven’t really done a good job of learning in this area. I found interested partners in Astrid Levelt [director, Medical Affairs], Dr. Martin Trotter, [department head, Pathology and Laboratory Medicine], Dean Chittok [then-Senior Medical Director, SPH and VCH] and Dr. Nardia Strydom who, from the beginning, were intrigued,” explains Camille. “So I think that the concept personally resonated with a lot of people, and I also think that we’re at a point of evolution with patient safety – we’re coming to a place of seeing this as the right way to learn, versus through a more punitive, individual focus.”
Additionally, the level of engagement and the quality and depth of discussions at the monthly Chart Clubs is something that Camille says she has never before seen.
“For those of us who are involved in it, I think it’s going to have a permanent impact on the way we approach our work even for those of us not in a clinical role,” says Camille. “For the nurse reviewers as well; that they feel like they’re being heard and that they have an equal voice that’s respected. That’s a significant win that this has brought about.”
Information from these reviews has been amassed to create a compelling argument for change. More information on the ways that this work will help to influence culture and practice will be outlined in future PHC News stories – stay tuned!
In the meantime, if you’re interested in hearing more about the Safety Learning System Collaborative or participating in the collaborative as a reviewer, please contact:
Dr. Nardia Strydom
PHC Communications & Public Affairs, Providence Health Care