Digital Incident Management

Incident reporting and follow-up is an onerous process to health care teams. CASA has recently established a five-year plan with a goal of doubling the number of patients served. To support the increase in number of patients and staff at CASA, they must ensure that incident reporting and tracking is simple and streamlined for the staff, patients and families of CASA.

CASA is seeking a solution to support electronic/mobile entry of incidents, improve reporting inefficiencies by decreasing the time and effort required to complete incident/event forms, and improve the process for incident management, follow-up and reporting.

Objectives:

1. Remove barriers to incident and patient safety event reporting.
2. Improve the quality and consistency of incident/event data.
3. Improve the implementation of corrective actions to improve patient and staff safety across the organization.

Essential (mandatory) outcomes

Requirements:

• Advanced logic capability
  • Several different forms/questions depending on previous answers
  • Custom questions and answers
• Use electronically guided documentation to:
  • Determine the root cause of the incident
    Perform post-event analysis and related data
  • Generate an action plan
  • Track action plan completion and cue accountable individuals
  • Perform follow-up for individuals who submitted or were named in the form
• Include built-in analytics to track trends and improve incident and patient safety event management, as well as integrated dashboards to view data in real time
• Variety of reporting methods such as platform entry, phone, text
• Enable CASA staff, patients and their families’ ability to report incidents
• Ability to group/link reports about the same incident
•  Levels of access/control
  • Administrators – all access
  • Manager/directors – their own teams/departments, high level dashboard
  • Staff – all other CASA staff can see their own report and follow up
  • Public/patient reporting – no log in, direct link to be shared
• Ability to export patient and/or staff data for further analysis or to send to the patient’s health care team, WCB, etc.
• Ensure alignment with relevant privacy legislation such as HIA, FOIP and PIPPA:
  • Patient data must be stored in Canada
  • All physical and electronic safeguards
  • Encrypted data (256 encryption), end to end
  •  No paper
  • Control access
  • Anonymized data when conducting audits

Potential outcomes:

• Increase reporting rates
• Reduce the time in between reporting, follow-up and post-event analysis
• Increase the number of corrective actions taken
• Garner staff acceptance

The maximum duration for a project resulting from this challenge is: 9 months.

CASA Child, Adolescent and Family Mental Health (CASA) is at an exciting turning point in providing mental health service for children and families with mental illness. They have recently established a five-year plan with an ambitious goal of doubling the number of patients they serve from 4,000 to 8,000.

Currently, CASA’s reporting system is divided into a patient safety event and an occupational (staff) incident reporting stream. Patient safety events have a higher reporting rate than staff incidents, although information flow, event analysis and follow-up on action plans completion is inconsistent. Information is not centrally stored in a way or location that allows for sharing and learning from events to prevent future events. Also, the current a lack of data collation and action plan tracking in higher-risk settings is resulting in multiple incidents of the same nature.

CASA has two pdf/paper forms that include several categories that represent different potential incidents and involvement from patients, staff and witnesses. Upon completion of the forms, staff must manually email them to a direct supervisor and/or health and safety representative(s). Separate forms that are multiple pages long can discourage staff from reporting multiple incidents/events.

Workers’ Compensation Board (WCB) cases are reported within the appropriate timeframe, but near misses and minor incidents resulting in first aid but no time loss are not being reported consistently. Injuries resulting from patient safety events are also underreported due to the length of reporting forms and time required to complete them. Additionally, due to lack of centralized incident reporting, historical data is limited and follow-up was done through email and not documented in a manner that allows for easy retrieval or consistency.

To support the increase in number of patients and staff at CASA, it is important that incident reporting and tracking is simple and streamlined across the organization. Pivotal to achieving this goal is the implementation of a digital incident management system that decreases the time and effort required to report incidents/events and addresses the inefficiencies in follow-up and reporting.

Part of CASA’s safety framework is to increase staff’s willingness to report incidents/events and increase the number of corrective actions taken to improve patient and staff safety. The first step to achieving this is to improve the reporting process by making it easier and stress-free for staff to report incidents/events. Second, by improving the accuracy and quality of their data, CASA can better investigate and address root causes to prevent future incidents and patient safety events.