Patient Safety Learning System (PSLS)

In earlier chapters, the Adverse Event Management System (AEMS) was introduced. As de- scribed in Section 3.1, this system implemented a prospective adverse event surveillance method. AEMS was used by OHRI to collect data regarding AEs. Pilot projects took place across several services of TOH such as: Obstetrics, Internal Medicine, Emergency, Cardiac Surgery, Orthope- dics, ICU, and Neurosurgery. Although this application served its purpose as a pilot tool, it was not generic and scalable enough to be used in all departments and services of the hospital. More- over, the fact that data could only be gathered using prospective surveillance also diminished the system’s value as an official, institution-wide tool. For example, Accreditation Canada (formerly known as the Canadian Council on Health Services) imposes requirements regarding the imple- mentation of a self-reporting system for accreditation purposes [TOH, 2010]. The self-reporting and the general reporting of incidents (including adverse events), by hospital personnel and even by patients and visitors, is complementary to prospective surveillance, and hospitals in Ontario are legally required to support such systems.

In order to comply with Accreditation Canada regulations, TOH had an existing institu- tion-wide implementation of a self-reporting system. However, the hospital realized this was a rudimentary, paper-based approach that promoted apathy as well as finger-pointing among hos-

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pital personnel, who were conscious of receiving the blame for the AEs that occurred. This sys- tem was also inadequate, as self-reporting mechanisms do not detect 90% of events classified as AEs [Gurwitz et al., 2000]. In addition, since this system was paper-based, it was very difficult to get meaningful reports with measures demonstrating how the hospital was performing.

TOH also needed to gather information regarding incidents in general. As described in Section 1.1, incidents are a far more generic type of event than AEs. Fires, complaints, security issues, law suits, thefts, etc. are all considered incidents. They might cause or have the potential to cause damage to patients, staff, visitors, equipment, or any property for which the institution is responsible, hence increasing the level of risk to the hospital.

In order to monitor this risk, TOH needed to collect and report data not only on events that directly or potentially cause harm to patients but also on incidents. Indeed, some of the TOH departments had already developed and adopted such systems. This was the case for Radiation Oncology with their “Incident Learning System” (ILS), Obstetrics and Gynaecology with the “Quality Indicator Notification” (QIN), and Surgery with the “National Surgical Quality Im- provement Program” (NSQIP).

The approaches used in different units varied greatly in terms of methodology, reporting- techniques, and objectives. There was no electronic system capable of monitoring AEs and inci- dents in the institution as a whole. To solve this difficulty, TOH considered the pros and cons of various solutions. They questioned whether a strict and standardized institution-wide tool made more sense, or whether each department needed to have a system tailored to their individual needs. It was determined by TOH executives that a combination of both was best suited for their organization.

5.1.2 New Datix-Based Patient Safety Learning System

The Ottawa Hospital selected the Datix system [Datix, 2010] to provide a solution to the incident reporting problem. Datix, having successfully implemented this type of system in hospitals in British Colombia, Alberta, UK, and elsewhere in the world, is a reputable company that offered an application that could be tailored to the needs of TOH, especially in terms of prospective sur- veillance.

The system provided by Datix is composed of several modules that can handle the man- agement of AEs and incidents. This compound solution was already named “Patient Safety

Learning System” (PSLS) in both British Columbia and Alberta. It was believed that this name was generic enough to avoid confusion between the terms AE and incidents while re-enforcing the goals of the initiative: to provide safety and to learn from errors.

PSLS is a web-based application that combines several methods for discovering and re- porting on AEs and incidents. It not only provides the voluntary (or self-) reporting method re- quested by Accreditation Canada, and the prospective surveillance method tested by OHRI, but also a more innovative and automatic technique based on electronic triggers. Such triggers repre- sent a promising tool to report on inconsistencies within the data collected, without the help of human involvement.

PSLS is a system that can be tailored to the needs of the stakeholders. It offers many op- tions and variables that can be adapted to the specific criteria sought by particular departments within a larger institution. This flexibility was precisely what TOH wanted to reconcile the dif- ferences between departments with the need for a common interface used by all.

In terms of risk management, PSLS offers reporting capabilities on AEs and incidents to allow the institution to not only understand the risk of the individual departments but also to as- sess potential future risks to the institution and its assets. Further, PSLS also provides users with a plethora of potential reports based on criteria selected by the user. The Datix website explains the benefits of “trend analysis” and customized “detailed reports on each incident for staff on wards, statistical breakdowns for the risk management committee, or graphical analyses of trends for the Board” [Datix, 2010].

For all of the benefits that PSLS brings to TOH, there are also drawbacks for which HC- GQM can offer solutions. Besides the many built-in reports that PSLS provides, this application presents users with a wide range of capabilities to build their own reports. This facilitates the customization of the tool to the users’ exact needs, but this also begs for questions such as: “What precisely should we report on?”, “How is this report going to help me improve my work?”, “I ended up with 3 reports, which kind of tell me the same thing... How I can combine them?”, etc. Such questions tend to overwhelm users and bring confusion.

Another issue is related to patient privacy and confidentiality. Under the Quality of Care Information Protection Act (QCIPA), disclosing the ratings of individual cases is prohibited [Government of Ontario, 2004]. It is however acceptable to disclose reports with aggregate data. PSLS is set up in such a way that allows for a “drill down” mechanism that exposes information

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relating directly to individual cases, patient by patient. As per QCIPA regulations, this is not al- lowed.

By following HC-GQM, it is possible to address the issues mentioned above. The meth- odology users develop goals that will guide them in generating appropriate metrics and meaning- ful reports, with a proper level of aggregation.