We #lovehate it, don’t we?
It can be refreshing, energizing, and full of promise. It can also be stressful, challenging, and uncertain. And no one knows this better than the many dedicated staff who have been involved with implementing Clinical & Systems Transformation (CST).
It’s right there, in the name.
So, where does patient safety fit in to all this?
Right at the forefront, as it turns out. And BCPSLS is committed to helping make sure it stays there as organizations transition to CST.
Patient Safety First
For those of you who haven’t heard, CST is a pretty big deal.
And that’s putting it mildly.
The project spans across three health organizations in BC—Vancouver Coastal Health (VCH), Provincial Health Services Authority (PHSA), and Providence Health Care (PHC)—and includes a new electronic health record, standardized clinical practices and workflows, computerized provider order entry, and closed loop medication management.
Given the scope, it’s no surprise that one of CST’s primary drivers is Patient Safety First: Reduce errors and adverse events.
Specific interventions aimed at reducing incidents include barcode scanning of medications, timely access to information and clinical decision support, and order sets that allow providers and clinicians to provide standardized, evidence-based care.
After several years of planning, designing, and testing, the first CST Go Live took place at Lions Gate Hospital and Squamish General Hospital one year ago on April 28, 2018, followed by Whistler Health Care Centre and Pemberton Health Centre in the fall.
R.W. Large Memorial Hospital in Bella Bella, Bella Coola General Hospital, Sechelt Hospital, and Powell River General Hospital activated CST’s medical imaging functionality in October and November 2018.
During transition, issues related to system functioning and access were telephoned into a central command centre and addressed by the implementation team. If a reported problem concerned patient safety, the team made it a priority to flag and triage it separately. And staff were encouraged to continue using PSLS, as usual, to report all concerns about patient safety, whether they might involve CST or not.
“At Go Live, extra staff were brought in to review PSLS reports and ensure follow-up,” says Cindy Sellers, Clinical Informatics Specialist, Coastal. “And while staff were using the PSLS system, we would also hear through the grapevine about issues and reach out to ensure those were submitted in PSLS as well.”
To prepare for the transition to Cerner, BCPSLS Central Office launched streamlined report forms to make reporting quicker and easier. A new specialized form was also developed for the VCH clinical informatics team to record and follow up on incidents.
Standardized reports were developed for CST leaders to help them track and trend safety incidents. The data was also included as an important component on their project dashboards.
A new notification process was set up, as well. Whenever the computer system was identified as a possible factor in an incident reported in PSLS, automatic notifications were emailed to staff who could immediately review the incident and begin investigating.
“We still get notified every single time there is a computer-related issue,” adds Cindy. “And to be extra thorough, our team monitored all PSLS reports submitted during Go Live to ensure that no CST-related incidents fell through the cracks, even if the computer system wasn’t indicated as a factor.”
Illuminating and eliminating gaps
Despite rigorous validation and testing, some issues don’t surface until Go Live.
“The biggest aha! was understanding that when we digitalize practices and workflows, any pre-existing gaps in either of these areas become illuminated,” says Barbara Cross, Professional Practice Director for Vancouver Acute, VCH. “Every inconsistency or workaround will be realized exponentially.”
One of these issues was duplicate orders.
Prior to CST, when plans for a patient were ordered, the care team could carefully sort through the paper orders and discard or ignore any duplicates before carrying out the plans.
In the new electronic system, all orders are digitized and front-facing to the end-user. If duplicate orders aren’t managed appropriately, this could present a risk to patients, as a duplicate order could result in a patient receiving an additional dose of medication or a repeated procedure.
Because this issue was identified and reported in PSLS during Go Live, the informatics team was able to investigate and determine that there was an education gap.
Care teams needed to know that the ability to view all orders actually helps mitigate safety issues. The electronic system stamps all orders with the date and time, so appropriate order management principles can be followed.
“Education was the number one issue,” observes Barb. “Most often, problems were related to changes in workflows rather than malfunctioning of the computer system.”
Another improvement facilitated by PSLS was a reminder for care teams to remove medication patches.
Previously, care providers could write the correct removal time in a patient’s medication administration record (MAR). For example, if a patient was given a nitroglycerin patch at 0800 (8 a.m.) the care provider could note in the MAR that the patch needed to be removed at 2000 (8 p.m.).
In the new electronic system, however, there is no paper MAR, so staff needed a different way to flag the removal.
The issue was quickly reported in PSLS and a team of nurses, pharmacists, and clinical informaticians set to work to address the problem. They now have successfully designed an electronic reminder in CST and have incorporated it into the build.
With each Go Live, issues are identified and addressed so each subsequent site implementing CST will benefit from the improvements.
Tips and takeaways
As passionate advocates for both CST and patient safety, Cindy and Barb are both excellent resources for lessons learned about the implementation process.
Cindy believes that it’s important for people to trust in the system and its ability to facilitate change.
“Even though it’s important to differentiate between problems due to CST and problems due to workflow,” says Cindy, “it’s better to capture too much than not enough in terms of reporting issues in PSLS.”
She also recommends that people identify themselves when submitting reports in PSLS.
“When reports are anonymous, we can’t let the reporter know about the changes that were made as a result of their report,” adds Cindy. “We appreciate each PSLS report and try to answer every single one.”
Going forward, Barb recommends onboarding clinical informatics specialists before Go Live and making education a top priority.
“The volume of PSLS issues is substantive in the immediate activation period, so resources need to be available and ready,” notes Barb. “With each Go Live, issues are resolved and education strategies can be improved upon. Practice and workflow changes need to be addressed before functionality of the system can be taught.”
The beat goes on
Providence Health Care (PHC) is next up with acute services at St. Paul’s Hospital, Mount St. Joseph Hospital, and Holy Family Hospital rehabilitation scheduled to go live with CST in fall 2019.
Over the next several years, the rest of the project will be implemented in phases. Following PHC, the next acute sites will be Vancouver General Hospital, UBC Hospital, and Richmond General Hospital.
And keep reporting! BCPSLS will continue its mission to foster patient safety culture as CST transforms the way healthcare is delivered within VCH, PHSA, and PHC.