Occurrence Reporting: Building a Robust Problem Identification and Resolution Process, Second Edition

Kenneth R. Rohde

You already captured the data. Now, use it to make real improvements in your patient care.

With the increased emphasis from CMS and The Joint Commission on reducing adverse events, it’s more important than ever to have an effective occurrence reporting process.

This updated resource by performance improvement expert Kenneth R. Rohde provides practical techniques to help you better analyze your occurrence reporting process, use your data to gain superior insight into why errors occur at your organization, and make improvements that decrease adverse events and enhance patient care.

Useful tools like self-assessment questions to evaluate reporting, a screening workflow, and a checklist for good corrective actions are included to help quality and risk professionals understand the big picture of occurrence reporting and how to ensure it is implemented effectively.

This book will help hospital quality professionals:

• Refine and improve their existing occurrence reporting system using a proven six-step approach
• Arm themselves with the right data to become an effective change agent in their organization
• Develop an occurrence reporting process that decreases adverse events and enhances patient care
• Improve their report screening process
• Easily identify trends through detailed, efficient analysis methods
• Organize and prioritize their reports through effective coding
• Implement successful corrective actions through ongoing tracking and evaluation

This freshly updated edition:

• Goes beyond simply reporting issues to help professionals establish an integrated program for identifying and resolving problems within the organization
• Includes all-new chapters on how Patient Safety Organizations (PSO) impact the occurrence reporting process
• Reviews how to get the most value from the Common Formats even if you don’t participate in a PSO

About the Author:

Kenneth R. Rohde is president of KR Rohde LLC, a consulting company specializing in helping organizations deal with their problems. He brings more than 35 years of experience in quality management to his work with hospitals, medical centers, power plants, and high-risk manufacturing facilities across the country. Rohde's roles in performance improvement and project management make him uniquely qualified to assist medical staffs and hospital leaders in developing solutions to their toughest challenges. He is the author of the HCPro books Beyond Root Cause Analysis: Building an Effective Program, Effective Process Management: Improving Your Healthcare Delivery, Failure Modes and Effects Analysis, and Making Your Data Work.

Published: 12/18/2017

Page Count: 278
Dimensions: 8.5 X 11
ISBN: 978-1-68308-687-1

Table of Contents

Chapter 1: Rethinking the Occurrence Reporting Process
Where Does Healthcare Go Wrong?
Healthcare Is Not the Only Industry That Does Problem Resolution and Identification (PIR)
Recommendations for an Ideal Process

Chapter 2: The PIR Process
Introducing the PIR Process
Six Steps in the PIR Process

Chapter 3: Reporting
Importance of Managing Reporting
Volume and Severity Must Dance Together
Reporting Thresholds
Tips for Normalization
Internal vs. External Identification of Issues
Two Simple Goals for Reporting Volume
Tips for Improving Your Reporting

Chapter 4: Screening
Screening Is Really Just Prioritization
Establishing Screening Criteria
Reporting Severity
Screening Quality Control
Tips for Improving Your Screening

Chapter 5: Analysis
A Graded Approach to Problem Analysis
Individual Analysis for High-Impact Problems and Moderate-Impact Problems
Aggregated Analysis for Watch/Trend Problems
Aggregated Analysis of Causes: The Big Payoff
Five Simple Data Questions
Trending and Aggregation Methods
A Typical Analysis Session
What Do Your Department Managers Really Want to Know?

Chapter 6: Coding
The Vital Process of Coding
Code Based on Data Utilization
A Practical Coding Structure
Coding the Event vs. Coding the Causes
Initial Event Codes
Code Cleanup Troubleshooting
Tips to Improve Coding

Chapter 7: Causing Change: Implementing Corrective Actions
Designing the Right Change
Getting Stuff Done
Dealing With External Commitments
Tips to Improve Implementation

Chapter 8: Tracking and Evaluation
Tracking Actions
Evaluation of Actions
Evaluating the Effectiveness of the PIR Process

Chapter 9: Occurrence Reporting and Big Data
Why Should I Care? We Don’t Use a PSO
Focused, Local Data for Management vs. Big Data for Research
The Formation of the PSO Process
The Players in the PSO Approach
Office for Civil Rights
The PSO Process—Getting Event Data in the PSO
Trading Data for Protection
Challenges to the Protections
Common Sense Approach to Using the PSO
PSO References

Chapter 10: Common Formats
The Common Format Approach
Common Formats for Hospitals
Common Formats for Nursing Homes
Common Formats for Community Pharmacy
Summary of the Common Formats
Data Elements and Categories
Version 2.0 Common Formats Data Elements—Hospital Incidents
Pharmacy Common Data Elements
Common Formats for Surveillance—Event-Specific Modules

Chapter 11: Taking Your PIR Process to the Next Level
Looking Toward the Future