Using High Harm Debriefs to Improve Event Reporting

Minnesota health center develops error response system

By Jay Kumar

After a CMS survey last summer resulted in a finding of Immediate Jeopardy, University of Minnesota Health (M Health) was able to quickly develop and implement a new system to bolster its response to patient harm incidents.

Speaking last month at the Institute for Healthcare Improvement Patient Safety Congress in Houston, representatives from M Health noted that the system had already begun training its staff in error prevention and leadership before the CMS surveyors arrived.

M Health began a partnership in 2017 with Healthcare Performance Institute, a Press Ganey affiliate, to train more than 11,000 staff and providers and 200 leaders, said Michelle Hodge, MA, vice president of operational excellence, quality and patient safety. The academic medical center has approximately 1,500 medical staff, 9,000 employees, and 900 allied health professionals. Starting in January 2019, M Health expanded its partnership with Fairview Health System, creating M Health Fairview, which has 12 hospitals, 56 primary care clinics, and 34,000 employees in the Minneapolis/St. Paul metropolitan area, surrounding areas, and greater Minnesota.

Extensive staff training

The staff training was focused on harm prevention using reliability behaviors and error prevention tools, while the leaders worked on building a culture of safety and supporting and sustaining error prevention work, she added.

The three-hour training emphasized the importance of event reporting and highlighted four reliability behaviors to prevent errors:

  1. Speak up: I will demonstrate an open, respectful and 200% team commitment to safety.
  2. Practice a questioning attitude: I will think it through and ensure my actions are the best for the situation at hand.
  3. Communicate clearly: I am responsible for professional, accurate, clear, and timely verbal, written, and electronic communication.
  4. Check details: I will act with intention and focus on the details to avoid unintended errors.

M Health also implemented the Daily Safety Huddle, also known as tiered management huddles, Hodge said. A frontline staff huddle is held at 8 a.m. every day, followed by a 10 a.m. huddle with the CEO. The huddles are used to communicate any important operational and safety issues, ensure two-way communication between frontline staff and leadership, and troubleshoot issues and ensure resources are available for safe and high-quality care.

The leadership methods course, which ran two to three hours, focused on finding problems and fixing causes, Hodge said.

“From a quality and safety perspective, we were feeling pretty good about our program,” she added.

Quick response to Immediate Jeopardy finding

But then last June, there were concerns about M Health’s use of restraints, Hodge said. After a CMS survey, M Health had to submit a corrective action plan. CMS returned for a weeklong visit and placed the organization on immediate jeopardy status.

“It was a shocking experience,” said Jody Rock, MS, RN, NE-BC, director of perinatal services. “It was disheartening as a leader.”

M Health wasted little time in coming up with a solution.

“We had regulatory pressure to address these issues immediately,” said Christy Swarthout, MBA, M Health’s director of quality and patient safety analytics.

“We created a high harm debrief (HHD) script and checklist and trained a small group of leaders to conduct HHDs,” she said. M Health went live with its HHD the day after the CMS finding and met several times in the following weeks to refine the process.

Swarthout said the HHD is a rapid response to a patient safety issue resulting in harm to the patient. The debriefs are led by a trained operations leader, including the staff and providers involved in the event. The HHD is meant to implement immediate stopgaps or actions to reduce patient harm and the risk of harm to other patients.

The initial rollout of HHDs focused on the inpatient section. In the last quarter of 2018, Swarthout said, it spread to the ambulatory areas, as well as the rest of the system.

The checklist includes questions about whether there were any deviations/variations from generally accepted performance standards, and if so, what stopgaps have been or should be implemented to reduce the chance of harm to other patients. In addition, the checklist asks if any equipment was involved in the event, and if so, that staff identify equipment possibly involved and verify that equipment has been appropriately sequestered.

Swarthout said there were several barriers to implementation:

  • Providing the same level of standards and coverage 24/7
  • Challenges/limitations with auto-notifications in the event reporting system
  • Duplication of efforts with subject matter experts
  • Manual process to audit compliance
  • Retraining as the process was refined

“In the first two weeks, we trained all unit leaders,” said Swarthout. M Health developed processes for normal business hours and “off hours” to ensure it worked around the clock.

Refining the process

It took time to develop an HHD documentation process within the patient safety reporting tool, Swarthout said. The second version of the HHD included a template that staff could fill in with details of each HHD.

M Health created a YouTube video to simulate an HHD in the post-partum unit, with a nurse manager, staff nurses, and a neonatal intensive care unit nurse practitioner, Rock said. The severity of the event will determine how long the debrief will take, but it usually goes quickly, she noted.

“It’s important to debrief quickly after the event happens,” said Rock. “Make sure to mention equipment involved.”

Rock said the benefits of HHDs include:

  • Real-time notification of events occurring in the acute care setting
  • Increased ability to respond timely with staff involved
  • Improved communication and follow-up between departments
  • Increased accountability of leaders
  • Ability to reinforce safety tools
  • Reduces patient harm by implementing stopgaps and long-term process changes

Implementation of HHDs posed several challenges, including:

  • Initial urgency of training
  • Significant volume of leaders and staff to train
  • Multiple notification process changes
  • Sustainment
  • Creation of accountability measures
  • Quality of stopgaps, training of new leaders, transition of leaders

Among the program’s initial successes was with M Health’s Early Recovery After Surgery (ERAS) spine protocol, which has seen more than 600 HHDs completed, Hodge said. The protocol has been refined and now there are no more issues.

Event reporting has increased at M Health, added Hodge. There is approximately 95% compliance with the process. The weekly median event volume reported has increased from 308 to 374.

Next steps for M Health include integration of HHDs into a new event reporting system and systemwide adoption and refinement, Hodge said.


Harm Rating Scale

Any patient safety event submitted as category E or higher by reporter would require a high harm debrief.

A—Capacity to lead to error

B—Error did not reach patient

C—Error reached patient but no harm

D—Monitor/intervene to preclude harm

E—Temp harm/intervention

F—Initial or prolonged hospitalization

G—Permanent harm

H—Intervention to sustain life