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Hospital Harm Improvement Resource

The Hospital Harm Improvement Resource links measurement and improvement by providing evidence-informed practices that will support patient safety improvement efforts. 

Topics
  • Patient safety
  • Hospital harm
Audience

  • Policy advisor or analyst

  • Quality or safety improvement lead

  • Point of care provider

Hospital Harm Improvement Resource

Patients expect hospital care to be safe and for most people it is. However, a small proportion of patients experience some type of unintended harm as a result of the care they receive.

The Canadian Institute for Health Information (CIHI) and Healthcare Excellence Canada (HEC) have collaborated on a body of work to address gaps in measuring harm and to support patient safety improvement efforts in Canadian hospitals.

The Hospital Harm Improvement Resource (improvement resource) was developed by HEC to complement the Hospital Harm measure developed by CIHI. It links measurement and improvement by providing evidence-informed practices that will support patient safety improvement efforts.

The purpose of measuring quality and safety is to improve patient care and optimize patient outcomes. The Hospital Harm measure should be used in conjunction with other sources of information about patient safety, including patient safety reporting and learning systems, chart reviews or audits, Accreditation Canada survey results, patient concerns and clinical quality improvement process measures. Together, this information can inform and optimize improvement initiatives.

The improvement resource is a compilation of guidance linked to each of the clinical groups within the Hospital Harm measure to help drive changes that will make care safer. Through research and consultation with clinicians, experts, and leaders in quality improvement (QI) and patient safety, the improvement resource is intended to make information on improving patient safety easily available, so teams spend less time researching and more time optimizing patient care.

Using the improvement resource

The layout of the improvement resource reflects the framework of the Hospital Harm measure (Figure 1) shown on page three and focuses on actions that can be taken to decrease the likelihood of harm. The measure includes four major categories of harm; within each category is a series of individual clinical groups, or types of harm, each of which connects to evidence-informed practices for improvement.

For each clinical group, the improvement resource provides the following:

  • an overview of the clinical group and goal for improvement

  • implications for patients experiencing the type of harm and their importance to patients and family

  • guidance for clinical and system reviews and incident analyses, including a list of resources specific to the clinical group

  • guidance on measuring improvement

  • success stories from organizations

  • references.

Definitions

As patient safety evolves it is important to be clear on the meaning and differences of specific words. For the purposes of the Hospital Harm measure, the following definitions apply:

  • Harm: An unintended outcome of care that may be prevented with evidence-informed practices and is identified and treated in the same hospital stay.

  • Occurrence of harm: Harmful event is synonymous with occurrence of harm.

  • Hospital Harm Measure: Acute care hospitalizations with at least one unintended occurrence of harm that could be potentially prevented by implementing known evidence-informed practices.

For harm to be included in the measure, it must meet the following three criteria.

  1. It is identified as having occurred after admission and within the same hospital stay.

  2. It requires treatment or prolongs the patient's hospital stay.

  3. It is one of the conditions from the 31 clinical groups in the Hospital Harm Framework.

If you have any feedback or suggestions for the Improvement Resource, please send your ideas to info@hec-esc.ca.

How to Use the Hospital Harm Measure for Improvement

Occurrences of harm are often complex with many contributing factors. Organizations need to: 

  1. measure and monitor the types and frequency of these occurrences 

  2. use appropriate analytical methods to understand the contributing factors 

  3. identify and implement solutions or interventions designed to prevent recurrence and reduce the risk of harm 

  4. have mechanisms in place to mitigate consequences of harm when it occurs 

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses or prospective analyses can all be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in the section "Resources for Conducting Incident and/or Prospective Analyses." 

Conducting a chart audit to drive quality improvement 

Chart audits are recommended as a good method to develop a more in-depth understanding of the care delivered to patients identified by the Hospital Harm measure. Chart audits can also help identify quality improvement opportunities. 

Step 1: Prioritize quality improvement opportunities

Prioritize the clinical groups for review with the help of your multidisciplinary team, and by considering the following factors.

  • Clinical groups with a high volume of patients.

  • Severity of harm including never events, serious reportable adverse events, serious safety events, and critical incidents.

  • Clinical groups that align with:

  • Quality improvement (QI) work already underway or planned in the organization.

  • Provincial/territorial or regional priorities or ministerial directives.

  • Priorities identified through the accreditation or risk assessment process.

  • Priorities from patient safety incident reporting and learning systems, patient safety or quality assurance reviews or patient complaints.

Step 2: Identify what you want to measure

Identify specifically what you want to measure through a chart audit. The input of experts is key in this step. Clinical groups are comprised of codes of different but related types of harm. Determine which codes contribute the most harm to the clinical group, what questions you need to answer, and what information you need to collect. The Hospital Harm improvement resource (improvement resource) lists some suggested outcome and process measures for each clinical group.

For example, C21: patient trauma captures in-hospital injuries such as fractures, dislocations, burns and asphyxiation. If C21 has been identified as a "high volume" clinical group for your facility/organization you will want to determine which codes contribute to the majority of harm (for example fracture, burns, etc.). If fractures are the focus of your audit, you may want to measure the number of fractures due to falls. To understand what contributed to the fall you may need to know where the fall occurred (from bed, wet floor, etc.) and whether the patient had a fall risk assessment, and medication review on admission, etc.

Step 3: Identify your patient population

Once your team has identified a clinical group to explore, with the help of the multidisciplinary team you will need to identify the patient population for study. For instance, you may decide to review all cases included in the clinical group or focus on a specific unit or patient population (for example medical, surgical, obstetrical, etc.)

Step 4: Determine your sample size for the chart audit

Sample size is at the discretion of your facility/organization. For a chart audit you may arbitrarily choose a sample size; the minimum is usually 10 to 20 charts or 10 percent of the population. For steps on determining a statistically valid sample size see The How’s and Why’s of Chart Audits:http://patientsafetyed.duhs.duke.edu/module_b/steps/step4.html

Step 5: Create your audit tools

Determine the demographic and care processes that you want to capture in your audit. Hospitals may use existing audit tools from external organizations or create their own audit tool. Here are examples of audit tools for medication reconciliation and preventing falls and injury from falls.

Step 6: Collect your data

Members of the multidisciplinary QI team can conduct the chart audit of the sample cases, or it can be done by staff familiar with conducting audits (for example health information analysts, clinical educators, risk managers).

Step 7: Summarize your results

Summarize the chart audit results and share them with members of your team for additional insights. The input of those who provide the care on a regular basis is also very valuable at this stage. Have them reflect on:"Does this match what you are experiencing in your day-to-day provision of care to our patients? Does it make sense to you or surprise you?"

Step 8: Use your results to inform and launch a QI initiative

Pull together a multidisciplinary QI team inclusive of content and process experts and those who provide the care on a regular basis. Analyze the results from the chart audits to identify specific improvement opportunities. Embark on a journey using QI methodology such as the model for improvement or any quality framework used at your organization.

Use the experiences of others to identify how to make improvements. Find out what high performing organizations are doing, and look at other resources.

Remember to include ongoing measurement and evaluation to understand if changes have resulted in improvement (see process measures listed for each clinical group in the improvement resource). Identify any other sources of complementary information (for example patient safety incident reporting and learning system data, ongoing quality audits, quality of care reviews).

If your organization would like further information on how to conduct a chart audit for quality, some helpful references include:

 

Learning from Harm

Healthcare Excellence Canada offers numerous resources to support reporting, responding, and learning from patient harm. 

General Patient Safety Quality Improvement and Measurement Resources

Driving quality improvement in a focused area such as a clinical group requires an understanding of the foundational elements of patient safety, quality improvement, and measurement.

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