5. IF YOU SEE SOMETHING, SAY SOMETHING: ENGAGING HOUSESTAFF IN PATIENT SAFETY AND EVENT REPORTING

Abstract

Background Residents and fellows play a key role in patient care at academic medical centers and have unique insights into quality and safety improvement opportunities. To increase integration of trainees into the quality and safety mission of our hospital, the Housestaff Quality and Safety Council (HQSC) was created in 2018. The HQSC represents a collaboration between the housestaff, Graduate Medical Education, office of Quality and Safety, interprofessional hospital staff, and senior leadership. At our institution, Aim Statement Our objective was to increase the monthly incidence of event reporting by graduate medical trainees by 20% from baseline within 12 months. Interventions We used improvement methodology to identify critical drivers of barriers to submitting event reports, which included 1) education and awareness of the hospital's reporting system, 2) time and effort associated with submitting reports, 3) culture of safety, and 4) lack of feedback and transparency surrounding reports (Figure 1). We used an iterative approach with multiple PDSA cycles to increase knowledge and engagement of event reporting. Tests of change included tip sheets, development of a trainee-run Morbidity, Mortality, and Improvement (MM&I) conference, acknowledgement by senior leadership for submitting reports, and educational interventions. Measures The baseline mean number of safety reports by trainees in the 12 months prior to our project was 24.6 per month. Results The number of safety event reports placed by trainees increased in the initial 5 months of the project, reaching special cause variation in month 2 and 4. Educational interventions and tip sheets were implemented in PDSA #1, the MM&I conference was implemented in PDSA #2, and acknowledgement by senior leadership was implemented in PDSA #3. Conclusions and Next Steps Engaging trainees in patient safety concepts through education, interactive conferences, and appreciation can increase safety event reporting by trainees. Future planned PDSA cycles include implementing changes to increase timely feedback, developing patient safety faculty and resident experts, and increasing audit and feedback of reporting data to trainees.