NR 544 Week 7 Unit Level Proposal Example

Unit Level Proposal: Two Written Lines Returned to Every Reporter Within Seven Days on One Medical Unit, With a Warning in Advance That the Number of Entries Will Rise

Student Name

College of Nursing, Chamberlain University

NR 544: Quality and Safety in Healthcare

Instructor Name

Month Day, Year

Unit Level Proposal: Two Written Lines Returned to Every Reporter Within Seven Days on One Medical Unit, With a Warning in Advance That the Number of Entries Will Rise

The Change

For six months, starting on the first of next month, the nurse manager of our 30-bed adult medical unit will send every person who files an incident entry from the unit a message of no more than two lines within seven days of submission. The first line says what was done with the entry. The second line says what, if anything, has changed or will change because of it. If nothing will change, the message says so and says why.

That is the whole proposal. It alters one step, the return path, on one unit. It does not change the form, the categories, the harm codes or the routing rules, all of which the earlier work in this course found wanting. Those are larger problems owned by people outside the unit, and a proposal that reached for them could not be tried by anyone writing it.

Why This Step

The appraisal of the unit's safety culture found that five of 52 closed entries in six months returned anything to the person who filed them, and that staff accurately predict this. They have stopped reporting near misses and standing hazards, not out of fear but because nothing comes back. Evans et al. (2006) found lack of feedback to be among the most frequently cited barriers to incident reporting. Benn et al. (2009) described feedback from incident reporting systems as including both information returned to staff and action taken to improve safety, and argued that reporting systems that do not close this loop lose the engagement of the people who feed them.

Of all the stages in the route an entry travels, the return path is the one the unit fully controls. The manager already reads and closes every no-harm entry. Writing two lines is a small addition to work already being done.

The change is also cheap to reverse. If it produces no benefit by the six-month review, the setting can be switched off and the manager's time returned, with nothing else in the system disturbed.

Who Does It and When

The nurse manager writes the message when closing each entry, using the reporting system's existing closure comment field, which can be set to send to the reporter. For entries still open at seven days, the manager sends a holding message saying what is being done and when the reporter will hear again. The manager estimates the unit files about 11 entries a month, so the work is about 11 short messages a month, perhaps 30 to 40 minutes in total.

To make room, the unit's patient safety champion, a staff nurse with four hours of protected time a month, will take over the monthly incident summary the manager currently prepares for the directors' meeting. The manager gives up that task; the champion gives up two hours of the audit work that has lapsed in any case.

The template has three parts: a greeting by name, the line on what was done and the line on what will change. The manager may add a sentence of thanks, but the office has asked that messages avoid promising outcomes the unit cannot deliver, such as changes to equipment owned by another department. Where a change depends on another department, the message says who has been asked and when the reporter will hear more.

Permission From the System Owner

The reporting system belongs to the patient safety office. The closure comment field can send a message to the reporter, but the setting is off by default across the hospital, and switching it on for one unit requires the office's agreement. The office will want to know three things: that the messages will not name other staff or include protected review content, that the manager will not use the channel to discipline anyone and that the trial will be evaluated. This proposal commits to all three, and the manager has agreed to use a short template reviewed by the office before the start date. Without the office's agreement, the change can still run by secure email, but the messages would then leave no trace in the system, which weakens the evaluation.

Predicting the Rise

If the change works, the number of entries from the unit will go up. Staff who have stopped filing near misses and standing hazards, including same-surname pairings, will start filing them again once they see that entries receive an answer. A rise from about 11 to perhaps 16 or 18 entries a month would be a sign of success, not of a unit becoming less safe. Leape (2002) argued that reporting systems succeed when they are responsive, and a responsive system generates more reports.

Writing this prediction down before the trial starts protects it. Without the warning, a manager or director seeing the count climb in month two could reasonably conclude that something had gone wrong and stop the trial. To tell a genuine rise in events from a rise in willingness to report, the evaluation will compare near misses with events that reached patients. If near misses rise and harm events stay flat, willingness has changed; if both rise together, something else may be happening and should be looked at.

The comparison is imperfect, since harm events can also go unreported, but it is the best the record allows.

What Would Show It Happened

The change leaves a trace: a closure comment sent to the reporter, visible in the system with a date. At the end of each month the champion will count entries closed and entries with a message sent within seven days. The target is at least 90%. If the proportion falls below that for two months running, the manager and champion will meet to decide whether the time estimate was wrong.

At six months, the evaluation will report the proportion of entries answered, the monthly count of entries by type and a short survey of the same 14 staff asked in the appraisal whether they expect a response. The review date is set for the first week of the seventh month, and the nurse manager owns it. Macrae (2016) warned that reporting systems can become ends in themselves, counting entries rather than learning from them; this proposal tries to make one small part of the system answer the people who use it.

References

Benn, J., Koutantji, M., Wallace, L., Spurgeon, P., Rejman, M., Healey, A., & Vincent, C. (2009). Feedback from incident reporting: Information and action to improve patient safety. Quality and Safety in Health Care, 18(1), 11-21. https://doi.org/10.1136/qshc.2007.024166

Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O'Shaughnessy, J., & DeWit, M. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care, 15(1), 39-43. https://doi.org/10.1136/qshc.2004.012559

Leape, L. L. (2002). Reporting of adverse events. New England Journal of Medicine, 347(20), 1633-1638. https://doi.org/10.1056/NEJMNEJMhpr011493

Macrae, C. (2016). The problem with incident reporting. BMJ Quality & Safety, 25(2), 71-75. https://doi.org/10.1136/bmjqs-2015-004732