Shared on behalf of Quality and Risk Management
Please be advised, we have revised the Hospital’s policy QM-80 Quality of Care Reviews.
Actions Required
Managers – Review this memo and the attached poster with your staff during Safety/Quality Huddles and post in your department. The approved updated policy is attached for reference and is now available on the iNtranet.
Key Policy Changes
Policy Statement Change: Focus on “Patient Safety” changed to “Just Culture”, and learners added to the employees listed.
New Definitions Added:
- Clinical Debrief (aka “Hot Debrief”): Following a critical incident, a meeting to summarize the case, determine what went well and opportunities for improvement, and to highlight where actions are required.
- Critical Incident: Unintended event, resulting in death or serious disability, injury or harm, and does not result from patient’s underlying medical condition or from a known risk inherent in providing treatment.
- Incident Triage Team (ITT): A group of leadership who will meet within 48-72 hours of a critical incident to determine if a Quality of Care (QOC) Review is required, and if so, what type of review.
- QOC Reviews: Further defined as Departmental Reviews, Morbidity & Mortality (M&M) Reviews, Critical Incident and Process Reviews for systemic issues.
Procedural Updates:
- Procedure 5.1:Updated to include reference to ITT.
- Procedure 5.2 & 5.3: Clarification provided regarding Quality of Care Information Protection Act (QCIPA)-protected reviews.
- Procedure 6.2: Insertion of Clinical Debriefing process.
- Procedure 6.3: Updated requirements of review and classification of incident.
- Procedure 6.4: Insertion of process for consultation with ITT and determining necessity of QOC review.
- Procedure 6.8: Clarification to whom information pertaining to reviews can be disclosed.
- Procedure 7: References updated; information on debriefing included.
- Appendix A: Incident Review Process Flowchart.
- Appendix B: Clinical Debriefing Guide (S.T.O.P.).
Key Process Reminders
Please see the attached poster. Please email us should you have any questions at TBRHSC.QualityandRiskManagement@tbh.net.