Memorial Health System is a community-based not-for-profit corporation dedicated to patient care, education and research. They are one of the leading healthcare organizations in Illinois. With eight affiliates based in Sangamon and the neighboring counties, Memorial Health delivers high quality, patient centered care in support of their mission to improve the health of the people and communities they serve. Among their values are:

• "We put safety first"
• "We seek continuous improvement"
• "We use resources wisely and maintain financial stability"
• "We work together to coordinate care and services across the health system"

Memorial Health System currently uses RLDatix's Risk and Feedback products, which allow them to support their values by being highly customizable. 

The Quality and Safety department puts their values into action by forming focus groups of subject matter experts (SMEs) from inpatient and outpatient care settings. Through this, they’ve learned that weekly meetings keep the momentum going. Technology such as Web conferencing to eliminate travel costs and loss of productivity, and Workplace by Facebook to share meeting minutes, drafts of revisions, and the final product are utilized.

One of the department's first projects was revising the Fall form. As a Magnet-accredited facility, Memorial Health needed to collect data for their certification. This was a burden for outpatient locations. As a result, a team was formed with representation from all affiliates to revise the form. One solution was to constrain the visibility/availability of the Fall Details section based on patient type.

Inpatient and outpatient locations screened patients for falls using differently and the team was able to customize the form to accommodate this based on “type of person affected”.

IP Fall Detail (conditional logic, type of person affected=IP)

OP Fall additional fields (conditional logic, type of person affected=OP)

Memorial Health listened to the voice of the customer and Culture of Safety Survey comments to streamline submission and make reporting easier. The form has been revised by type of person affected based on recommendations from SMEs across the system. 

Patient FALL Form Revisions

Following the success of the subject matter expert team, they were later assigned to build a workplace violence form before RLDatix released their own. The radiation form was made live, mirroring employee injury form to the fields in Risk Master, and revised product complaint, professional conduct, breach of confidentiality and medication fluid forms. They've had two rounds of revisions to the Feedback form, most recently revising the Category and Type pick tree and creating organizational definitions for the category types. 

Specific event type Product Complaint Report

Product Complaint Report

Here is an example of the pick tree category and type with operational definition:

When their organization's Facilities was having a tough time, they asked that the existing form be built in SENSOR (their brand for RLDatix's Risk software). Their department built the form and automated reports that were previously done manually:

"Customization is such a way of life, that Memorial Health makes changes on the fly."

They realized that the forms asked "should anyone be nominated for a good catch". If yes, then a new field for "who should be nominated" opened. We hid should anyone be nominated and made who should be nominated available and visible without conditions. IL law requires Memorial Health to track workplace violence for OSHA Typology. The HR manager requested this be added to the manage side of the form and it was implemented immediately. They have a Steering Team consisting of quality leadership throughout their System that meets quarterly. During a meeting, there was a request to make the date of follow up for breach of privacy a text field. The System Chief Privacy Officer approved the change and the field became text.

Workplace Violence OSHA Typology

When Severity interrater reliability needed improvement within and across sites. Memorial Health used their SMEs to create standardized definitions, vetted them with relevant department leaders across the system, and embedded a link in the Resolutions and Outcomes section for just in time reference. They now monitor interrater reliability monthly, coach file managers on outliers, and report on it quarterly at their Steering Team meeting. 

Standardized Severity Tool for Fall Events

Memorial Health System continuously strives to balance meaningful data collection and end user experience. RLDatix products allow them to live their values through cooperation, reduction of waste, actionable reporting, and coordination of services. 

Author: Mary McKee, System Admin and Patient Safety Analyst