quality reflection improving systems and processes
Notice
The quiet act of observing and paying attention. We are encouraging team members to notice. A lot of error is because we are on auto-pilot, busy or stressed and not able to attend to what is happening. We encourage and reward the act of noticing, remind your team there is no such thing as a bad QLP. We are alert to incidents of harm and keen to learn from near-misses however ideas, suggestions for service improvement are always welcome. Keeping the language positive and professional.
Reflect
Giving pause and consideration to what has been noticed. We often misattribute error, apply blame and make things personal. Taking time to reflect allows us to look at the systems and context within which we are working - once we see these we can begin to effect change. Different team members will be at different stages in their capacity for in depth reflection, use the QLP as an opportunity to help nurture growth in your team and develop mature reflective practice.
Connect and Consider
We recommend each meeting have a clear focus and agenda. QLPs can be tabled with time allocated. The manager or quality lead can supply a comment and direct the discussion asking the team to reflect on patient factors, task/technology factors, team factors, environmental factors or organisational factors.
During a meeting one member can be chair, or facilitator of the meeting and another delegated to minute the discussion. The facilitator should be able to help maintain the professionalism and pertinence of the discussion. An event resulting in patient harm, or a significant near miss may benefit from a Manager or Quality Lead helping keep the focus of the conversation and hold a space that values professionalism and privacy. Minutes should be simple, covering the main themes of discussion. The facilitator should help land an agreed outcome, and relevant actions.
Act
There is a wide range of possible outcomes following a discussion. Its up to your team. The discussion itself may have been deemed sufficient to embed learning and the outcome can simply summarise the learning, acknowledging the work of the team member who generated the QLP.
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More information may be required before a decision can be reached - in this case a specific action can be created and the QLP can be tabled for further discussion once this is action is completed. The action may be as simple as ordering new equipment or as involved as review of the legislative requirements. The outcome may recommend patient / whanau engagement to gather information as part of a healing, learning and restorative process or contact with an external organisation. The QLP may be re-tabled to a specific meeting to allow further consideration, discussion and outcome.
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There may be change to process or policy that the whole team need to be aware of. In this instance the QLP may again be re-tabled to another meeting so the policy changes can be considered and reviewed. The team may decide further work is required. QLPs make natural springboards for PDSA cycles or Clinical Audit. There may be a training need identified, the QLP can be tabled for relevant education or training session and further learning, discussion and outcome added. Final changes to policy or process can be circulated amongst the whole team by creating an update.
The QLP may be identifying an incident of patient harm, or a near miss. In these instances the manager or quality lead may choose to undertake Significant Event Analysis and consider completing a SAC (Severity Assessment Code) form. One aim of qrisp is to actively encourage the identification of, and learning from, near misses to reduce the incidence of actual patient harm.
Embed
The intent of qrisp is that the regular noticing of and reflecting on instances in practice will itself create an awareness. Allied with the chance to connect and consider with your team will itself embed learning. From an organisational perspective learning can be considered 'embedded' once a reasonable outcome has been landed. Whether that is an update, a change to policy or just the fact that a conversation happened. qrisp provides a record of these conversations and reflective learning as well as encouraging regualr review of policy and process.