Tool: Collaborative Case Review (CCR) programs include inter-professional teams who use structured tools to retrospectively review individual patient encounters, in order to improve future patient outcomes and determine how to improve care for the next patient.
Problem: The Agency for Healthcare Research recommends institutions understand system processes and take proactive steps to reduce preventable harm. There are several pockets of highly successful case reviews at University of Colorado Hospital (UCH); however, with independent reviews and data collection, the information gained from the event remains siloed.
Tool Selection: Collaborative Case Reviews improve care systems and create a learning organization that leads to higher reliability and optimal outcomes. The multidisciplinary collaboration promotes a Just Culture of safety while increasing job satisfaction when participants feel the value of being part of a high functioning, action oriented team.
Usage: A CCR Tool Box was developed including an introductory presentation on CCR, education for clinical leaders and quality improvement RNs, a CCR toolkit with roles and responsibilities and step by step process, templates for presentation, and a reporting tool for tracking and trending events and improvement actions throughout the region.
Results: Over the course of 17 months, the CCR Optimization project launched 28 CCR programs at UCH, joining 12 established programs. Critical to the success of the project were the CCR Sponsor Committee, development of a standardized CCR Tool Box, frequent communication and education, and dedicated quality improvement RN resources.