Implementing a New Incident Reporting System and Improving Quality Culture during a Pandemic

As a part of maintaining a high quality radiation treatment program, both actual incidents and potential incidents that occur during any part of the patients experience should be reported and analyzed. Barriers to incident reporting include the length of time it takes to submit, lack of understanding the importance of submitting near-misses and a lack of feedback on submitted reports. In late 2019 Sunnybrook’s Odette Cancer Centre purchased Improvement Flow; an combination incident reporting system and project management software. The goal of using Improvement Flow was to increase the amount and consistency of incident reporting by decreasing the amount of time it takes for frontline staff to report as well as establish a for standardizing Improvement Projects and feedback format. In March 2020, three weeks before the initial Improvement Flow training sessions were to be scheduled, a pandemic was declared.

With traditional in-person training cancelled indefinitely due COVID-19 and a software system purchased, configured and ready to launch, we were challenged with finding new and appropriate avenues for educating staff and building quality culture in order to maximize use of Improvement Flow during the time in which formal education could be transferred to the hospitals online Learning Management System (LMS).

Using an internally created Model for Quality, changes were implemented into the Radiation Therapy Program, factoring in: education, availability of resources, positive behavior modeling, opportunities to be heard and share concerns, clarity of expectations, clarity regarding what is reportable, what is measured and what is shared.

Inherent to the Improvement Flow workflow, all submissions are reviewed weekly as a Quality + Safety Committee meeting which includes a rotating roster of team leads, physicists, oncologists and leadership. QA matters became standing items at all staff meetings and operations meetings with the team leads. The intranet was fully re-designed with easily digestible educational materials, a quick link to contact the QA coordinator and includes an archive of new monthly newsletters geared towards education and information sharing. The role of the QA coordinator included supporting a just culture and being a visible champion for positive change. In addition to the above, the new education that is currently in the queue for online LMS delivery, has been used as onboarding material for new and returning staff during one-on-one, socially distant training sessions.

During November 2019-November 2020, the number of Good Catches submitted was 3.5x higher than that of the year prior (972 to 271). The average monthly number of submissions has gone from 22 to 81 with a significant number of reports coming from simulator staff and dosimetry staff compared to the year prior. The increased number of reports has allowed us the opportunity to isolate processes where problems originate and where they are caught with more confidence and to implement Improvement Projects. We expect these trends to continue for the positive as formal education will be launching by end of 2020 to complete our education and expand use of Improvement Flow into the physics department.