• EC: –  Clarifications and Expectations (C&E): The Information Collection and Evaluation System (ICES) Simplifying data collection and analysis[®] [REF: EOC, JCSC, PI, SFT] EC News May 2013, Vol 16, #5, Pg 6 #JCe1305_B5

Since at least 2002, TJC has been encouraging the implementation of an Information Collection and Evaluation System (ICES).  It used to be described in the EC Chapter overview.  Although the term is no longer specifically referenced anywhere in standard that we can tell, TJC “does require organizations to have a defined process in place and to follow that process consistently.”  The expectation of using an ICES to “continuously measure, assess and improve the status of the environment” is still very much alive and well in the 4th subsection of the current EC standards chapter.  In this article, ICES is operationally defined as ” the way your hospital collects and responds to information about deficiencies and improvement opportunities in the environment of care”.  The rest of the article breaks this down into the three key aspects of an ICES:
• 1: Monitoring, collecting and reporting data (EC.04.01.01) – Data should be collected not only on incidents and related issues, but also circumstances with the potential to cause incidents.  Daily observations, EC tours, staff evaluations and satisfaction surveys are suggested as useful sources for the latter.  [PEARL] A  sidebar on page 7 provides a list of incident types to include in an ICES.
• 2: Analyzing data/prioritizing improvement opportunities (EC.04.01.03) – The analysis process need not be fancy.  A dashboard (see A Sample Dashboard for Performance Improvement also in this issue) spreadsheet, run chart, even bar graphs can do.  The idea is to convert the data to useful information that allows you to see trends and opportunities for improvement.  Remember, this standard requires “an organization should select and implement at least one EC performance improvement project each year”.
• 3: Making Improvements (EC.04.01.05) – The ultimate goal of the ICES is to address at least one of the identified opportunities and improve safety.
TIP: Every Safety Officer should read this article.
Tip: Make sure you have a written description of your ICES (frequently included as part of the Safety Management Plan) and that it collects data in the areas indicated in the sidebar referenced above.
Tip: See also Sample ICES Policy and some Sample ICES Descriptions