The Quality Corner: January 2024

January 8, 2024
  1. Suicide Risk Documentation using Columbia-Suicide Severity Rating Scale (C-SSRS):

Situation: An RCA (Root Cause Analysis) recently identified multiple opportunities where a provider did not request appropriate assessment of patient’s risk using the validated system tool (C-SSRS).

Background: A recent RCA identified that the C-SSRS was not requested nor completed when a patient endorsed suicidal ideation. The RCA further identified knowledge gaps among providers and caregivers regarding this tool, when its use is required, and how to request completion. This tool has a bulit-in workflow that ensures minimal recommended interventions when a certain level of risk is assessed and is our validated tool for both ministries.

Assessment: Knowledge gaps exist about the Columbia-Suicide Severity Rating Scale (C-SSRS) as a tool to assess patient risk.

Request/Recommendation: Additional information can be found at the link below including EPIC training as well as recommended training in HealthStream.

  1. Epic Learning Link: Suicide Risk Documentation (C-SSRS) (
  2. PROV: Care of Patients at Risk for Suicide-Direct Caregivers eLearning:

  1. Placing Referral Orders:

Situation: Referral Orders placed in Epic are not flowing to the correct work queues leading to delays in care.

Background: Referral orders placed during discharge are being placed as external (Providence to outside facility) when they are intended as internal (Providence to Providence). Referrals are not hitting the internal work queues to be processed by Providence teams and may be the cause of delays in care.

Assessment: Provide a step-by-step guide for new and existing providers to use as a reference when placing referral orders.

Request/Recommendation: Please reference the link below: Placing Referral Orders (

  1. Ensure Correct Context/Location of Care (some will auto-acknowledge orders):

Situation: Providers logged into some contexts (eg. WSP PACU) will result in orderes being auto-acknowledged due to EPIC system process resulting in nursing missing orders needing action.

Background: Provider ordered removal of a drain, which showed as active in orders with no indication on the main screen, appearing to have been acknowledged by another party. Order not discovered until mid-shift chart review leading to delayed removal of drain.

Assessment: UOR submitted and clinical informatics able to troubleshoot, determined this is a technical issue associated with the context/unit being set to auto acknowledge orders.

Request/Recommendation: Please ensure providers are aware of the issue and use specialty specific context when placing orders. Personalization, Favorites, Customize Epic Toolbar, and Change Context (

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