Behavioural Alert Flagging System

Overview

In the fast-paced, high-stress environment of Sunnybrook Health Sciences Centre —Canada’s largest trauma center and home to one of Ontario’s busiest emergency departments—rising patient aggression presented a significant challenge to staff safety and care quality. To address this, I collaborated closely with hospital leadership and clinical teams to design a user-centered flagging system that enables frontline staff to quickly identify and document patients exhibiting high-risk behaviours.

Alongside the flagging system, we developed an intuitive assessment tool that guides staff to capture patient behaviours using clear, objective, and respectful language. This solution not only improves communication across care teams but also supports safer, more informed decision-making at the point of care.

Timeline

Jan 2022 to Nov 2023

Client

Sunnybrook Health Sciences Centre (SHSC)

Role / Team

UX Design Specialist and Software Liaison for the Patient Violence Flagging Working Group (PVFWG), along with 2 developers

Platform

Website App

Tools

Axure, Figma, Jira

Methods

Workflow Analysis, Usability Testing (Moderated, In-person and Remote)

Due to the proprietary and confidential nature of this project, I have omitted and obfuscated exact designs.

Creating assessment questions to objectively flag patients with high risk behaviours

Behavioral assessment examples from other hospitals were used as a baseline, but they didn’t quite fit the specific needs of our hospital and felt too arbitrary.

So, to gather feedback that would help shape our hospital’s workflow and policy, a committee (PVWG - Patient Violence Flagging Working Group) was formed with representatives from occupational health, security, legal, ethics, mental health leadership, nursing and physician teams.

Main Feedback Points

Early drafts of the behavioural assessment were lengthy—nearly two pages—and some scoring categories lacked balance. For example, behaviours like “anxious” received similar weighting to more serious incidents involving actual harm, which diluted the focus on violence.
Questions were too wordy, and the phrasing needed to clearly align with the purpose of raising the flag. For instance, we considered wording such as “Observed behaviours within the last … days?” to ensure clarity and relevance for clinicians.

When and How Should the Patient be Assessed?

Now that the assessment was finalized, the main questions remained about staff responsibility and hospital policy.

QUESTION
Who should be responsible for completing the assessment to determine whether a Behavioural Alert (BeA) should be initiated on the patient? Should it be the nurses or security?

COMMITTEE CONCLUSION
The committee agreed that patients involved in a Code White should definitely be flagged.

QUESTION
Who should have access to the flag?

COMMITTEE CONCLUSION
Nursing staff recommended interfacing with EDIS (Emergency Department System) and BMS (Patient Flow System), as EDIS is used in areas with frequent patient violence, and BMS is widely used on patient floors.

QUESTION
Should the BeA flag stay on the patient’s electronic chart indefinitely? If not, when and how should it be reassessed?

COMMITTEE CONCLUSION
Reassessment was suggested to monitor if the patient’s condition has improved, with implemented reminders at 7 days, on transfers, and at discharge.

Most platforms have no search functionality to find specific events and activities, e.g. by topic. We also tested the apps, and found navigation to be difficult

Technical Considerations for Clinical Decision Support

With the behavioural assessment, workflow, and policy nearly finalized, our next focus was on developing software solutions to help clinicians follow these guidelines more easily.

Sunnybrook Health Sciences Centre currently relies on multiple, disparate IT systems, e.g. the security system is separate from clinical and patient flow systems. This fragmentation prompted us to explore opportunities to streamline and automate these systems to better support clinicians in their day-to-day work.

To guide this effort, we established several key requirements:

SunnyCare (SC), the hospital’s primary clinical IT system used by most staff, must serve as the single source of truth for behavioural assessments and flags to prevent conflicting information.
Workflows should be automated wherever possible to reduce documentation burdens and staff workload.
Since the security team logs incidents of aggressive or violent behaviour requiring their response in a separate system called “RL Solutions,” and because non-clinical staff like security personnel should not have access to SC, we needed to identify alternative integration methods between these systems.
The solution must also interface with systems such as EDIS and BMS to ensure that all relevant staff have full visibility of behavioural flags.

Proposed Future State Solution

I led the effort to define these requirements and translate them into technical specifications, resulting in the proposed future state outlined below.

Implement read-only access to the RL Solutions database to query new Code White incidents logged by security on an hourly basis, automatically triggering Behavioural Alert (BeA) flags without requiring staff to manually flag patients.

Example of BeA (Behavioural Alert) Flag States set automatically by system

Build a BeA Flag Assessment Module within SC to allow staff to answer questions that determine whether the BeA flag should remain active or be inactivated.

Example State of BeA Flag Assessment Module

Create special permissions for certain committee members to remove the BeA flag after committee review.

Users with special permissions have the additional option to 'Remove Active BeA'

Develop automatic interfaces from SC to EDIS and BMS to ensure clinicians and nursing staff see real-time updates to the BeA flag. We utilized existing HL7 interfaces to reduce vendor costs and developed HL7 specifications for the development team.

Partial Screenshot of the Interface Workflow

Include BeA flags on printed patient census reports, such as volunteer mobility, discharge, and sign-out/handover lists.

Example of volunteer mobility patient list with identified BeA patient

Commitee Approval and Site-Wide Implementation

I presented the proposed future-state solution to the Patient Violence Flagging Working Group (PVFWG), and it was approved to move forward.

Additionally, I:

Translated clinical workflows and policy requirements into logical, implementation-ready specifications, ensuring alignment between PVFWG goals and technical development
Developed HL7 interface requirements for developers to reference when building HL7 messages between SunnyCare and EDIS/BMS
Conducted usability testing with nursing staff using a prototype I built, ensuring that the BeA assessment tool and flags were intuitive and easy to use

Project Launch

Training and Implementation

We went live in November 2023. I collaborated closely with the implementation team to develop training materials and deliver sessions that supported front-line staff in adopting the new workflow.

Screenshot of the printed training pamphlet distributed on units

Power BI Reporting

I also partnered with the Business Analyst team to define the requirements for a Power BI dashboard, enabling leadership to monitor utilization and ensure compliance with hospital policy related to the new BeA flag. The solution was designed with scalability and usability in mind, providing a strong foundation for ongoing alignment with organizational goals.

One of the BeA Flag Stats from the Power BI Report