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Patient Safety, FTCA, RM, and Quality Working Together December 2, 2008 Petra S. Berger PhD RN, CPHRM Healthcare Quality, Risk, and Patient Safety Consultant [email protected] - Phone: 517–281-7816 1 Learning Objectives Outline how the overall Quality management (QM) agenda at Health centers can be practically integrated with the distinct missions and goals of Risk management (RM), Quality improvement (QI), Patient safety (PS), and FTCA. Discuss how Quality management strategies can insure that efforts are aligned, coordinated and measured between all four aspects: Risk management, Quality improvement, Patient safety, and FTCA. 2 Concepts of Integration in QM/QI, RM, Patient safety, and FTCA 3 Bridging the Quality Chasm QUALITY MANAGEMENT Patient Safety = Q. I. Risk Management = identify risk – respond – prevent 4 QUALITY GOALS: 4 + RM on O N E Quality Management Platform Clinical Effectiveness: e.g. hypertension, DM Patient Satisfaction complaint management Regulatory compliance: e.g. P & Ps Continuity of care vs. fragmentation missed diagnosis after hours coverage patient education omitted Efficiency, UR, Cost control some staff unqualified for job scope 5 QM and RM: Clinical Protocols Pre natal risk assessment & OB practice Fever in Children (ACEP) Stroke Chest pain Abdominal pain Anticoagulant Management Sample protocols can be accessed at http://www.guideline.gov/ 6 QM and RM: TJC: National Pt Safety Goals Patient identification Verbal /phone orders Critical lab value reporting Hand off @ transition Patient /family involvement in care Medication reconciliation Suicide assessment 7 CORE PURPOSE of PROACTIVE RISK MANAGEMENT S T O P ADVERSE OUTCOMES Eliminate Patient harm Protect Healthcare facility from due to medical error & oversight litigation and financial loss patient and community distrust Protect involved Providers 8 FTCA focus Health Center Claims Management RECENT FTCA CLAIMS DATA Claims Occurrence Error in Diagnosis 30% Treatment related 21% Medication related 10% OB Related 22% Surgical Procedures 6% Claims Location Health Center 65% Hospital 35% 9 Summary of Risk issues @ CHS’s Risk aspect Risk aspect Risk aspect Risk aspect #1: Patient communication #2: Provider Team Communication #3: The Medical Record #4: Clinic Operation & Flow Diagnostic test tracking After hours coverage; telephone triage Risk aspect Risk aspect Risk aspect Risk aspect Risk aspect Risk aspect #5: Clinical Practice #6: Misdiagnosis (clinical) #7: Medication Safety #8: Equipment – EOC – Emergency #9: Clinic Staff performance #10: Medical Provider Quality/ Peer review 10 QM & RM factor: Patient communication Patient assessment & interview Treatment planning & contracting Importance of preventive services Encourage self-management of health issues Health instruction – literacy – interpreters Health instruction, dialogue and rapport Explain back / read back Patient feedback & satisfaction 11 The Medical record & Legibility: Guess that Prescription Handwritten prescriptions are often misread In the prescription above, the drug name was incorrectly interpreted as Coumadin. http://www.medscape.com/viewarticle/557740?src=mp From American Journal of Health-System Pharmacy “Avandia” 12 Quality & Risk aspects MEDICAL RECORD DOCUMENTATION ? Illegibility & error prone abbreviations ?Treatment rationale ?Diagnostic Follow Up ?Omissions \ delays in care ?Contradictions; confusion between provider ?Finger pointing, subjective statements ?Corrections: Write overs & White out Altered Medical Records; “Late entries” 13 QM & RM, Clinic operation & Flow: Telephone triage & legible Documentation Using protocols adopted by medical staff, or direct consultation w/ med. provider Name of Caller & purpose of call Advice & orders given (prescription refills) Follow-up instructions Date, time, AND initial of provider Review through Q.I. process Based on criteria of clinical protocols 14 Clinic operation & Flow Missed appointments – ‘No Shows’ Tracking high-risk patients who miss scheduled appointment Pending diagnostic results? Documenting all notification attempts Include medical implication of missing appointments If worsened outcome possible, a certified letter is sent, with copy & receipt in medical record 15 Clinical practice Pre-natal risk assessment PRE NATAL ASSESSMENT per protocol (standardized) Consistent documentation, prenatal visits Prompt high risk referral PRE NATAL MED. RECORD TO HOSPITAL @ 36 wks Maternal conditions: hypertension – diabetes – drug & alcohol http://www.rmf.harvard.edu/; AAFP standards / ACOG standards 16 Clinical practice BEHAVIORAL HEALTH Initial Assessment & Treatment Plan Suicide assessment and precautions Case management Medication therapy (?informed consent) Monitoring of effects and patient compliance Patient /family education: purpose /side effects On-going acuity assessment & referrals Documentation standards & confidentiality 17 Medication Safety Adverse Medication events related to 4 phases: Product labeling, packaging, nomenclature Prescribing: Indications, interaction, off label Antibiotics, anticoagulants, narcotics, cardiovascular, steroids; serum levels Dispensing: compounding, distribution error Administration: wrong drug/ dose/ route Verbal or phone orders Source: National Coordinating Council on Medication Error Reporting and Prevention –www.nccmerp.org 18 Credentialing Focus Initial credentialing varies from re- credentialing INITIAL: Licensure verification, References re: privileges Qualifying education & experience, NPDB RE-CREDENTIALING: Quality & Risk data required Which value-added measures to select How to obtain the data efficiently What to do with quality information 19 Quality Strategies to Align, Coordinate, Measure QM/QI, RM, Patient Safety, FTCA efforts 20 QM & RM COLLABORATION FOR PATIENT SAFETY Co-design corrective Quality Improvement actions from a systems-based perspective Correct flawed systems and processes: Are Policies written from Q & R perspective Quality & Risk aspects in Medical record policies Similar QI projects already underway? New Risk event info used to adjust QI priorities ASHRM Task Force. “Different Roles, Same Goals: Risk and Quality Management Partnering for Patient Safety.” Monograph. 2007 21 What does Risk perspective contribute to QM Co-use DATA and avoid redundancy – Incident reports, RCA results, Claims data Generic Quality screens w/ RM implication but protect risk information Waiting time Unplanned admission to hospital Infection = now a ‘medical error’! Medical Record reviews can identify unexpected PCE (pot. comp. event) 22 Risk Identification = Quality Assessment Generic screens: e.g. no show rate Incident (or occurrence) reporting (1 - 30%) Omitted or delayed diagnostic reporting Adverse medication event –or near miss Patient or family complaint Staff feedback & surveys Quality & Risk reporting marathons 23 RM Case: Incomplete Medication History 58-year-old male patient was scheduled for a major diagnostic procedure at the hospital where a certified registered nurse anesthetist (CRNA) provided conscious sedation. A required copy of the clinic medical record was sent preoperatively. No mention was made of the patient’s seizure medication. 24 RM Case: Seizure & Respiratory arrest No recent blood level had been obtained related to the patient’s seizure medication. Patient compliance with the medication was unknown. The patient underwent scheduled procedure Patient experienced a grand mal seizure during the procedure and had a respiratory arrest. Intubation was delayed and the patient suffered permanent brain damage. 25 Risk response = QI = Patient Safety A. RCA results: CHC Clinical standards of care = ‘duty’ Monitoring, patient medication & document Test result reported & signed off by provider Treatment plan updated, w/ or w/out change Reliable medical record system @ hand off with external medical providers and hospital B. CRNA & Hospital standards of care 26 QI opportunity for Patient Safety Process re-design Patient assessment & Medication monitoring Diagnostic test ordering Diagnostic test tracking Treatment plan continuity Hand-off with ext. medical providers, hospital Provider and Staff communication Medical record documentation 27 Quality audit = ”QA” Diagnostic test tracking Test ordered by med. provider & log Request form created - copy retained Test completed - patient compliance? Results received & logged in / ck log Results reported to provider (same day for abnormal /critical results) Patient notification documented 28 Quality & Risk measures: need both Sample QUALITY MEASURES Medical record documentation audits /criteria Diabetic HgbA1C baseline & improvement Pediatric Immunization rates Hypertension improved Sample RISK MEASURES Patient complaints Misfiled and non initialed test results Missed diagnosis: Cancer Insulin medication error and patient harm Adherence to Anticoagulation guidelines 29 • Select problem process • Make change permanent (standardize) or • Understand the process • Continue the PDCA cycle • Decide on process steps to improve • Collect data • Analyze data • Data collection • Determine the effectiveness of the change • Implement the change /pilot • Data analysis 30