Transcript Risk management - National Association of Community Health

Fundamentals of Risk Management &
Patient Safety for Community Health Centers
On-site RM Training Seminar 2008
Petra S. Berger PhD RN, CPHRM
Healthcare Risk and Patient Safety Consultant
[email protected]
-
Phone: 517–281-7816
1
Learning Objectives, 4 Modules

Demonstrate understanding of risk issues inherent
in providing community health center services

Explain leadership tools & methods related to:
Proactively identifying risk concerns, and
 Responding from the risk control, quality, and
patient safety perspective
Recognize the critical role played by patients and
families regarding high risk aspects of patient care
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Evaluate own learning gain regarding principles
and practice of proactive risk management
2
RM 101
Overview, Risk & Quality Management

What is “Risk management” @ CHCs
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Concepts in Professional Liability
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D & O (Fin., Reg., Contracting)\Property\Gen.
Employment Practice \Workers’ Comp
Professional Liability (=Clinical RM) & FTCA
Risk identification & reporting
Clinical Liability review
Risk intervention: immediate & QI referral
Ten common (clinical) risk issues at CHCs
Staff & Leadership roles
3
VITAL BRIDGE OVER TROUBLED WATERS
QUALITY MANAGEMENT
Patient Safety = Q. I.
Risk Management
= identify risk – respond – prevent
4
CORE PURPOSE of RISK MANAGEMENT
S T O P ADVERSE OUTCOMES
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Preventing patient harm
Protecting the Healthcare facility from
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the chaos of adverse outcomes
litigation and financial loss
patient and community distrust
Protecting involved Providers
5
QUALITY OUTCOMES & RISK ASPECTS
on O N E Quality Management Platform
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Patient Satisfaction
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Clinical Effectiveness
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informed consent \ after hours coverage
Regulatory compliance
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missed pediatric meningitis
Policies & Protocols
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complaint management
NPSG Implementation expectations
Efficiency, UR, Cost control
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omitted care elements
6
Health Center Trends and Issues
FTCA CLAIMS DATA
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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%
7
Liability Question: Allegation of NEGLIGENCE
Duty – based on existing provider-patient relationship
“To exercise degree of care that a reasonable
& competent provider would exercise under
same or similar circumstances”
Breach of Duty
Plaintiff must show that defendants failed to
exercise ‘reasonable’ care, and adherence to
established clinical standard (expert testimony)
Injury proximately CAUSED by breach (foreseeable)
8
Case: Incomplete Medication History
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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.
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A required copy of the clinic medical record
was sent preoperatively.
No mention was made of the patient’s seizure
medication.
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9
Case: Seizure & Respiratory arrest
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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.
10
Immediate RISK INTERVENTION
PATIENT status?
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Incident management >> mitigate liability & loss
 Skilled, fact-based investigation
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No premature conclusions
Timelines and event analysis (RCA)
Sequestering evidence
Privileged & protected information
MEDICAL RECORD AS CORE EVIDENCE
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Alleged ‘Negligence’ = ‘Process Failures’
Duty? Breach? Injury? Damages?
A. Clinic standards of care = ‘duty’
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Monitoring, patient medication & document
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Test result reported & signed off by provider
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Treatment plan updated, w/ or w/out change
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Reliable medical record system @ hand off
with external medical providers and hospital
B. [CRNA & hospital standards of care]
12
Purpose & Type of Risk Outcome Monitoring
Risk identification – Evidence – RCA – Q.I
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Event \Claims review: Root Cause analysis
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Incident reporting - adverse single event (1 - 30%)
 Omitted or delayed diagnostic workup
 Adverse medication event – outcome or process
 Patient or family complaint; Feedback
 Staff feedback & surveys
 ‘Risk reporting marathons’ = snapshots
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Occurrence Screens – global events
 Missed appointments; Waiting times
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Optimum Electronic information system
13
Procedures of
Incident reporting - How
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H o w to report in writing (incident report)
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Fact based, objective, concise, w/ timeline
 not: “gave wrong med”
 No speculation, opinion, blaming
Persons notified: RM, provider, family
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No copy, no staples, no MR placement\mention
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Medical record documentation
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Date\time, pt.’s clinical status, provider actions
Only patient-pertinent information; using quotes
NO PERSONAL NOTE KEEPING
14
Type of Risk Process Monitoring
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Monitoring results – Quality audits per criteria
 Adherence to Anticoagulant guidelines
 Misfiled and non initialed test results
 Medical records documentation
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Regulatory & Professional standards
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National Pt Safety Goals: Patient identification;
Verbal orders – Hand off @ transition – Infection
control – Medication safeguards: reconciliation,
high alert meds – Critical lab value reporting –
Patient involvement in care – Suicide assessment
15
Risk vs. Quality measures: need both?
Sample RISK MEASURES
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Patient complaints re: non response to adverse
effects of new medication & patient harm
Insulin medication error and patient harm
Missed diagnosis: meningitis, age 2
Sample QUALITY MEASURES
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Patient satisfaction trends
Diabetic HgbA1C baseline & improvement
Pediatric Immunization rates
16
Culture of Patient safety
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Transparency
 Errors are discussed openly between
colleagues incl. lessons learned (under
protection of confidentiality)
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Non – punitive reporting
 Medical provider who missed diagnosis
does not automatically get blamed;
instead,
 Objective RCA takes place; corrective
action plans are jointly developed
17
High Reliability Organizations (HROs)
Reason J. Human error: models & management. BMJ. 2000;320:768-770
 Acknowledgment of high-risk, error-prone
nature of organization’s activities, AND
commitment to safety
 A culture of safety in which individuals can
draw attention to potential or real hazards,
barriers, gaps, or failures without fear of
censure
 Capacities to detect unexpected threats AND
contain them before they cause harm
 Attentiveness to error prone processes facing
workers at the frontline
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Risk & Quality Leadership Roles
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Strategic Risk & Quality planning based on
Risk identification & prioritization
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Policies & Protocols, Guidelines
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Implementation of process re-design &
monitoring through Q. I.
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“Knowledge transfer” to create internal
inventory of patient safety practices
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Electronic information systems:
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Baselines & progress made
19
Why & How internal Policy compliance?
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Policy = standard by which care is judged
Difficult to defend internal policy/procedure:
 If not congruent w/ evidence-based guidelines
 If local practice not congruent w/ policies
 If no allowance made for clinical judgment to
vary from protocol
 If level of detail & requirements of local
policies are difficult to follow
 If not adjusted & monitored w/practice change
20
Risk aspect #1:
Risk aspect #2:
Patient communication
Provider Team Communication
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PATIENT COMMUNICATION
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Patient interview & Treatment planning
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Health instruction – literacy – interpreters
Patient feedback & complaints
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PROVIDER TEAM COMMUNICATION
 Hand off @ transition points
 Inter-provider relations & teamwork
21
Risk aspects #3: The Medical Record
Risk aspects #4:
Clinic Operation & Flow
The Medical Record
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Content & What To Document
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Legal aspects: alterations, legibility, etc.
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Confidentiality & Release of information
Clinic Operation & Flow
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Continuum of care (62% claims) vs. fragmentation
Diagnostic test tracking
After hours coverage; telephone triage
22
Risk aspects #5:
Risk aspects # 6:
Clinical Practice
Medical Mis-Diagnosis
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Medical evaluation & Treatment
Use of Practice Guidelines
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Complications, preventable
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OB, Surgical procedures, Emergency
Most frequent Mis-Diagnosis
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Cancer – Myocardial infarction – Stroke –
Meningitis – Acute abdomen – Fractures
– Prenatal risk factors – Infections
23
Risk aspect # 7: Medication Safety
Risk aspect #9: Medical Provider Quality
Adverse Medication events related to phases:
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Product labeling, packaging, nomenclature
Prescribing: Indications, interaction, off label
Dispensing: compounding, distribution error
Administration: wrong drug/ dose/ route
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Medical Provider Quality & Peer review
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Review mechanism - who and how
Data sources: 1) Quality 2) Risk
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24
Risk aspect #8:
Clinic Staff performance
Risk aspect #10: EQUIPMENT – EOC – EMERGENCY
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Staff qualification & orientation
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Clear directives/protocols & Training
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Staffing levels & Material resources
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Emergency Preparedness
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Crash cart (incl. pediatrics) & checks
Behavioral
Building /weather
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25
Risk Aspects of Clinic Services &
The Medical Record
RM 102
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Risk Aspects of Clinic Services
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MEDICAL RECORD DOCUMENTATION
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Confidentiality and release of information
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DIAGNOSTIC tracking, follow up, referrals
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MEDICAL EMERGENCY response
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Safe MEDICATION management
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STAFF QUALIFICATION
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PROVIDER COMMUNICATION
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Culture of Safety – dual focus of RCA:
(1 – 99%) Systems & Providers (1 – 99%)
Blunt End:
Org. ‘Systems’
Sharp end:
Providers
Organizational Factors: Clinical
protocol; Resources (Staff, Edu);
established flow, Clinic Operation
Communication Factors:
Patient & Family relations;
Inter-Provider teamwork
Human Factors:
Knowledge
& Skills requirement; Cognitive
limits (memory, fatigue, distraction,
confirmation bias)
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Risk aspects #3:
The Medical Record - Content
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Medical history, comprehensive & in ink
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Lab work, other diagnostic results
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Diagnosis & Current medical problem list
Double check @ each visit before chart returned
All results initialed by medical provider: QC
Patient notification documented: QC
Current medication log in ink (herbals, OTC)
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Double check @ each visit before chart returned
Cross off old info w/single line, explain i. e. D/C
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What To Document – Concurrent
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Notification: Referrals & consultations
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Patient’s response to intervention
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Instruction to patient /family, in writing
Questions addressed
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Correspondence to & from pt / family
Informed consent / refusal DISCUSSION
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Patient's failure to keep appointments
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All entries are dated & signed /initialed
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Guess that Prescription
 Handwritten prescriptions are often misread
 In the prescription above, the drug name
“Avandia”
 was incorrectly interpreted as Coumadin.
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http://www.medscape.com/viewarticle/557740?src=mp
From American Journal of Health-System Pharmacy
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Risk & litigation aspects
MEDICAL RECORD DOCUMENTATION
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?Treatment rationale; ?Diagnostic Follow Up
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Omissions \ delays in needed care
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Contradictions; confusion between provider
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Finger pointing; subjective statements
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Corrections: Write overs & White out
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Illegibility & error prone abbreviations
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Altered Medical Records; “Late entries”
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Do not: mention ‘incident report completed’
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Alteration of Medical Records
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A recent case in Ohio involved a physician who
“whited out” the following phrase:
“I do not feel that a biopsy is necessary
at this time”
And replaced it with:
“The patient does not want a biopsy at
this time”
Jury returned a verdict for $3 Million in an
otherwise defensible case !
Destruction of records is equally detrimental
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Policy development
Confidentiality & Release of information
Release of information
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verify request authenticity
Incapacitated adults; Minors
Families of deceased patients
Law enforcement officials /agencies
Employers and other third parties
Protecting Confidentiality
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Leaving message on answering machine /at work
Sign in sheet at front desk & privacy
Privacy re: staff conversation /phone calls, reception area
Faxing protocols
34
Faxing documents & Confidentiality
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What not to fax: HIV results, mental health records
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Avoid sending to general locations, e.g. mailrooms
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Request that the recipient acknowledge receipt
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Include confidentiality statement on fax cover sheet
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If intended recipient does not receive fax because
of incorrect dialing, fax request using incorrect fax
number & request return or destruction of material
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Risk related
Documentation Audit Criteria
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Legibility
Omissions
Treatment Rationale
Diagnostic Follow Up
Abbreviations
Corrections
No White out
No Write over
Late entries
Correct patient’s chart
Accurate content
Timely notations
Objective and factual
Continuity
No finger pointing
Avoid adjectives;
instead, quote directly
Signature verifiable
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Risk aspects #4:
Clinic Operation & Flow
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Continuum of care (62% claims)
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vs. Fragmentation across settings
Referral management
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Diagnostic test tracking
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After hours coverage & Telephone triage
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Access to care & No shows
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Missed Appointments:
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Tickler system, patient return for annual
exams, FU tests, preventive screens
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Monitor for action steps of test tracking:
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Test ordered by med. provider & log
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Request form created - copy retained
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Test completed - patient compliance?
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Results received & logged in / ck log
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Results reported to provider (same
day for abnormal /critical results)
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Patient notification documented
38
Risk aspect #2:
Provider Team Communication
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Half of communication breakdowns
occurred as patients were HANDED OFF
@ TRANSITION POINTS between
providers (verbal & written)
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2/3 of serious medical errors occur @
transition points (TJC reports)
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Inter-provider relations & teamwork
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PROVIDER COMMUNICATION
& MEDS
PHARMACIST function
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Legible prescriptions for Pharmacist
Including indications / purpose and/or diagnosis
Explicit directions: “stop Lipitor, start Zocor”
Include all of the following components in order:
dose – strength – units/metric – route – frequency
Guarding against LASA drugs:
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Restoril ordered, Remoran dispensed (Antidepressant)
Patient also taking another anti-depressant
Contact pharmacist about error & join in RCA task
(26)
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PROVIDER COMMUNICATION & MEDS
NURSES and Verbal Orders
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Restricting Verbal Orders – Limit to Emergencies
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Speaking slowly & deliberately
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Specific indications /purpose provided for all
medication, including for “as needed” P.R.N.
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“Read back” verification, with spelling of drug
name as necessary
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Caution w/ sound alike and high alert drugs
Nurses to ask for clarification of illegible or
unclear orders; eliminating second guessing
41
Risk aspects # 7:
Medication Safety
Adverse Medication events related to phases:
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Product labeling, packaging, nomenclature
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Prescribing: Indications, interaction, off label
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Antibiotics, anticoagulants, narcotics,
cardiovascular, steroids; serum levels
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Dispensing: compounding, distribution error
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Administration: wrong drug/ dose/ route
Source: National Coordinating Council on Medication Error Reporting and
Prevention –www.nccmerp.org
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Clinical Protocols
Documenting MEDICATION MONITORING
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Cholesterol – liver panel, lipids
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Anticonvulsants – drug levels, liver, CBC
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Chronic anti-inflammatory /arthritis meds
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kidney function, esp. geriatric patients
Anticoagulant
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Warfarin / Coumadin – INR, PT, PTT
43
Anti Coagulant Monitoring
heparin – warfarin – other anticoagulants
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Warfarin dispensed by pharmacy per Patient
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Clinical pharmacist resource support
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Education about anticoagulants for
prescribers, nurses and pharmacists
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Patient /caregiver education includes
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reasons and benefits of therapy
follow-up monitoring /compliance
dietary restriction; potential drug interaction
44
ABBREVIATIONS “Do Not Use” list
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- NOT: U (unit) or IU (international unit)
- NOT: Q.D., Q.O.D.
- NOT: MS, MSO4, MgSO4
- NOT: Trailing zero (X.0 mg)- write X mg
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- DO use leading zero (NOT .X mg) instead
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Do write 0.X mg
45
Medication security
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Manage controlled substances
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Manage sample drugs
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Storing & securing (authorized access;
log in & out)
No prescription pads in exam rooms
Monitoring expiration dates
Dispensing function
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log in & out; lot #
Recall function
46
Protocol: Prescription refills
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Medical records reviewed prior to renewals for
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Needed labs,
Most recent & next appointment (missed appt?)
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Medication renewals limited to patients
previously seen by medical provider in clinic
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Pain med renewal ONLY by Medical provider
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Document:
 Medication name, dose, amount, date of last
appointment, completed labs as applicable
47
Preventive actions
Associated with Medication Safety
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Patient knowledge: Hx,
liver / kidney disease,
multi prescribers, OTC
Knowledge of proper
dose, interaction,
contraindications
Similar drug names
High risk drugs &
inadequate warning
labels / unclear labels
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Verbal orders
Including purpose on
med order & PRN
Educating patients
Monitor use by patient
& response
Prescriber Access to
Drug Information
Pharmacy Resources
Source: Cohen, Current Issues in Medication Safety, Institute for Safe Medication Practices, 1998. www.ismp.com
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Risk aspect #10:
EQUIPMENT – EOC – EMERGENCY RESPONSE
Emergency protocols implemented and monitored for
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Medical emergency
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1 BLS trained staff on-site at all times
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Crash cart (incl. pediatrics) & checks
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Behavioral
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Building /weather (power outage; fire)
49
Pediatric office emergencies
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“…occur more commonly than perceived by
family physicians; most offices not well
prepared
Obtaining training in pediatric emergencies,
performing mock ‘codes’ to assure office
readiness can improve actual handling of
pediatric emergencies
Common airway emergencies include foreignbody aspiration and croup.”
Source: Wheeler, Kiefer and Poss. American Family Physician, Pediatric Emergency
Preparedness in the Office, June 1, 2000.
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EQUIPMENT LIABILITY
How to protect against risk
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THE EQUIPMENT WAS:
appropriate for procedure
used in reasonable manner (vs. ‘user error’)
inspected for obvious defects prior to use
on regular preventative maintenance schedule
All staff using the equipment were adequately
educated and trained
Procedures developed & staff trained on how to
respond in case of equipment failure
51
Environment of Care
Infection control & Hazardous Material
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Develop, implement and monitor an Infection
control (I.C.) plan pertinent to the facility
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Involve I.C. professional
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Trend I.C. issues & take corrective action
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Protect staff, providers, patients, and
visitors from hazardous material
52
Behavioral Emergencies

OSHA cites healthcare facilities under general
duty clause for failure to prevent patient violence
against healthcare workers
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Medical providers & staff exposed to potentially
dangerous confrontations incl. ill-intended
trespassers

Security audits needed to reveal problems
Address aspects of potential risk of violence

Source: ECRI, HRC Risk Analysis – Overview: Managing Risks in Physician Practices, July
2003.
53
Risk aspect #8: STAFF PERFORMANCE
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Staff qualification & orientation
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Clear directives/protocols & Training
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Staffing levels & Material resources
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Human factor remedies:
distraction, memory overload, fatigue,
confirmation bias
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Performance feedback (data based)
54
Human Factor:
Patient safety Ownership & Just Culture
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Imperfect behaviors, lapses, oversight
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At-risk behaviors -- e.g. shortcuts
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Inadequate realization of risk, poor risk awareness,
inadequate diligence – systems barriers & gaps?
Intentional conduct that unintentionally increases
risk of harm: policy non compliance re: double checks
Reckless behavior /questionable moral judgment
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Recognition of high risk, BUT risk is disregarded;
commission of intentionally hazardous acts -- cause
violation of trust; e.g. alteration of medical records
55
MEDICAL STAFF QUALITY REVIEW
Credentialing & Privileging
RM 103
56
Medical Staff Quality
Peer Review & Credentialing

Credentialing, privileging, and peer
review of medical providers
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Medical quality measures and use of
clinical protocols
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Clinical risk aspects of perinatal,
surgical, behavioral, dental services
57
Risk aspects #5:
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Medical evaluation & Treatment
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Complex medical condition: Cancer, Co-morbidities
Medication therapy
Pre-natal risk factors
Pre-, intra- & post-surgical Tx & evaluation
Use of Practice Guidelines: decrease variability
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Clinical Practice
Asthma, Anticoagulants, Stroke, Pediatric Fever
Complications, preventable
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OB, Surgical procedures, Emergency
Sample protocols can be accessed at http://www.guideline.gov/
58
Clinical Protocols w/ Risk Focus
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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/
59
Risk aspects # 7:
Medication Safety
Adverse Medication events related to 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
Source: National Coordinating Council on Medication Error Reporting and Prevention –
www.nccmerp.org
60
Risk aspects # 6:
Clinical Mis-Diagnosis
Most frequent

Cancer – Myocardial infarction – Stroke –
Meningitis – Acute abdomen – Fractures –
Prenatal risk factors – Infections
Factors
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Atypical signs & symptoms
Incomplete or inaccurate information about
medical history; many co-morbidities
Insufficient diagnostic work up; Delays
61
Pain assessment: a diagnostic Key

Assessment (Pain & Headache) & DOCUMENT
 Location and Radiation (All locations)
 Onset – Duration - Frequency
 Severity (per scale 1 – 10)
 Pain Quality or Type (pressure, cramps etc.)
 Last dose of Pain medication / frequency
 Recent Health history, events, procedures
 Other S & S: weakness, numbness, neck pain,
stiffness, photophobia, diaphoresis, N-V, SOB
(LMP)
62
Confirmation Bias
Paris in the
the Spring
Once we decide that we “know” what
something is, we tend to exclude or neglect
information that may be contrary to our
original perceptions
63
Pre-natal risk assessment

PRE NATAL ASSESSMENT per protocol (standardized)
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PRE NATAL MEDICAL RECORD TO HOSPITAL
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Consistent documentation of ALL prenatal visits
Weekly clinical update; prompt high risk referral
36wk for continuity
Maternal conditions: hypertension \diabetes \drug &
alcohol\ antepartum hemorrhage \ cardiac \ prior PE
http://www.rmf.harvard.edu/; AAFP standards / ACOG standards
64
SURGICAL PROCEDURES
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Scope of Privileges
Patient assessment, pre procedure
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Informed Consent and Refusal


Patient education / Health literacy
Post procedure follow up:


History & Physical
Past events related to procedures
Complication? Infection? Pain?
Updated Treatment plan
65
BEHAVIORAL HEALTHCARE

Initial Assessment & Treatment Plan



Suicide assessment and Safety precautions
Case management
Medication therapy (?informed consent)


Monitoring of effects and compliance
Patient /family education: purpose /side effects

On-going acuity assessment & referrals

Documentation standards & confidentiality
66
Suicide assessment - Document


Concurrent Dx: depression \bi-polar \psychosis
Family history

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Previous patient attempts
Lack of social support

Recent significant loss

Alcohol /drug intoxication
Terminal or chronic debilitating disease
Abrupt withdrawal from normal routine

John Hopkins Health Information, 1998. Spotting the Warning Signs of Suicide


67
Incidental Assessment
of Abuse or Neglect

Domestic violence: child – dep. adult – partner
Mandatory reporting laws: suspect, not prove

How to assess:


Ask about abuse in private w/ respect, non blame
Feel safe? What stress? Should I be concerned?

Emergency plans? Resources: friends, family?

Contusions, abrasions (head, chest, abd); fractures
Abuse during pregnancy



DOCUMENT in detail a n d objectively
68
Risk aspect #9:



Medical Provider Quality Review
Quality measures defined PER SCOPE
Review mechanism - who and how
Electronic information systems


Quality:


Data sources
service volume; guideline adherence
Risk:

adverse outcomes, high risk processes
69
Human Factor: Knowledge & Skill

Communication skills: providers, patients

Documentation skills

Understanding Patient needs:
assessment & clinical monitoring

Clinical /technical judgment & knowledge

Diagnostic skill and experience

Medication knowledge – indications,
interaction, off label use, etc.
70
Credentialing Files: Risk & Quality section

Credentialing files organized into 2 sections

Separate Quality file per practitioner

Sect. A:
Guideline adherence; Documentation

Sect. B:
P.C.E. = Potentially compensable event
Adverse event review
Peer review result

Top Confidential, keep secured
71
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
72
Credentialing process:
Initial and bi-annually





Responsibility of medical staff and board
Include all mid level providers & residents
Documented process to grant privileges

Reference letters address privileges sought

Qualifying education and experience - criteria
NPDB query, all states w/ previous practice

Initial criminal background check

Check all staff & volunteers, all pertinent states
Results of Quality & peer review s/p 2 y.
73
Initial Credentialing Scope - Resources
http://www.aafp.org/online/en/home/practicemgt/privileges/positionpapers.html
Procedural Position Papers

Cesarean Delivery in Family Medicine

Diagnostic OB-GYN Ultrasonography by
Family Physicians

Colposcopy by Family Physicians

Family Physician Interpretation of Outpatient
Radiographs
74
Re-credentialing – Risk Outcomes

Diagnostic and treatment concerns (51%)
 Omissions, delays, errors, lost results
 Referral issues

Adverse Medication outcomes (10%)

Prescribing, dispensing, administering

Complications – OB, Surgical (28%)

Patient & family complaints (clinical focus)
75
California Dept. Managed Health Care (DMHC) Fines
Kaiser Health Plan for Lack of Quality Oversight (7/07)
DMHC observed that of 228 peer-review files, onethird were deficient, such as
 Not handling quality concerns promptly
 Not fully considering a physician’s
complaint history in evaluating peerreview matters.
 Not carrying out corrective actions
HRC Alerts at http://www.ecri.org
76
Re-credentialing – Risk Process

Guideline adherence: e.g. Anticoagulant Tx

Patient assessment & monitoring (MR)

Diagnostic test tracking & follow up

Unclear /inconsistent documentation

Medication errors made (no harm)

Communication – hand-off; after hrs; verbal

Disruptive practitioner
77
PATIENT RELATIONS &
COMMUNICATION
RM 104
78
Risk aspect #1: Patient communication

Patient assessment & interview

Treatment planning & consent
 Conflict resolution; Non compliance
 Behavioral incidents
 Termination of care

Health instruction – literacy – interpreters
 Explain back / read back

Patient feedback & satisfaction


Complaint management
Disclosure
79
Nat. Patient Safety Goals - JCAHO
PATIENT PARTICIPATION -- GUIDELINES
 Goal 13 - Encourage patients’ active involvement in
their own care as a patient safety strategy
 13A: Define & communicate the means for patients
and their families to report concerns about safety
and encourage them to do so
 When patients know what to expect, they are more
aware of possible errors and choices. Patients can
be an important source of information about
potential adverse events and hazardous conditions.
80
Informed Consent


Used whenever an invasive procedure is
proposed that carries a material risk of harm
Need to have a discussion of the





Procedure and benefits (P)
Risks of the procedure ( R)
Alternatives to the procedure (A)
Questions asked (Q)
What should be documented?

Consent process, any questions answered
81
Informed Refusal - signed

Should be obtained whenever refusal to
have a test or procedure done may have
adverse results

Examples

Mammograms

Chest or other x-rays

Cardiac work-ups

Lumbar punctures

Other
82
Informed Refusal – sample text





This is to certify that I, __ a patient @ CHC, am refusing
to permit the following procedure___ against advice of
my medical provider __ (name) because ___ .
My present diagnosis and condition, specific medical
risks of my refusal, and alternative treatment have been
fully explained to me.
I was given the opportunity to ask questions which
have been answered.
I hereby release __ CHC and its medical providers from
liability for any consequences of my treatment refusal.
Signed ______
Date____ Time ___ Witness ____
83
Medication safety &
PATIENT COMMUNICATION

50% non-adherence to prescribed meds

10% hospital admission (older adults)

8.4 mio not taking hypertension meds

Continuity vs. episodic care; missed appt

Medical literacy & English proficiency

Lay language & validated understanding

Hearing, vision, cognitive limitations ?

Eliciting information & closing loop at next visit
84
Medication Reconciliation

RN/ MA intake interview: takes time
 Interview skills
 Medication knowledge
 Pt. brings in all current medications & OTC
 Establish / update Medication Inventory




Keep in visible location on pt. chart
Patient keeps copy and updates
Patient uses Medication inventory daily
Update medication supply @ each visit to
reduce refill requests between visits
85
Personal Health Record (PHR)

Manual or electronic version


Portable / Paper / web based / CD ROM
Content




Updated medication list incl. OTC
Allergies & immunizations w/ dates
Significant recent diagnostic test results
Medical history incl. procedures




Family medical history
Special diet and other health measures
Health insurance information
Living will
86
Telephone triage & Documentation
Using protocols adopted by medical staff,
or direct consultation w/ med. provider

Name of Call recipient & purpose of call
Advice & orders given (prescription refills)
Follow-up instructions & comprehension
Legible, full sentences, no abbreviations.
Date, time, AND initial of medical provider

Review through Q.I. process: assure competency





Based on criteria of clinical protocols
87
Telephone communication w/ Patients

Document phone calls incl. AFTER HOURS
calls, in the medical record if the following
was discussed:
 medical symptoms, new or continued
 abnormal test results reported
 medical advice offered
 disagreement about medical treatment
 prescriptions provided
88
Missed scheduled appointments

Tracking high-risk patients who miss
scheduled appointment

Diagnostic results? Specialist referral?

Written correspondence with patient include
medical implication of missing appointments

Documenting all notification attempts

If worsened outcome possible, a certified
letter is sent, with copy & receipt in medical
record
89
Risk ID through Patient Complaint

Categorize types of complaints

Prioritize by severity & risk level

Establish who is responsible for
responding to the complaints

Log and trend complaints & resolution

Address systems issues through P.I.
90
Why Do People Sue?

Study of law suits against a large medical
center indicated Problematic Relationships:

Perceived desertion of the patient

Devaluing patient and/or family views

Poorly delivering health information

Failing to understand the perspective of
patient and/or family
91
Risk-related Inventory
Reasons for Care Termination

Group A


1. Repeatedly missing appointments w/out prior notification
2. Disagreement over treatment recommendations
3. Non-adherence /non-cooperation w/ treatment plan

Group B


1. Verbally disruptive and hostile behavior toward medical
provider and/or staff [by patient or family /caregiver]
2. Threatening behavior toward medical provider / staff

Group C

1. Noncompliance with office policy re: prescriptions

Group D

1. Delinquency on bill payments

92
Termination of Care
Solution of ‘last resort’

Patient given notice of termination


Patient given reasonable amount of time in
which to obtain alternative care


Evidence of certified letter in chart
Usually thirty days
Patient given assistance in obtaining
alternative care

e.g., a list of appropriate potential providers
93
Perhaps not now -- Termination of Care


During treatment for an imminent or unstable
medical condition

Mental health disability if yet untreated

in process of medical workup for diagnosis
Pregnant patient, approx. last trimester

Pregnant patient approx. last 2 trimesters if high risk

Patient in immediate postoperative stage

Precaution w/discrimination issues, e.g. HIV

Remote area and lack of alternate providers
94
• 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
95