Transcript AN OVERVIEW PRESENTATION - MidWest Clinicians` Network

Clinical Risk
Management: 101
AN OVERVIEW PRESENTATION
FOR
MIDWEST CLINICIANS NETWORK
WEBINAR & PHONE
THURSDAY, OCTOBER 8, 2009
Your Presenters Today Are…….
Becky Simer RN BS
Network Performance Improve Manager for
IA/NEPCA
and
Linda Ruble ARNP PA
Clinical Consultant for
HRSA and IA/NEPCA,
DEFINITION of “RISK MANAGEMENT”
RISK: The possibility of loss or injury;
peril; a dangerous element
MANAGEMENT: The act or art of
conducting or supervising something or the
judicious means to accomplish an end.
SO, PREPARE!!!
Our goal is to
identify the
“dangerous
elements” in our
environment,
processes and
products, and
minimize the
possibility of loss,
injury, and…. (yes)
peril.
THINK:
If
something
can go
wrong, it
will…
Murphy’s Law
FTCA (Federal Tort Claims Act)
Claims Data
2004 - 2008
THERE ARE 937 FTCA DEEMED
HEALTH CENTERS, REPRESENTING
87% OF THE TOTAL NUMBER OF
HEALTH CENTERS (CY2009)
HRSA Medical Claims
Total Claims by Nature of Occurrence (2004 - 2008)
80
60
40
20
0
2004
2005
2006
2007
2008
Diagnosis Related
54
48
68
75
67
Obstetrics Related
55
68
57
55
73
Treatment Related
54
31
25
53
59
Medication Related
19
25
16
33
35
7
14
15
10
22
24
22
3
15
6
3
Surgery Related
NULL
Other Miscellaneous
Anesthesia Related
10
1
1
5
HRSA Medical Claims
Standard of Care Met or Not Met
Standard of Care (2004 - 2008)
2008
133
2007
121
2006
2005
9
96
85
26
100
91
7
97
117
2004
0%
126
20%
Met
28
86
40%
Not Met
60%
27
80%
Unable to Determine
100%
HRSA Claims by Secondary Factors
Identified
Secondary Factors Identified (2004 - 2008)
140
120
100
80
60
40
20
0
2004
2005
2006
2007
2008
Documentation
106
100
80
120
139
Policies/Protocols/Procedures
103
77
65
125
114
Training/Lack of Supervision
37
87
72
110
134
Communication
3
28
21
93
89
No Secondary Factors Found
50
29
51
38
42
Referral Issues/Recurring Complaint
15
5
4
39
19
Staffing/Availability/Scheduling
24
4
8
9
18
[FOR THIS
PRESENTATION
ONLY]
This Symbol,
Represents
EMR
Project
Enhancement
↓
Primary Liabilities for
PROVIDERS
Lack of documentation of treatment
Inadequate work-up (based on accepted standards)
Acts of others (e.g. nurses) if exercising control
Failure to follow up
Mistaken identity (provider and center)
Misdiagnosis, if based on inadequate examination and testing
Wrong diagnosis followed by improper treatment causing injury
MORE Primary Liabilities for PROVIDERS
Wrong treatment or procedure based on diagnosis.
Treatment outside field of competence (or not privileged for)
Abandonment (neglect or failure to follow up after the acute stage of illness – unilateral
termination of the physician patient relationship without notice to the patient)
Failure to obtain full informed consent
Failure to see consultation or refer to a medical/surgical specialist
Use of unprecedented procedures, unless approved by a respectable minority of medical
opinion
MORE Primary Liabilities for Providers
Failure to order diagnostic tests that are considered to be a
“matter of common knowledge”
Failure to obtain results of diagnostic tests ordered
Infections resulting from failure to utilize proper procedures or
precautions
Aggravation and/or activation of a preexisting condition if injury
results
Premature dismissal or discharge of patient
Primary Liabilities
of NURSES
Administration of drugs inconsistent with prevailing statutes,
nurse practice acts, or institutional policies
Failure to follow provider orders
Failure to report significant concerns or changes in a patient’s
condition
Failure to take correct verbal or telephone orders
A FEW More for NURSES…
Patient burns
Patient falls
Failure to report defective equipment
Failure to follow established policies or procedures
Negligent handling of patient valuables
What About “Negligence”?
As a basis for
malpractice,
negligence
means lack
of proper or
reasonable
care
• “Proper Care” is
based on a defined
standard established by
law to protect others
against harm; in
medical malpractice,
“proper care” is judged
by peers;
• “Reasonable Care”
means there is both a
rationale for doing and
for not doing, and that
rationale is the basis for
decision making
NEGLIGENT CONDUCT
Doing what a reasonable person would not do
Failure to do what a reasonable person would do:
• Exercise reasonable care
• Protect or assist another
[Contributory negligence: A plaintiff’s proven
contribution to his or her own harm, perhaps forcing
forfeiture of claim]
BURDEN OF PROOF for
NEGLIGENCE
ALL THREE (3) elements must be proven!!!
1)
BREACH of DUTY – Based on policies or procedures, or
reasonable standards of care (laws, regulations, or peers)

DUTY
 Ensure patient’s safety throughout “transaction” (visit)
 Protect from foreseeable harm
 Protect from malpractice
2)
MEASURABLE HARM -- (Injury)
3)
CAUSATION – (The breach of duty caused the injury)
Highest Number of Claims
in AMBULATORY CARE by SPECIALTY
Internal Medicine
Family Practice
Ob/Gyn
TOP ALLEGATIONS
• Failure to diagnose
• Failure to perform
surgery
• Improper performance of
tests or procedures
• Delay in diagnosis
• Improper management
of course of treatment
• Failure to communicate
• Lack of informed consent
RISK MANAGEMENT is….
An ORGANIZATIONWIDE PERFORMANCE
IMPROVEMENT PROCESS
considered by most references to be one key component of the giant
quality umbrella
Risk management needs good outcomes;
good outcomes require good quality
management
Quality
Management
Risk
Management
Good
Outcomes
QI and RM Share…
A
commitment to eliminate or reduce problems in
patient care and maximize patient safety
 Concern for prevention of harm and loss
EFFECTIVE RISK MANAGEMENTS EMPHASIZES
“HARM PREVENTION” FOR PATIENTS,
VISITORS AND STAFF MORE
THAN FINANCIAL LOSS.
RISK MANAGEMENT and
QUALITY MANAGEMENT
GO “HAND-IN-HAND”
“QUALITY IS THE OPTIMAL
ACHIEVEMENT OF THERAPEUTIC
BENEFIT AND AVOIDANCE OF
RISK AND MINIMIZATION OF
HARM.”
THE JOINT COMMISSION
QI and RM Share…
Improved processes for QI enhances RM
 Both benefit from efficient resource utilization and minimal
effort duplication
 Both are committed to reducing problems for patients and
maximizing their safety and good care
 Both are concerned for prevention of harm and loss.

RISK MANAGEMENT and QUALITY IMPROVEMENT
have mutual “CAUSATIVE, POSITIVE CORRELATION”!!!
RISK MANAGEMENT
FOR
AMBULATORY CLINICS
RISK MANAGEMENT Specific to
Ambulatory Clinics or Health Centers
Patient scheduling must be defined by written protocols.
Have clear guidelines for triage, especially for emergency and
urgent visits
Missed appointments should be brought to the provider and
documented in the medical record
Keep appointment records for as long as the clinic records are
kept
Maintain clear policies for triage or urgent visits and stick to
them
RISK MANAGEMENT Specific to
Ambulatory Clinics or Health Centers
Have written policies for patient tracking of referrals and diagnostic follow up
• Log labs, diagnostic tests and referrals; keep tickler file
• If serious and cannot contact patient, send certified letter
Keep tickler of recommended preventative testing and document informed
refusals
• One role is held accountable for maintaining up-to-date follow up
Keep medication sheet in MR with date, name of med ordered, dose, quantity, #
of refills, provider’s initials, staff initials, and any adverse reactions.
Document and check allergy status consistently
RISK MANAGEMENT Specific to
Ambulatory Clinics or Health Centers
Referrals
•
•
•
•
•
Document referrals in chart with timeframes
Document conversations between providers
Send pertinent records
Include all patient communications
Develop procedure to monitor receipt of
consult reports
• Providers must review and initial ALL
reports before adding to MR
Patient Education
Review all written materials for accuracy before adopting
them
Create policies for readability regarding health literacy and
cultural diversity in education materials
Maintain a master file and archived files of all patient
education materials along with dates used
Have patients confirm understanding of instructions and
return demonstration if applicable
Ask provider and patients to sign off on important
instructions
RM for Clinics
Give and get report after practice coverage. Put documentation in patient charts
Locum Tenens: Credentialing and privileging is essential, along with abbreviated orientation
Triage Policy and Telephone Protocols:
• Consider checklist form organized by S/S or pt. complaint
• With triage, err on the site of caution with appointments. or referrals to
urgent care or ER
• PULL CHART and check medical record if symptomatic
Receptionists can handle administrative calls but NURSES SHOULD HANDLE CALLS THAT
INVOLVE PATIENTS WITH SYMPTOMS. These calls should be documented in the medical
record.
INFORMED CONSENT
Remains a persistent basis for liability claims
Responsibility belongs to the care provider who is to conduct the
proposed test or treatment
Support staff may have the patient read but not sign, prior to the
provider’s review with the patient.
Exceptions:
• Life threatening illness or injury needing immediate attention
• Patient cannot communication or take part in communication
• There is no time to secure treatment authorization from someone else who is
legally empowered to act on patient’s behalf.
MEDICAL ERRORS
“AN ACT OF COMMISSION (DOING
SOMETHING WRONG) OR OMISSION
(FAILURE TO DO THE RIGHT THING) THAT
LEADS TO AN UNDESIRABLE OUTCOME OR
SIGNIFICANT POTENTIAL FOR SUCH AN
OUTCOME”
“CATEGORIZATION” of Medical Errors
“Active Errors” or errors at the “Sharp End” occur at
point of contact between a human and some aspect of
the system (e.g. instrument, machine) or patient
“Latent Errors” or errors at the “Blunt End” occur
through failures of organization, design, or layers of the
healthcare system affecting the human making contact
“Error Chain” is a series of events that lead to an
adverse outcome, typically uncovered by a “root cause
analysis” (Swiss Cheese Model)
The SWISS CHEESE ERROR Model
Taking a Risk with Swiss Cheese Demonstration
http://lessons.workforceconnect.org/reflib/defan
And “TYPES” of ERRORS
Error: Failure of a planned action to be completed as intended
or use of a wrong plan to achieve an aim
Adverse Event: An injury resulting from a medical intervention
Serious Error: An error causing permanent injury or transient
but potentially life-threatening harm
Minor Error: An error causing harm that is neither permanent
nor life-threatening
Near Miss: An error that could have caused harm but did not,
either by chance or intervention
Most Common Medical Errors (IHI)
Missed and delayed diagnoses
Medication errors
Delayed reporting of results
Miscommunications during transitions in care
UNDERLYING CAUSES of
MEDICAL ERRORS (IHI)
Communication problems
Inadequate information flow
Human factors-related problems
Patient-related issues
Organizational transfer of knowledge
Staffing patterns and workflow
Technical failures
Inadequate policies and procedures
SBAR
(Situational Briefing Model)
SBAR facilitates clear communication between staff
and providers
SBAR is a standardized situational briefing model
BEFORE using SBAR and talking to provider:
•
•
•
•
Assess the situation
Know the primary diagnosis
Read recent progress notes, assessments, and labs
Have chart or medical record available
SBAR (pronounced ‘S’-bar)
SITUATION – (I need to tell you about…)
BACKGROUND
ASSESSMENT -- (what has changed)
RECOMMENDATION
MEDICATION ERRORS
EVENTS RELATED TO MEDICATIONS
ARE THE THIRD-LEADING CAUSE OF
DEATH IN THE US AFTER HEART
DISEASE AND CANCER
MEDICATION Errors
in Clinics
Incorrect prescribed dosage
Incorrect medication for diagnosis or condition
Multiple pharmacy prescriptions
Medication incompatibility
Inappropriate dispensing of sample meds
Illegible handwriting on prescriptions
Verbal Orders? No, no!!
Verbal orders (VOs) are a major cause of medication errors
VOs should be eliminated except in emergency situations
As an extra check, spell unfamiliar drug names, with “T for Tom” and “C for Charlie”
Pronounce each numerical digit separately saying “one six” instead of “sixteen” to avoid
confusion with “sixty
The receiver must ensure that the verbal order makes sense with the patient’s diagnosis
IF VOs are allowed, prescribers must enunciate; receiver should always repeat the
order to the prescriber to avoid misinterpretation
The MANDATORY READ BACK policy is essential for critical lab results also
OTHER RISK MANAGEMENT RULES
TO PREVENT MED ERRORS
Always put the indication for the medication on the order
Order should be complete including strength & concentration of medication, route, and
rate of administration (if applicable)
Do not use any abbreviations or use very sparingly
NEVER use “DO NOT USE” abbreviations
Verbal orders are used in emergencies only
Script pads are locked and stored away from patient care
Never pre-sign or post-date prescriptions
MORE MEDICATION ERROR
RISK MANAGEMENT RULES
Track manufacturer lot numbers
Avoid samples or review policies for RM
Monitor expiration dates and remove outdates
Keep medication samples locked
Lot numbers of any samples given to patients should be
recorded in the medical record
High Risk Patient Populations
Renal/liver impairment
Pregnant/breastfeeding patients
Neonates
Elderly/chronically ill patients
Patients on multiple meds
Patients with multiple co-morbidities
Oncology patients
It comes down to
COMMUNICATION
60% of med errors are caused by
mistakes in interpersonal
communication. (Joint Commission)
Introduction to
National Patient Safety Goals
PROVIDED COURTESY OF THE
JOINT COMMISSION
FOCUSING ON THOSE RELATED TO
MEDICATION ERRORS
Accurately & completely RECONCILE MEDICATIONS
across the continuum of care (Goal 8)
“There (must be a) process for comparing the
patient’s current medications with those ordered
for the patient while under the care of the
organization.”
The Joint Commission
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_amb_npsgs.htm
Medication Reconciliation
When a patient is referred to or transferred from one
organization to another, the complete and reconciled list of
medications is communicated to the next provider of service and
the communication is documented.
When a patient leaves the organization’s direct care directly to
his/her home, the complete & reconciled list of medications is
provided to the patient’s known PCP, or the original referring
provider, or a known next provider of service.
When a patient leaves the organization’s care, a complete &
reconciled list of the patient’s medications is provided directly to
the patient & the patient’s family as needed, and this list is
explained to the patient and/or family.
“DO NOT USE” ABBREVIATION LIST
http://www.jointcommission.org/PatientSafety/DoNotUseList/
There are TONS of TIPS for
“Implementing Elimination of
Dangerous Abbreviations”…
HTTP://WWW.JOINTCOMMISSION.ORG/
PATIENTSAFETY/
NATIONALPATIENTSAFETYGOALS/ABBR_TIPS.HTM
Look Alike – Sound Alike Meds
for AMBULATORY CARE
“LASA” MEDICATIONS
HTTP://WWW.JOINTCOMMISSION.ORG/
NR/RDONLYRES/C92AAB3F-A9BD-431C-862811DD2D1D53CC/0/LASA.PDF
Confusing Drug Names
•Losec (Omeorazole) and Lasix (Frusemide)
•Avanza (Mirtazapine) and Avandia (Rosiglitazone)
•Celebrex (Celecoxib) and Cerebyx (Fosphenytoin)
and Celexa (citalopram hydrobromide)
•Reminyl (Galantamine) and Amaryl (Glimepiride)
•Diamox (Acetazolamide) and Zimox (Amoxicillin)
•Lamisil (Terbeniafen) and Lamictal (Lamotrigine)
•Taxol (Paclitaxel) and Taxotere (Docetaxel)
More Confusing Drug Names
Avandia (rosiglitazone) and Coumadin (warfarin)
Catapres (clonidine) and Klonopin(clonazepam),
Concentrated Roxanol and oral morphine liquid (traditional concentration)
Hydromorphone injection and morphine injection
Insulin products
• Humalog and Humulin, Novolog and Novolin, Humulin and Novolin, Humalog and Novolog, Novolin
70/30 and Novolog Mix 70/30
Lorazepam (Ativan) and alprazolam (Xanax)
Topamax (topiramate) and Toprol-xl (metoprolol).
Flagyl (metronidazole) and Glucophage (metformin)
Zyprexa (olanzapine) and Zyrtec (cetirizine)
RISK MANAGEMENT for “LASA’s”
Consider when adding to formulary
Use both brand names and generic names when possible
Change appearance of look-alikes on labels and records by bolding, highlighting, or
enlarging the letters that are different
Change order on computer screens so they don’t appear consecutively
Store in different locations in pharmacy.
Employ independent double checks in dispensing: one interprets and enters into
computer; another reviews the printed label against the original prescription
Who would imagine confusion between
these two products?
Zyrtec or Lipitor?
How about even “high-risk
medications”?
Avandia or Coumadin
ISMP (Institute for Safe
Medication Practices)
HAS PROVIDED A LIST OF
HIGH ALERT
MEDICATIONS
(SEE ATTACHMENT)
HIGH ALERT
MEDICATIONS
“HIGH-ALERT MEDICATIONS”
HEIGHTENED
RISK
OF
ARE DRUGS
CAUSING
THAT BEAR A
SIGNIFICANT
PATIENT
HARM WHEN THEY ARE USED IN ERROR.
ALTHOUGH
MISTAKES
MAY
OR
MAY
NOT
BE
MORE
COMMON WITH THESE DRUGS, THE CONSEQUENCES OF AN
ERROR ARE CLEARLY MORE DEVASTATING TO PATIENTS.
HIGH ALERT MEDICATIONS
http://www.ismp.org/Tools/highalertmedications.pdf
HIGH ALERT MEDICATIONS (ISMP):
Purpose of List
Improving access to information about these drugs
Limiting access to high-alert medications
Using auxiliary labels and automated alerts
Standardizing the ordering, storage, preparation, and administration
of these products
Employing redundancies such as automated or independent double
checks when necessary
THE RISK MANAGEMENT
PLAN
AND ITS ESSENTIAL COMPONENTS!
HRSA FTCA (Federal Tort Claims Act) DIRECTION
PAL 2009-05 (http://bphc.hrsa.gov/policy/pal0905/)
Application requires information on the following health center activities:
• Risk Management Systems
• Board approved Quality Assurance/Quality Improvement Plan
• Clinical protocols
• Patient records management
• Patient follow up and tracking
• Incident tracking and reporting
• Peer review/staff training
• Credentialing Systems
• Primary Source Verification
• Verification of education and training, board certification, professional references,
health fitness,
• National Practitioner Data Bank (NPDB) query
• Formal Privileging Process
• Professional Liability History
RM Plan Should Include At Minimum:
Policy or statement of purpose
Goals
Scope, including linkages with QM, case management, patient safety, and safety
management
Authority and responsibilities of:
•
•
•
•
Governing body
Administration
Physicians/Licensed Independent Practitioners
Risk Manager, Quality Manager, Patient Safety Officer(s), Case
Management Director, and other roles
RISK MANAGEMENT PLAN:
Additional Components
Confidentiality and Conflict of Interest Policies
Data sources and referrals
Documentation and reporting mechanisms
Integration of activities and information
Program evaluation
Organizational charts and flow charts as applicable
RISK MANAGEMENT PLAN: Standards
FOR EXAMPLE:
Risk Management is a leadership (governing body, administration,
medical/professional staff, management) activity linked to quality and safety
Regarding quality and safety, leaders are responsible for organization wide
planning for structures and process, establishing priorities for Performance
Improvement, including high-risk procedures.…., and designing new or
modified processes, while implementing an integrated patient safety
program.
Include Description of RM Model and
Systems
DO include organizational model and/or vision (“just culture”) as well as
safety standards, audit practice, and guidelines for occurrence or incident
reporting
DO describe tracking & analysis mechanisms for RM and QI
DO NOT use an originating occurrence reporting form itself in any peer
review activities. Abstract important information onto a practical tool to
utilize for the review
DO NOT document the name of the person originating the occurrence
report. It is adequate to state that the issue originated in QM
RM Models and Systems
FOR SINGLE SITE OR MULTIPLE SITE
CLINIC SETTINGS
Organizational Models for
Risk Management
A RM Committee (may be closely linked to QI Committee:
subcommittee or regular component of QI agenda)
A RM Director or Coordinator (may be part of QI or
Compliance role)
• Supervisors and managers work with designated RM Lead
to report occurrences and potential adverse events;
possible risk factors; and department specific and
organization wide safety initiatives
Smaller Clinics: Center Manager or Director incorporates
risk management plan into daily operations
Clinical Risk Management Models
Early Warning System
An organization-wide system to screen all patients
and systems for real or potential adverse incidents,
issues, and occurrences that might result in
increased risk to the organization and/or less than
optimal quality of care
Clinical Risk Management Models
Generic Screens -- Used to concurrently screen every ambulatory
patient encounter for given time periods. Covers all important aspects
of a visit; or may be modified according to specific concerns or services
• A general adverse outcome criteria set serves a warning for a
claim or increased risk, which is then proactively addressed.
This method is statistically effective in identifying nearly all
occurrences.
Adverse Patient Occurrences (APOs) – Unexpected untoward events
with actual or potential negative impact on the patient
Potentially Compensable Events (PCEs) -- Those APOs that might
become claims based on the degree of actual or potential negative impact
on the patient
Clinical Risk Management Models
Predicting Adverse Events
Use analysis and historical data to predict potential for adverse occurrence, degree
of risk, and to estimate financial impact on the organization in case of occurrence
Prioritize risks by frequency, severity, and potential for reduction
Investigate potential risks
Map processes and systems and analyze for risk reduction
Utilize PDSA’s to identify improved processes to eradicate identified risk
DATA COLLECTION
AND ANALYSIS
COLLECTION AND ANALYSIS
OF RELATED DATA IS AN
ESSENTIAL COMPONENT OF
ALL EFFECTIVE RISK
MANAGEMENT PLANS
Continuous Measurement
of Risk Management Data
Occurrence reporting
Performance measures
Quality and utilization management screening
Surveillance, audits, and surveys
External review data/denials
Patient satisfaction/dissatisfaction and complaints/grievances
Financial audits and billing disputes
Continuous Measurement
of Risk Management Data
Root Cause Analyses (RCA), Failure Mode and Effect Analyses , special
studies
Grapevine information system and anonymous reporting
Physician/nurse referrals
Safety and other committees
Observation of daily operations and care
Review of contracts
Making the Data MEANINGFUL
Analyze all data in a variety of
relationships and perspectives to identify
trends or spikes
Utilize PDSA’s or other improvement
initiatives (start small and do pilots
first) to address trends before they
become big problems.
Other Significant RM Data
Review:
• Any recent or current liability claims
• Cases where patient’s medical records are
requested
• Case types identified through literature review,
news media, or new state or federal law
• Practices that may create liability
• ALL occurrence or incident reports
OCCURRENCE Vs. INCIDENT?
Occurrence Reporting uses generic screening to
catch APOs. RM determines which APOs may be PCEs
• Supports ongoing data collection, tracking, trending, and
analysis
• Allows timely intervention
• Allows identification of areas for preventive action
Incident Reporting is the oldest method of risk
identification and analyzing loss potential
• Is largely anecdotal
• Is an internal source for actual or potential compensable
events
• Is historically an administrative documentation system
and is generally considered “discoverable”
Occurrence/Incident Report
Tracking and Analysis
Set up an organizational system for
tracking occurrences
• According to service line
• According to problem or cause, or type of problem or
cause
• May need to categorize in multiple ways to ensure
accurate tracking (systems, processes, time, place)
• Use this as a tool to track and trend systems problems or
issues in certain services
• Include categories for equipment problems and
medication problems, and ensure appropriate follow up
National Patient Safety Foundation
ENCOURAGES ALL WORKERS TO ACCEPT
RESPONSIBILITY FOR THE SAFETY OF
THEMSELVES, THEIR COWORKERS,
PATIENTS AND VISITORS
BREAK TIME / INTERMISSION
COMMUNICATION
Insurance claims administrators and medical
liability defense attorneys estimate that
communication failure is a contributing factor in 80%
of all professional claims and lawsuits
In 20% of the cases, it is the primary reason for the
filing of the lawsuit.
Provider Communication
JOINT COMMISSION HAS BUILT SEVERAL
STRATEGIES TO IMPROVE
PROVIDER COMMUNICATION
INTO
NATIONAL PATIENT SAFETY GOALS
E4 Component of Clinical Care
1) ENGAGEMENT



Greet by name with patient fully clothed
Be curious about the person
Learn person’s agenda, including goals and all complaints
2) EMPATHY



Validate expressed fears, concerns, symptoms, and pain
Sit, maintain eye contact, remove physically barriers
Learn to have open and relaxed body language
E4 Component of Clinical Care
3) EDUCATE – about the encounter, diagnosis, etiology,
treatment options and follow up




Assess current knowledge
Assume there will be questions
Reassure patients that there will be time available for them to ask
questions
Ensure patient understands information provided by asking them to
restate
4) ENLISTMENT –


Invitation to patient to collaborate in decision making and
compliance.
Many patients have a self diagnosis. Provide rationale for yours
ANGRY or DIFFICULT?
THIS IS NOT A TYPE OF PATIENT, BUT
A CLINICIAN EXPERIENCE. (SORRY…)
The experience is based on interaction between the
patient and the provider
Difficulties stem from frustrations (either
party), inflexibility, and misaligned
expectations
• Be aware that anger is expressed both verbally and
non-verbally
• Acknowledge the patient’s anger or dissatisfaction.
• Establish the goal to assist him or her in expressing
and resolving concerns in the best possible manner
• Allow the patient to express her/his anger in a
private area, away from other patients.
Frustrating or Difficult Visits
(continued)
Demonstrate empathy
Focus on content rather than delivery of patient’s message
Use self disclosure cautiously and when appropriate
After the patient has vented, respond by talking about those issues that can be
readily resolved
Enlist patient in the problem solving and get his/her input before
determining plan of action
DOCUMENT EVERYTHING, omit nothing.
How to Handle an Adverse Outcome or
Potential Adverse Event
 COMMUNICATION is an essential liability
avoidance measure
 DISCLOSURE is core in management of clinical
crises, adverse outcomes, unanticipated events,
medical errors, and medical mishaps
 For consistency, centers should establish and use
similar terms and nomenclature for DISCLOSURE
DISCLOSURE METHODS
 DISCLOSURE MODELS



One person (RM or QI)
Team Model (RM, Manager,
Key Staff involved)
Just in Time – Disclose at
the point of care or adverse
event. This is the ideal
model
 DISCLOSURE
STRATEGIES




Acknowledgement that the
event occurred
Communication of regret
An apology
Objective statements
What occurred
 Event is being investigated
 Steps will be taken to avoid
recurrence


Remain in close contact with
pt. and family till resolved
“Best Practice” Communication
Failure to communicate effectively is responsible for the vast
majority of avoidable accidents
Replace top down communication with bi-directional
communication
A majority of healthcare workers regularly see colleagues break
rules, make mistakes, fail to offer support, and/or appear
critically incompetent. LESS THAN 20% SAY ANYTHING
ABOUT IT!
How to Implement a
Reliable and Consistent
Occurrence Reporting System
OR,
“PLEASE DON’T FIRE THE MESSENGER!
MYTHS that PREVENT
OCCURRENCE REPORTING
“If I can make it right, it’s not an error.”
“If it’s not my issue, it is not an error.”
“If another patient’s needs took priority over this, it is not an
error.”
“A ‘Clerical’ (documentation) error is not a real med error.”
“If my actions prevent something worse, it is not an error.”
Creating a “JUST CULTURE of
Safety”
“THE MEDICAL CULTURE THAT SILENTLY TAUGHT
THE ABC’S AS ACCUSE, BLAME AND CRITICIZE IS
FADING. RISING IN ITS PLACE IS A SAFETY
CULTURE EMPHASIZING BLAMELESS REPORTING,
SUCCESSFUL SYSTEMS, KNOWLEDGE, RESPECT,
CONFIDENTIALITY, AND TRUST.”
DR. TOM HELLMICH OF PATIENT SAFETY COUNCIL
For Decades, Occurrence Reports Often Led
to Termination
Staff were afraid to report
errors or near misses for
fear of repercussions to
themselves or their coworkers.
If asked to fill one out by a
supervisor, staff felt like
there was automatic
blame placed on the one
who wrote or reported it.
Transition from Punitive Response
to “Blameless” Reporting
There was an interim period in the late 80’s and 90’s
termed a “non-punitive culture.” This raised concerns
that people who acted recklessly would not be held
accountable. While leadership talked “non-punitive,”
occurrence reporting continued to be avoided by many
employees fearing repercussions and blame for
reporting errors.
Creating the “JUST CULTURE”
in Healthcare
Lucien Leape, Harvard surgeon, father of recent
patient safety movement, introduced the “just
culture”… “Having a safety culture doesn’t mean
there is no role for punishment. Punishment is
indicated for willful misconduct, reckless behavior,
and unjustified, deliberate violation of rules… but
not for human error.”
More on the “JUST CULTURE”
David Marx, Attorney in HR and Organizational Development
Providers in a ‘just culture’ must:
•
•
•
•
•
•
Recognize that professionals make mistakes
Acknowledge that even professionals will use shortcuts
Support zero tolerance for reckless behaviors
Openly admit that, “I have made a mistake.”
Call out when they see risk
Participate in a learning culture (where information about
mistakes and near misses is shared with others so they can
prevent similar situations.)
• Must be sensitive to risk, as they try to identify where and
how the next mistake might occur, and then work to prevent
it form happening.
“SILENCE KILLS: THE SEVEN CRUCIAL
CONVERSATIONS IN HEALTHCARE”
Book by Stacy Nelson, EdD: Referenced by Joint Commission recommendations—
www.silencekills.com

This book and the study it details is the first attempt to
link people’s ability to discuss emotionally and
politically risky topics in a healthcare setting with
key results in:
 Patient safety
 Quality of care
 Decreased turnover in nursing
This study identifies SEVEN categories
of conversation which are…
…especially difficult, and at the same
time appear to be especially essential
for people in healthcare to master:
•
•
•
•
•
•
•
Broken rules
Mistakes
Lack of support
Incompetence
Poor teamwork
Disrespect
Micromanagement
Benefits of “Tough” Conversations
The study shows that the 10% of healthcare workers
who are confident in their ability to raise those
“sensitive” concerns:
•
•
•
•
Experience better patient outcomes
Work harder
Are more satisfied
And are more committed to their jobs
A primary goal for healthcare leaders is to create an
environment that encourages open discussion and
transparency in these sensitive conversations.
Suggestions for Leadership to Encourage
Openness in “Sensitive” Topics
“Have you observed any actions or omissions that could have
caused patient harm but didn’t? Tell me about it.”
“Do you feel comfortable speaking to other care providers if you feel
they are jeopardizing patient safety? Do you feel comfortable
reporting lapses you observe in patient safety? Why or why not?”
“Can you tell me about a time when a patient was harmed? Tell me
how you think that happened and your ideas on how we could
prevent it from happening again.”
Occurrences may appear to increase at first, but that is due
to more honest and realistic reporting of actual and potential
adverse events.
Leaders in Risk Management
Change Agent:
• Uses PI processes for & in RM and RM processes for &
in PI
• Part of PI team: identifies RM and safety related issues
in PI projects and points them out constructively
• Encourages researching other centers’ solutions;
frequently uses PDSA’s
• Actively opens up “silo” mentality in center or
organization
• Uses a team-based model with all stakeholders
involved in solutions, including patients when possible
Leaders in Risk Management
Prioritize and advocate for safety above financial and
operational goals
Encourage and reward identification, communication, and
resolution of safety issues
Provide for organizational learning from accidents
Allocate appropriate resources, structure, and accountability to
maintain safety systems
Absolutely avoid modeling reckless behavior in any form or in
management decisions
Leadership Pitfalls
B
E
W
A
R
E
•
Beware of introducing a NEW
risk by implementing a
solution whose implications
have not been fully assessed.
•
Do not change a process based
on one disastrous occurrence,
without assessing a “special
cause variation.”
High Quality Care is Safe Care
Remember, it’s
really all about
providing safe,
quality care for our
patients.
Any questions,
please feel free to call or write:
Becky Simer, RN BS
[email protected]
(W)515-333-5014
(C) 515-868-8458
THANK
Linda Ruble, PA ARNP
[email protected]
(H) 515-255-4147
(C) 515-778-3318 (Never
answers cell when driving – a part
of her personal risk management
plan!)
YOU!!!