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Patient Safety, FTCA, RM, and Quality Working Together

December 2, 2008

Petra S. Berger PhD RN, CPHRMHealthcare Quality, Risk, and Patient Safety Consultant

pberger@rmpsi.com - Phone: 517–281-7816

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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.

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Concepts of Integration in QM/QI, RM, Patient safety, and FTCA

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Bridging the Quality Chasm

QUALITY MANAGEMENT

Patient Safety = Q. I. Risk Management

= identify risk – respond – prevent

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QUALITY GOALS: 4 + RM on O N E Quality Management

Platform Clinical Effectiveness: e.g. hypertension, DM

Continuity of care vs. fragmentation missed diagnosis

Patient Satisfaction complaint management

Regulatory compliance: e.g. P & Ps after hours coverage patient education omitted

Efficiency, UR, Cost control some staff unqualified for job scope

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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/

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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

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CORE PURPOSE of PROACTIVE RISK MANAGEMENT

S T O P ADVERSE OUTCOMES

Eliminate Patient harm due to medical error & oversight

Protect Healthcare facility from litigation and financial loss patient and community distrust

Protect involved Providers

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FTCA focusHealth Center Claims Management

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%

RECENT FTCA CLAIMS DATA

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Summary of Risk issues @ CHS’s Risk aspect #1: Patient communication

Risk aspect #2: Provider Team Communication Risk aspect #3: The Medical Record Risk aspect #4: Clinic Operation & Flow

Diagnostic test tracking After hours coverage; telephone triage

Risk aspect #5: Clinical Practice Risk aspect #6: Misdiagnosis (clinical) Risk aspect #7: Medication Safety Risk aspect #8: Equipment – EOC – Emergency Risk aspect #9: Clinic Staff performance Risk aspect #10: Medical Provider Quality/ Peer

review

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QM & RM factor: Patient communication Patient assessment & interview

Health instruction, dialogue and rapport

Treatment planning & contracting Importance of preventive services Encourage self-management of health

issues

Health instruction – literacy – interpreters

Explain back / read back

Patient feedback & satisfaction

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The Medical record & Legibility:

Guess that Prescription Handwritten prescriptions are often misread In the prescription above, the drug name

“Avandia” was incorrectly interpreted as Coumadin.

http://www.medscape.com/viewarticle/557740?src=mp From American Journal of Health-System Pharmacy

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Quality & Risk aspectsMEDICAL 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”

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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

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Clinic operation & FlowMissed 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

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Clinical practicePre-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

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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

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Medication SafetyAdverse 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

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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

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Quality Strategies to Align, Coordinate, Measure

QM/QI, RM, Patient Safety, FTCA efforts

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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

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What does Risk perspective contribute to QM

Co-use DATA and avoid redundancy – Incident reports, RCA results, Claims data

but protect risk information

Generic Quality screens w/ RM implication Waiting time Unplanned admission to hospital Infection = now a ‘medical error’!

Medical Record reviews can identify unexpected PCE (pot. comp.

event)

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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

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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.

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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.

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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

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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

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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

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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

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• Collect data

• Analyze data

• Determine the effectiveness of the change

• Data collection

• Data analysis

• Implement the change /pilot

• Select problem process

• Understand the process

• Decide on process steps to improve

• Make change permanent (standardize) or

• Continue the PDCA cycle