Patient Safety, FTCA, RM, and Quality Working Together December 2, 2008

1. Patient Safety, FTCA, RM, and Quality Working TogetherDecember 2, 2008 Petra S. Berger PhD RN, CPHRM Healthcare Quality, Risk, and Patient Safety Consultant pberger@rmpsi.com - Phone: 517–281-7816

2. 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 measuredbetweenall four aspects: Risk management, Quality improvement, Patient safety, and FTCA.

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

4. Bridging the Quality Chasm QUALITY MANAGEMENT Patient Safety= Q. I.Risk Management= identify risk – respond – prevent

5. QUALITY GOALS: 4 + RMon 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

6. 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/

7. 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

8. CORE PURPOSE ofPROACTIVERISK MANAGEMENT S T O PADVERSE OUTCOMES • Eliminate Patient harm • due to medical error & oversight • ProtectHealthcare facilityfrom • litigation and financial loss • patient and community distrust • ProtectinvolvedProviders

9. 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% FTCA focusHealth Center Claims Management RECENT FTCA CLAIMS DATA

10. Summary of Risk issues @ CHS’s • Risk aspect #1:Patient communicationRisk 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

11. 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

12. 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

13. 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”

14. 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

15. 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

16. Clinical practicePre-natal risk assessment • PRE NATAL ASSESSMENTper 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

17. Clinical practiceBEHAVIORAL 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

18. 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

19. Credentialing Focus Initial credentialing varies from re- credentialing • INITIAL: Licensure verification, Referencesre: privileges Qualifying education & experience, NPDB • RE-CREDENTIALING: Quality & Risk data required • Which value-added measures to select • Howto obtain the data efficiently • What to do with quality information

20. Quality Strategiesto Align, Coordinate, Measure QM/QI, RM, Patient Safety, FTCA efforts

21. QM & RMCOLLABORATION 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 inMedical record policies • Similar QI projectsalready 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

22. What does Risk perspective contribute to QM • Co-use DATA and avoid redundancy – • Incident reports, RCA results, Claims data • but protect risk information • Generic Qualityscreens w/ RM implication • Waiting time • Unplanned admission to hospital • Infection = now a ‘medical error’! • Medical Record reviews • can identify unexpected PCE (pot. comp. event)

23. 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

24. 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.

25. 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.

26. Risk response = QI = Patient Safety • RCA results: CHCClinicalstandardsof care = ‘duty’ • Monitoring, patient medication & document • Test result reported & signed off by provider • Treatment plan updated, w/ or w/out change • Reliablemedical record system @ hand off with external medical providers and hospital B.CRNA & Hospital standards of care

27. 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

28. 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

29. 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

30. Select problem process • Understand the process • Decide on process stepsto improve • Make change permanent (standardize) or • Continue the PDCA cycle • Collect data • Analyze data • Determine theeffectiveness of the change • Data collection • Data analysis • Implement the change /pilot